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1
The Shoulder Complex and
Elbow Clinical Update in
Conventional and Integrative Rehabilitation
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Course Outline ndash Hour 1
bull Shoulder Injury Causes Problems Risks
bull Biomechanics Update of Shoulder Complex Kinematics amp Injury Prevention
bull Scapular Dyskinesia Update and Testing
bull Pathophysiology of RTC Syndrome
bull Case Study
bull Integrated Rehab Methods
Objectives
1 Apply evidence-based methodology for incorporating a biopsychosocial model into current rehabilitation programs
2 Identify a minimum of 5 methods for use in shoulder rehabilitation or injury prevention
3 Describe safe application and appropriate use of yoga for the shoulder complex through understanding indications and contraindications
4 Identify movement therapy and specific patterns that allow for concurrent evaluation and therapeutic intervention in integrated shoulder rehabilitation
5 Analyze a case study format in evaluation and management of a common shoulder diagnosis
2
Our Loss Whorsquos Gain
Changing the Conversation
ldquoI dont want to survive I want to liverdquo
ldquoI donrsquot want to survive I want to liverdquo~wall-e
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
Mind Over Matter
in All Health Outcomes
3
The Biopsychosocial Model
Based on a biopsychosocial model of care the patient-
centered approach has been shown to be the most
effective and cost-effective way to address pain
~ Institute of Medicine 2011 report ldquoRelieving Pain in America A Blueprint for Transforming Prevention Care Education and
Researchrdquo
WHO (2001) and IOM support (2011)
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
copy2014 Ginger Garner All rights reserved
Biopsychosocial Model(not just biomedical)
EastWest Model for
Systemic Health
1 Mindful Eating -
Adoption of a holistic bio-
psycho-socio-spiritual
model when dealing with
FGID patients (Chen et al 2010)
2 Mindful Movement ndashMedical therapeutic yoga
Systems-Based
Team Approach
Healthy Systemic Function including
bull Epigenetic regulation
bull Immunity amp Longevity via Telomere Preservation
bull HPA Axis Regulation and Allostasis
bull High bone mineral density and low pro-inflammatory activity
bull High parasympathetic input
4
Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK
2015
Yogic MedicineMedical Therapeutic Yoga is
copy2014 Ginger Garner All rights reserved
BPS Model
copy2014 Ginger Garner All rights reserved
5
BPS Self-Management Strategies
Change Stress
Response
Experiential
learning amp
practice
Intuitive
Bio-energetic
methodsOR
copy2014 Ginger Garner All rights reserved
Integrated Rehab
The MTY Model allows for ampor establishes
bull Inter-rater and intra-rater reliability through standardization of biomechanical alignment of posturesbreath
bull Rationale for documented approach
bull Improving patient outcomes and consumer safety
bull Culturally relevant context for postures
bull Educational competencies for yoga used as therapy or medicine
bull Lesson plans for wellness (prevention) programs and pathophysiology
bull Therapists to supervise and design medical therapeutic yoga programs for integrative medicine facilities
bull Stabilization (and safety) rather than mobilization (proximal to distal) ie Spine then extremities Shoulder then elbow
PYTI graduate international lecturer and Canadian physio Shelly Prosko PT PYT
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Anterior and Posterior Shoulder
Anterior right shoulder Posterior right shoulder
6
Clinical Scenario
ProblemYou have to inform your patient that she cannot return to recreational activities and sports until she has reached certain levels of objective functioning in therapy due to her shoulder conditionhellip
Think about how you will answer her questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer her question you must know
bull 36 of documented RT (resistance training)-related injuries and disorders occur at the shoulder complex (Kolber et al 2010)
bull 3rd most common MS complaint in general population (Croft 1993 Glocker 1995 Hudson 2010)
bull Peak incidence between ages 40-60 (Isabel et al 2011 Kolber et al 2010 Krogsgaard
et al 2009 Lamberts et al 1991)
bull Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics(Lucado et al 2010 Lucas 2007)
copy2014 Ginger Garner All rights reserved
Is this serious
bull In order to answer her question you must know
