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A Kinetic Chain Approach to A Kinetic Chain Approach to Musculo-Skeletal Pain Combining Musculo-Skeletal Pain Combining Manual Therapies Nutrition and Manual Therapies Nutrition and
Corrective ExerciseCorrective Exercise
GEOFF LECOVIN DC ND LAc CSCSGEOFF LECOVIN DC ND LAc CSCS
ADAM RINDE ND ASCM-HFI ADAM RINDE ND ASCM-HFI CESCES
Integrative Approaches to Integrative Approaches to PainPain
This class is a synthesis of cutting-edge This class is a synthesis of cutting-edge chiropractic osteopathic naturopathic chiropractic osteopathic naturopathic massage nutrition and dry needling techniques massage nutrition and dry needling techniques and principlesand principles
Practitioners and students will learn the Practitioners and students will learn the different phases of pain and how to effectively different phases of pain and how to effectively assess and manage each phase with physical assess and manage each phase with physical medicine exercise nutrition and prescription medicine exercise nutrition and prescription drugsdrugs
Participants will refine their skills in soft tissue Participants will refine their skills in soft tissue and joint manipulative therapy and get exposure and joint manipulative therapy and get exposure to dry needling They will be able to effectively to dry needling They will be able to effectively manage the most common orthopedic and sports manage the most common orthopedic and sports medicine problems seen in private practicemedicine problems seen in private practice
Course ObjectivesCourse Objectives Understand the Understand the different phases of pain different phases of pain Differentiate between an orthopedic approach and Differentiate between an orthopedic approach and
Integrative approach to musculoskeletal painIntegrative approach to musculoskeletal pain Understand the significance in assessing the Understand the significance in assessing the
kinetic chainkinetic chain Learn about common distortion patternsLearn about common distortion patterns Understand the role of trigger points Understand the role of trigger points Understand the significance of perpetuating Understand the significance of perpetuating
factors factors Learn how to assess musculoskeletal conditionsLearn how to assess musculoskeletal conditions Learn how to decide which manual therapy or Learn how to decide which manual therapy or
modality is indicatedmodality is indicated Understand the role of corrective exercise as part Understand the role of corrective exercise as part
of the treatment plan and preventionof the treatment plan and prevention
PAINPAIN
ldquo ldquoAn unpleasant sensory and An unpleasant sensory and emotional experience associated emotional experience associated with actual or potential tissue with actual or potential tissue damage or described by the patient damage or described by the patient in terms of such damagerdquoin terms of such damagerdquo
International Association for the Study of PainInternational Association for the Study of Pain
3 PHASES OF PAIN3 PHASES OF PAIN
1 ImmediateNociceptive1 ImmediateNociceptive
2 AcuteInflammation2 AcuteInflammation
3 Chronic3 Chronic
IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN
Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage
Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few
weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta
and C Fibersand C Fibers Good prognosisGood prognosis
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Integrative Approaches to Integrative Approaches to PainPain
This class is a synthesis of cutting-edge This class is a synthesis of cutting-edge chiropractic osteopathic naturopathic chiropractic osteopathic naturopathic massage nutrition and dry needling techniques massage nutrition and dry needling techniques and principlesand principles
Practitioners and students will learn the Practitioners and students will learn the different phases of pain and how to effectively different phases of pain and how to effectively assess and manage each phase with physical assess and manage each phase with physical medicine exercise nutrition and prescription medicine exercise nutrition and prescription drugsdrugs
Participants will refine their skills in soft tissue Participants will refine their skills in soft tissue and joint manipulative therapy and get exposure and joint manipulative therapy and get exposure to dry needling They will be able to effectively to dry needling They will be able to effectively manage the most common orthopedic and sports manage the most common orthopedic and sports medicine problems seen in private practicemedicine problems seen in private practice
Course ObjectivesCourse Objectives Understand the Understand the different phases of pain different phases of pain Differentiate between an orthopedic approach and Differentiate between an orthopedic approach and
Integrative approach to musculoskeletal painIntegrative approach to musculoskeletal pain Understand the significance in assessing the Understand the significance in assessing the
kinetic chainkinetic chain Learn about common distortion patternsLearn about common distortion patterns Understand the role of trigger points Understand the role of trigger points Understand the significance of perpetuating Understand the significance of perpetuating
factors factors Learn how to assess musculoskeletal conditionsLearn how to assess musculoskeletal conditions Learn how to decide which manual therapy or Learn how to decide which manual therapy or
modality is indicatedmodality is indicated Understand the role of corrective exercise as part Understand the role of corrective exercise as part
of the treatment plan and preventionof the treatment plan and prevention
PAINPAIN
ldquo ldquoAn unpleasant sensory and An unpleasant sensory and emotional experience associated emotional experience associated with actual or potential tissue with actual or potential tissue damage or described by the patient damage or described by the patient in terms of such damagerdquoin terms of such damagerdquo
International Association for the Study of PainInternational Association for the Study of Pain
3 PHASES OF PAIN3 PHASES OF PAIN
1 ImmediateNociceptive1 ImmediateNociceptive
2 AcuteInflammation2 AcuteInflammation
3 Chronic3 Chronic
IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN
Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage
Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few
weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta
and C Fibersand C Fibers Good prognosisGood prognosis
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Course ObjectivesCourse Objectives Understand the Understand the different phases of pain different phases of pain Differentiate between an orthopedic approach and Differentiate between an orthopedic approach and
Integrative approach to musculoskeletal painIntegrative approach to musculoskeletal pain Understand the significance in assessing the Understand the significance in assessing the
kinetic chainkinetic chain Learn about common distortion patternsLearn about common distortion patterns Understand the role of trigger points Understand the role of trigger points Understand the significance of perpetuating Understand the significance of perpetuating
factors factors Learn how to assess musculoskeletal conditionsLearn how to assess musculoskeletal conditions Learn how to decide which manual therapy or Learn how to decide which manual therapy or
modality is indicatedmodality is indicated Understand the role of corrective exercise as part Understand the role of corrective exercise as part
of the treatment plan and preventionof the treatment plan and prevention
PAINPAIN
ldquo ldquoAn unpleasant sensory and An unpleasant sensory and emotional experience associated emotional experience associated with actual or potential tissue with actual or potential tissue damage or described by the patient damage or described by the patient in terms of such damagerdquoin terms of such damagerdquo