bull If left untreated shoulder pain could result in
bull RTC Tendonitis or bursitis
bull Impingement
bull Strain or sprain
bull AC joint separation
bull Anterior instability or capsular laxity
bull SLAP (superior labral ant-post) lesions
bull Posterior shoulder instability
copy2014 Ginger Garner All rights reserved
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
2
Our Loss Whorsquos Gain
Changing the Conversation
ldquoI dont want to survive I want to liverdquo
ldquoI donrsquot want to survive I want to liverdquo~wall-e
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
Mind Over Matter
in All Health Outcomes
3
The Biopsychosocial Model
Based on a biopsychosocial model of care the patient-
centered approach has been shown to be the most
effective and cost-effective way to address pain
~ Institute of Medicine 2011 report ldquoRelieving Pain in America A Blueprint for Transforming Prevention Care Education and
Researchrdquo
WHO (2001) and IOM support (2011)
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
copy2014 Ginger Garner All rights reserved
Biopsychosocial Model(not just biomedical)
EastWest Model for
Systemic Health
1 Mindful Eating -
Adoption of a holistic bio-
psycho-socio-spiritual
model when dealing with
FGID patients (Chen et al 2010)
2 Mindful Movement ndashMedical therapeutic yoga
Systems-Based
Team Approach
Healthy Systemic Function including
bull Epigenetic regulation
bull Immunity amp Longevity via Telomere Preservation
bull HPA Axis Regulation and Allostasis
bull High bone mineral density and low pro-inflammatory activity
bull High parasympathetic input
4
Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK
2015
Yogic MedicineMedical Therapeutic Yoga is
copy2014 Ginger Garner All rights reserved
BPS Model
copy2014 Ginger Garner All rights reserved
5
BPS Self-Management Strategies
Change Stress
Response
Experiential
learning amp
practice
Intuitive
Bio-energetic
methodsOR
copy2014 Ginger Garner All rights reserved
Integrated Rehab
The MTY Model allows for ampor establishes
bull Inter-rater and intra-rater reliability through standardization of biomechanical alignment of posturesbreath
bull Rationale for documented approach
bull Improving patient outcomes and consumer safety
bull Culturally relevant context for postures
bull Educational competencies for yoga used as therapy or medicine
bull Lesson plans for wellness (prevention) programs and pathophysiology
bull Therapists to supervise and design medical therapeutic yoga programs for integrative medicine facilities
bull Stabilization (and safety) rather than mobilization (proximal to distal) ie Spine then extremities Shoulder then elbow
PYTI graduate international lecturer and Canadian physio Shelly Prosko PT PYT
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Anterior and Posterior Shoulder
Anterior right shoulder Posterior right shoulder
6
Clinical Scenario
ProblemYou have to inform your patient that she cannot return to recreational activities and sports until she has reached certain levels of objective functioning in therapy due to her shoulder conditionhellip
Think about how you will answer her questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer her question you must know
bull 36 of documented RT (resistance training)-related injuries and disorders occur at the shoulder complex (Kolber et al 2010)
bull 3rd most common MS complaint in general population (Croft 1993 Glocker 1995 Hudson 2010)
bull Peak incidence between ages 40-60 (Isabel et al 2011 Kolber et al 2010 Krogsgaard
et al 2009 Lamberts et al 1991)
bull Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics(Lucado et al 2010 Lucas 2007)
copy2014 Ginger Garner All rights reserved
Is this serious
bull In order to answer her question you must know
bull If left untreated shoulder pain could result in
bull RTC Tendonitis or bursitis
bull Impingement
bull Strain or sprain
bull AC joint separation
bull Anterior instability or capsular laxity
bull SLAP (superior labral ant-post) lesions
bull Posterior shoulder instability
copy2014 Ginger Garner All rights reserved
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
3
The Biopsychosocial Model
Based on a biopsychosocial model of care the patient-
centered approach has been shown to be the most
effective and cost-effective way to address pain
~ Institute of Medicine 2011 report ldquoRelieving Pain in America A Blueprint for Transforming Prevention Care Education and
Researchrdquo
WHO (2001) and IOM support (2011)
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
copy2014 Ginger Garner All rights reserved
Biopsychosocial Model(not just biomedical)
EastWest Model for
Systemic Health
1 Mindful Eating -
Adoption of a holistic bio-
psycho-socio-spiritual
model when dealing with
FGID patients (Chen et al 2010)
2 Mindful Movement ndashMedical therapeutic yoga
Systems-Based
Team Approach
Healthy Systemic Function including
bull Epigenetic regulation
bull Immunity amp Longevity via Telomere Preservation
bull HPA Axis Regulation and Allostasis
bull High bone mineral density and low pro-inflammatory activity
bull High parasympathetic input
4
Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK
2015
Yogic MedicineMedical Therapeutic Yoga is
copy2014 Ginger Garner All rights reserved
BPS Model
copy2014 Ginger Garner All rights reserved
5
BPS Self-Management Strategies
Change Stress
Response
Experiential
learning amp
practice
Intuitive
Bio-energetic
methodsOR
copy2014 Ginger Garner All rights reserved
Integrated Rehab
The MTY Model allows for ampor establishes
bull Inter-rater and intra-rater reliability through standardization of biomechanical alignment of posturesbreath
bull Rationale for documented approach
bull Improving patient outcomes and consumer safety
bull Culturally relevant context for postures
bull Educational competencies for yoga used as therapy or medicine
bull Lesson plans for wellness (prevention) programs and pathophysiology
bull Therapists to supervise and design medical therapeutic yoga programs for integrative medicine facilities
bull Stabilization (and safety) rather than mobilization (proximal to distal) ie Spine then extremities Shoulder then elbow
PYTI graduate international lecturer and Canadian physio Shelly Prosko PT PYT
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Anterior and Posterior Shoulder
Anterior right shoulder Posterior right shoulder
6
Clinical Scenario
ProblemYou have to inform your patient that she cannot return to recreational activities and sports until she has reached certain levels of objective functioning in therapy due to her shoulder conditionhellip
Think about how you will answer her questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer her question you must know
bull 36 of documented RT (resistance training)-related injuries and disorders occur at the shoulder complex (Kolber et al 2010)
bull 3rd most common MS complaint in general population (Croft 1993 Glocker 1995 Hudson 2010)
bull Peak incidence between ages 40-60 (Isabel et al 2011 Kolber et al 2010 Krogsgaard
et al 2009 Lamberts et al 1991)
bull Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics(Lucado et al 2010 Lucas 2007)
copy2014 Ginger Garner All rights reserved
Is this serious
bull In order to answer her question you must know
bull If left untreated shoulder pain could result in
bull RTC Tendonitis or bursitis
bull Impingement
bull Strain or sprain
bull AC joint separation
bull Anterior instability or capsular laxity
bull SLAP (superior labral ant-post) lesions
bull Posterior shoulder instability
copy2014 Ginger Garner All rights reserved
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
4
Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK
2015
Yogic MedicineMedical Therapeutic Yoga is
copy2014 Ginger Garner All rights reserved
BPS Model
copy2014 Ginger Garner All rights reserved
5
BPS Self-Management Strategies
Change Stress
Response
Experiential
learning amp
practice
Intuitive
Bio-energetic
methodsOR
copy2014 Ginger Garner All rights reserved
Integrated Rehab
The MTY Model allows for ampor establishes
bull Inter-rater and intra-rater reliability through standardization of biomechanical alignment of posturesbreath
bull Rationale for documented approach
bull Improving patient outcomes and consumer safety
bull Culturally relevant context for postures
bull Educational competencies for yoga used as therapy or medicine
bull Lesson plans for wellness (prevention) programs and pathophysiology
bull Therapists to supervise and design medical therapeutic yoga programs for integrative medicine facilities
bull Stabilization (and safety) rather than mobilization (proximal to distal) ie Spine then extremities Shoulder then elbow
PYTI graduate international lecturer and Canadian physio Shelly Prosko PT PYT
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Anterior and Posterior Shoulder