International Association for the Study of PainInternational Association for the Study of Pain
3 PHASES OF PAIN3 PHASES OF PAIN
1 ImmediateNociceptive1 ImmediateNociceptive
2 AcuteInflammation2 AcuteInflammation
3 Chronic3 Chronic
IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN
Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage
Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few
weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta
and C Fibersand C Fibers Good prognosisGood prognosis
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
PAINPAIN
ldquo ldquoAn unpleasant sensory and An unpleasant sensory and emotional experience associated emotional experience associated with actual or potential tissue with actual or potential tissue damage or described by the patient damage or described by the patient in terms of such damagerdquoin terms of such damagerdquo
International Association for the Study of PainInternational Association for the Study of Pain
3 PHASES OF PAIN3 PHASES OF PAIN
1 ImmediateNociceptive1 ImmediateNociceptive
2 AcuteInflammation2 AcuteInflammation
3 Chronic3 Chronic
IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN
Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage
Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few
weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta
and C Fibersand C Fibers Good prognosisGood prognosis
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
3 PHASES OF PAIN3 PHASES OF PAIN
1 ImmediateNociceptive1 ImmediateNociceptive
2 AcuteInflammation2 AcuteInflammation
3 Chronic3 Chronic
IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN
Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage
Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few
weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta
and C Fibersand C Fibers Good prognosisGood prognosis
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN
Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage
Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few
weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta
and C Fibersand C Fibers Good prognosisGood prognosis
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
ACUTE INFLAMMATIONACUTE INFLAMMATION
Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness
increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by
damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)
Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or
NSAIDS analgesics and restNSAIDS analgesics and rest
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
CHRONIC PAINCHRONIC PAIN
11 Ongoing nociception or Ongoing nociception or inflammationinflammation
22 PsychologicalPsychological
33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses
on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests
FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology
The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Traditional Orthopedic Traditional Orthopedic Approach Approach
Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Integrative Functional Integrative Functional ApproachApproach
Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)
Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements
Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization
Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists
Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Regional Regional InterdependenceInterdependence
Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint
Wainner et al JOSPT 2007Wainner et al JOSPT 2007
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Optimum AlignmentOptimum Alignment
Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity
Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain
Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS
Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)
Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce
Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint
Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Optimal Neuromuscular Optimal Neuromuscular ControlControl
Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics
Optimal sensorymotor integrationOptimal sensorymotor integration
Optimal neuromuscular efficiencyOptimal neuromuscular efficiency
Optimal tissue recoveryOptimal tissue recovery
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain
Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma
Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints
Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg
PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae
and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder
movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS
Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to
prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during
functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the
body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns
NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Functional Muscle Functional Muscle DivisionDivision
Stabilization GroupStabilization Group Movement GroupMovement Group
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)
PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)
GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
FUNCTIONAL MOVEMENT DIVISION SUMMARY
Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement
patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of
the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response
of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the
inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer
unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES
Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration
following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Postural Distortion Postural Distortion PatternsPatterns
Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control
Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury
Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance
Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES
A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers
Travell and SimonsTravell and Simons
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS
1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and
waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
PathogenesisPathogenesis
Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic
reticulum Release of calcium++ Sustained muscle contraction
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Physical Findings of Physical Findings of MTrPsMTrPs
Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or
neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Classification of Trigger Points Classification of Trigger Points
SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Classification of Trigger pointsClassification of Trigger points
Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain
Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE
HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel
syndromesyndrome Joint pain (arthritis Joint pain (arthritis
tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)
Tennis elbowTennis elbow Contributing cause of Contributing cause of
scoliosisscoliosis
EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS
lowered resistance to lowered resistance to infectioninfection
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Kinetic Chain Kinetic Chain ImbalancesImbalances
Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension
relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the
functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Cumulative Injury CycleCumulative Injury Cycle
Adhesions
Muscle imbalance
Cumulative injury cycle
Altered neuromuscularcontrol
Tissuetrauma
Inflammation
Muscle spasm
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Postural Distortion Postural Distortion PatternsPatterns
When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance
JandaJanda