Anterior right shoulder Posterior right shoulder
6
Clinical Scenario
ProblemYou have to inform your patient that she cannot return to recreational activities and sports until she has reached certain levels of objective functioning in therapy due to her shoulder conditionhellip
Think about how you will answer her questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer her question you must know
bull 36 of documented RT (resistance training)-related injuries and disorders occur at the shoulder complex (Kolber et al 2010)
bull 3rd most common MS complaint in general population (Croft 1993 Glocker 1995 Hudson 2010)
bull Peak incidence between ages 40-60 (Isabel et al 2011 Kolber et al 2010 Krogsgaard
et al 2009 Lamberts et al 1991)
bull Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics(Lucado et al 2010 Lucas 2007)
copy2014 Ginger Garner All rights reserved
Is this serious
bull In order to answer her question you must know
bull If left untreated shoulder pain could result in
bull RTC Tendonitis or bursitis
bull Impingement
bull Strain or sprain
bull AC joint separation
bull Anterior instability or capsular laxity
bull SLAP (superior labral ant-post) lesions
bull Posterior shoulder instability
copy2014 Ginger Garner All rights reserved
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
5
BPS Self-Management Strategies
Change Stress
Response
Experiential
learning amp
practice
Intuitive
Bio-energetic
methodsOR
copy2014 Ginger Garner All rights reserved
Integrated Rehab
The MTY Model allows for ampor establishes
bull Inter-rater and intra-rater reliability through standardization of biomechanical alignment of posturesbreath
bull Rationale for documented approach
bull Improving patient outcomes and consumer safety
bull Culturally relevant context for postures
bull Educational competencies for yoga used as therapy or medicine
bull Lesson plans for wellness (prevention) programs and pathophysiology
bull Therapists to supervise and design medical therapeutic yoga programs for integrative medicine facilities
bull Stabilization (and safety) rather than mobilization (proximal to distal) ie Spine then extremities Shoulder then elbow
PYTI graduate international lecturer and Canadian physio Shelly Prosko PT PYT
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Anterior and Posterior Shoulder
Anterior right shoulder Posterior right shoulder
6
Clinical Scenario
ProblemYou have to inform your patient that she cannot return to recreational activities and sports until she has reached certain levels of objective functioning in therapy due to her shoulder conditionhellip
Think about how you will answer her questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer her question you must know
bull 36 of documented RT (resistance training)-related injuries and disorders occur at the shoulder complex (Kolber et al 2010)
bull 3rd most common MS complaint in general population (Croft 1993 Glocker 1995 Hudson 2010)
bull Peak incidence between ages 40-60 (Isabel et al 2011 Kolber et al 2010 Krogsgaard
et al 2009 Lamberts et al 1991)
bull Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics(Lucado et al 2010 Lucas 2007)
copy2014 Ginger Garner All rights reserved
Is this serious
bull In order to answer her question you must know
bull If left untreated shoulder pain could result in
bull RTC Tendonitis or bursitis
bull Impingement
bull Strain or sprain
bull AC joint separation
bull Anterior instability or capsular laxity
bull SLAP (superior labral ant-post) lesions
bull Posterior shoulder instability
copy2014 Ginger Garner All rights reserved
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
6
Clinical Scenario
ProblemYou have to inform your patient that she cannot return to recreational activities and sports until she has reached certain levels of objective functioning in therapy due to her shoulder conditionhellip
Think about how you will answer her questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer her question you must know
bull 36 of documented RT (resistance training)-related injuries and disorders occur at the shoulder complex (Kolber et al 2010)
bull 3rd most common MS complaint in general population (Croft 1993 Glocker 1995 Hudson 2010)
bull Peak incidence between ages 40-60 (Isabel et al 2011 Kolber et al 2010 Krogsgaard
et al 2009 Lamberts et al 1991)
bull Shoulder pain is second only to knee pain for referrals to orthopedic surgery or primary care sports medicine clinics(Lucado et al 2010 Lucas 2007)
copy2014 Ginger Garner All rights reserved
Is this serious
bull In order to answer her question you must know
bull If left untreated shoulder pain could result in
bull RTC Tendonitis or bursitis
bull Impingement
bull Strain or sprain
bull AC joint separation
bull Anterior instability or capsular laxity
bull SLAP (superior labral ant-post) lesions
bull Posterior shoulder instability
copy2014 Ginger Garner All rights reserved
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
7
How can you be sure what the
problem is with my shoulder
In order to answer her question you must know
Patients with chronic or acute shoulder pain might experience the following symptoms
bull Audible pop or feeling of internal popping
bull Feeling of instability
bull Pain (during the day and at night)
bull Swellinghemarthrosis or bleeding in the joint
bull Limited ROM and restricted ability to complete ADLrsquos
bull Pain before during andor after activity
copy2014 Ginger Garner All rights reserved
Pain Mapping
Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for
common shoulder disorders Am J Orthop (Belle Mead NJ)
201140(7)353-358copy2014 Ginger Garner All rights reserved
How did this happenThe Mayo Clinic cites that factors
contributing to shoulder pain might include
bull Age - gt40
bull Engaging in athletic activities that
involve repetitive arm use
bull Working in the construction or other
similar trades that involve repetitive arm use
bull Having poor posture
bull Having weak shoulder muscles
copy2014 Ginger Garner All rights reserved
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
8
Despite identifiable high risk populations shoulder pain is considerably preventable Shoulder pain
causes fall into 3 movement categories
1 Repetitive Stress Syndrome
2 Poor ergonomic set up
3 Poor technique in sport
including yoga execution
The highest prevalence of shoulder
injuries is found in
bull 1st - Water hockey (swimming
+ overhead throwing)
baseball tennis swimming
bull 2nd ndash Volleyball (overuse)
bull 3rd ndash Ice hockey (acute)
American football wrestling
copy2014 Ginger Garner All rights reserved
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
What would happen if I continue
the same activitiesIn order to answer her question you must know that continued use of her shoulder could also result in
bull Articular cartilage damage
bull Labral lesion (SLAP tear)
bull Ligament damage
bull AC joint injury
bull Subluxation or joint instability
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Scapular Dyskinesis
bull ldquoDysrdquo ndash alteration of
bull ldquoKinesisrdquo ndash motion
bull Changes in GH angulation
bull AC joint strain
bull Subacromial space
dimension
bull Shoulder muscle activation
bull Humeral position and motion
Conclusions
bull Dyskinesis OFTEN implicated in shoulder injuries
bull Impingement often implicated
bull Tx more effective by addressing dyskinesis
bull Reliable observational clinical method is needed
bull Restoration of scapular position and motion required
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
9
copy2014 Ginger Garner All rights reserved
SD Etiology amp Testing
1 GH Joint Angulation
2 GH Joint Integrity
3 Neurological Causes
4 Soft Tissue Mechanisms
bull GIRD ndash short post capsule
bull Short pec minor and biceps short head
5 Periscapular Muscle Activation and Force Coupling
bull Dynamic Scapular Dyskinesis Tests
bull SAT
bull SRT
bull Cadaver Models -
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The
2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425
101136bjsports-2013-092425
copy2014 Ginger Garner All rights reserved
SD Classification
bull Upward rotation is primary
and posterior tilt secondary
during normal overhead UE
elevation with
internalexternal rotation
being minimal until 100deg (2009)
bull Kibler classification (2002)
bull Type I - inferior
bull Type II ndash medial
bull Type III - superior
Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg
Am200991378-389
Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow
Surg200211550-556
copy2014 Ginger Garner All rights reserved
SAT
bull httpswwwyoutubecomwatchv=XXiskkfNaHQ
bull Seitz et al 2012
bull 42 subjects (21 SAIS 21 control)
bull Effect of SAT on shoulder kinematics and subacromial
space measures in patients with SAIS
Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during
static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640 doi httpdxdoiorglibproxylibuncedu101016jjse201101008
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
10
copy2014 Ginger Garner All rights reserved
SRT
bull Baseline AROM and pain is evaluated
bull ldquo+rdquo Test ndash pain reduction with therapist assist for active elevation by applying a posterior tilt and external rotation motion to the scapula
bull May be used in conjunction with other tests such as Neers Hawkins-Kennedy and Jobes relocation
bull Tate et al 2008
bull 142 college students
bull 98 ldquo+rdquo impingementbull 46 ndash reduced pain with SRT
bull All experienced increase in strength but only clinically sig in frac14 of athletes
Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation
strength in overhead athletesJOSPT2008384-11
Glenohumeral Force Couple
Deltoid amp RTC
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises
Sports Med 200939(8)663-685
(graphic) Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeral joint J Orthop Res
2002 May20(3)439-46
bull 35-65 - MD
bull 30 - SSbull 25 - SSp
bull 10 - IS
bull 2 - AD
copy2014 Ginger Garner All rights reserved
Teres Minor amp Infraspinatus
Posterior Cuff
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity
and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
11
copy2014 Ginger Garner All rights reserved
Serratus Anterior amp Trapezii
bull SA + Pec Minor (protract)
scapula
bull SA + LTUT (upwardly rotate)
scapula
bull SA rules
bull Contributes to all 3-D
components of scapular
movement during humeral
elevation
bull Stabilizes medial border and
inferior angle of scapula
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
copy2014 Ginger Garner All rights reserved
Scapulothoracic Force Couples
W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder Pain J Am AcadOrthop Surg MarchApril 2003 11142-151
Pathophysiology of RTC Syndrome
copy2014 Ginger Garner All rights reserved
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
12
Impingement
To Be or Not To Be
ldquoonly states that you have ruled out cervical referred pain
adhesive capsulitis GH instability for examplehelliprdquo Kibler et al 2013
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
Empty Can or Full Can
Empty Can
1 Reduced subacromial width
2 Abd + extreme IR = abduction moment at SSp at 0 to 90 deg Abd
3 Increased tensile force of SSp
4 Delayed healing of SSp tendon
5 Nonoptimal scapular mechanics
1 Posteroinferior capsule tension
2 Diminished IR and ER strength by 13-34 and 20 repsectively
Full Can
1 Enhanced SSp force
production - better scapular
kinematics
2 Equally accurate to empty
can in identifying SSp tears
3 Less pain provocation
4 Most optimal SSp isolation
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder
injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885
Integrated Injury Prevention
Matrix
The science of yoga in a holistic biopsychosocial model
bull Identify postural anomalies
bull Consider Regional Interdependence
Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson
ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009 Garner 2015
copy2014 Ginger Garner All rights reserved
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
13
WHO ICF Model
Case Study Application
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Post-partum routine was walking and pt
was familiar with yoga already from prenatal required ADLrsquos ie lifting infant
32 yo femaleL shldImpression Stage III RTC tearexternal
impingement
Left shoulder pain night pain unable to care for
infant or complete ADLrsquos
Some history of prenatal
yoga participation BMI 19 motivated proactive no
PPD
good family support system
no other children in home flexible work situation but self-employed and injury
prevents working
ldquo+rdquo Impingement (Hawkins Neer) empty can MMT 2+-
3+5 and painful ROM NT 2nd pain Mild scapular dyskinesis global UE weakness
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
BPS Model in Action
Physical
bull Posture Prescription
bull Prevention of (re)injury
Energetic
bull Breathing for awareness and healing
as well as posture maintenance and
self correction
bull ADL Completion using good postural
alignment and core initiation
bull Pain management and healing
Psycho-emotional
bull Healing Meditation with breath practice
bull Comfort measures (sleep positioning)
Intellectual
bull Patient education
bull Movement modification
Bliss
bull Social support for stress management
bull Identification of root causes of injury
Plan Program designed as adjunct to patientrsquos regular post-partum fitness routine
Duration 6 weeks x 15-30 minutes daily HEP Fu at 3 months
copy2014 Ginger Garner All rights reserved
Contraindications
If a patient is unable to perform pre-asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical alignment
bull Not introducing low level force loads for dynamic stability in the shoulder joint during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that include but are not limited to
bull Cow arms
bull Eagle arms
bull Inversions such as
bull 4 point weight bearing such as in handsknees posture or downward facing dog without specific biomechanical modification
bull Dolphin dive
bull WB headstand
bull Shoulder stand
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
14
Activation Sequencing Treating Scapular Dyskinesis amp Impingement
ldquoSyndromerdquo bull Downtrain UT (watch for lsquoshruggingrsquo during
shoulder elevation)
bull Balance UT and LT force couple ndash correct latent
firing of LT
bull Correct decreased SA activation
bull Shortened pectoralis minor (creates excessive
posterior protraction at rest and limits scapular posterior tilt or external rotation with arm motion)
Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med
201347(14)877-885
copy2014 Ginger Garner All rights reserved
Regional Interdependence
bull Cervical spine core work and related synergists (Isabel de-la-Llave-
Rincoacuten et al 2011)
bull Thoracic mobility (Sueki et al 2011)
bull Elbow and wrist function (Lucado et al 2010)
bull Latent trigger points in scapular positioning and muscle activation patterns
(Lucas 2007)
bull Impaired balance scores (SLBT) and core stability (DLL) in athletes with
shoulder pain (Radwan et al 2014)
Lucado Ann1 Kolber Morey2 Cheng M Samuel2Echternach John3 Subacromial impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy Reviews
Volume 15 Number 2 April 2010 pp 55-61(7) Lucas K 2007 Effects of latent myofascial trigger points on muscle activation patterns during scapular plane elevation PhD Thesis School of Health Sciences RMIT UniversitySueki Derrick G Chaconas Eric J The effect of thoracic manipulation on shoulder pain a regional interdependence model Physical Therapy Reviews Volume 16 Number 5 October 2011 pp 399-408(10)Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)Radwan A Francis J Green A et al Is there a relation between shoulder dysfunction and core instability Int J Sports Phys Ther 20149(1)8-13
copy2014 Ginger Garner All rights reserved
Acute Program A graduated approach for Deep Abdominal Breathing Shoulder Lock TATD Breath (0-6 weeks)
Yoga Couch (Three tier Approach)
bull Flexibility of pectoralischest
bull Restorative for joint mobility and positioning for jt Mobs
bull Arthrokinematics Grade I-II jt Jobs for pain relief and gentle capsular mobility PRN (after acute phase)
Easy Seated Pose
bull Dynamic Neuromuscular Re-education Spinal Neutral
bull Seated Meditation Centering Stress management Pain management
Sleep PositioningEducation
Pectoralis FlexibilityJt MobilityPostural Re-educationStress amp Pain Management
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
15
Energetic + Physical Stability TATD Breath
There are distinct biomechanical and physiological benefits to using the
TATD breath including increase of safety in using yoga as medicine
1 Anatomical Principle
of Movement
Biomechanical
2 Science of Action
Physiological
3 Safety
Clinical Efficacy
(Renovato et al 2010 Hides et al 2011 Fraca et al 2012 Willson et al 2005 Richardson et al 1999 Hides et al 2006 Hodgest and Richardson
1997 Cholewicki amp McGill 1996 Cholewicki amp Panjabi 1997 Cresswell and Thostensson 1994 Lee 2001 Hodgest and Gandevia 2000 Hodges et
al 2003 McCandless 1975 Morris et al 1961 Critchley 2002 Lee 2005 Sapsford 2001)
NM Re-edScapular Kinematics
bull Arm Floats Progression from AAROM with bamboo cane to AROM
bull Core and trunk Control
bull Neuromuscular re-ed Proprioception
bull Regional Interdependence model
bull TATD breath
bull SH and LP awareness
bull Rib controlobliques amp serratusanterior
bull Started with 45-60 degrees flexion and progressed to 180 deg Flexion by end of 6 weeks
Childrsquos Pose to Upstretched Mountain
Subtle Body
bull Restorative Biofeedback Proprioceptive and neuromuscular
re-education Myofascial release
Gross Body
bull LT isolation UT inhibition
Postural alignment
Positioning