11 Upper crossed syndromeUpper crossed syndrome
22 Lower crossed syndromeLower crossed syndrome
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up
Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and
stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint
function function bull Problems at one joint usually show up as Problems at one joint usually show up as
pain in the joint above or belowpain in the joint above or below
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Patient HistoryPatient HistoryOPQRSTOPQRST
OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other
meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)
The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL
I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
PosturePosture
DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Static Posture LandmarksStatic Posture Landmarks
Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear
Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head
Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Common Dysfunctional Common Dysfunctional PatternsPatterns
AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Observing Dynamic PostureObserving Dynamic Posture
Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing
Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and
imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Movement assessmentMovement assessment
11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-
tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis
33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation
44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally
55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)
FootAnklendash Straight ahead w neutral position at the ankle
Kneendash Straight ahead in line w 2nd and 3rd toes
Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in
Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint
Headndash Neutral center of ear in line with center of shoulder
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance
Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion
ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
GOAL OF TREATMENTGOAL OF TREATMENT
11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback
loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been
restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak
musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an
appropriate exercise programappropriate exercise program
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
TREATMENTTREATMENT
ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Progressive Pressure Progressive Pressure Release TechniqueRelease Technique
Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier
Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce
vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia
Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)
Specific contact is made on the muscle Traction is applied to the tissue in
order to trap the lesion The muscle is moved either actively or
passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different
positions and planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE
1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions
2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed
3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Manipulation Manipulation ConsiderationsConsiderations
11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)
Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction
11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments
22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)
33 Ten repetitions for two secondsTen repetitions for two seconds
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION
11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment
22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction
33 Respiration expedites water Respiration expedites water absorptionabsorption
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Tissue PressureTissue Pressure
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
LengtheningLengthening Stretching used to increase the Stretching used to increase the
extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint
11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos
momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
ActivateActivate Isolated (intramuscular) Isolated (intramuscular)
StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises
Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
IntegrateIntegrate
Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)
Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)
eg Squat to roweg Squat to row
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
PERPETUATING FACTORSPERPETUATING FACTORS
11 Mechanical StressesMechanical Stresses
22 NutritionalDietary factorsNutritionalDietary factors
33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies
44 Psychological factorsPsychological factors
55 Chronic InfectionChronic Infection
66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
MECHANICAL STRESSMECHANICAL STRESS
11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal
22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics
33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing
44 Degenerative joint diseaseDegenerative joint disease
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND
MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of
energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress
Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function
Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health
Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY
B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone
B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters
B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism
Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment
CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine
Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation
Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least
3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of
each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Dietary Factors in Dietary Factors in InflammationInflammation
Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin
connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic
regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined
carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE
When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg
11 HypoglycemiaHypoglycemia
22 HypothyroidHypothyroid
33 MenopauseMenopause
44 HyperuricemiaHyperuricemia
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
AllergyInfectionAllergyInfection
Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS
There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg
11 StressStress
22 DepressionDepression
33 AnxietyAnxiety
44 Insomnia Insomnia
55 FatigueFatigue
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection
Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions
StressStress
Abnormal Autonomic ActivityAbnormal Autonomic Activity
Reduced Local Circulation of BloodReduced Local Circulation of Blood
Mild Oxygen DeprivationMild Oxygen Deprivation
Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness
Tendon PainTendon Pain
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Practical ApplicationsPractical Applications
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Evaluation and TreatmentEvaluation and Treatment
Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist
handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
Practical FormatPractical Format
Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and
biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment
Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen
activate integrate)activate integrate)
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT
ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT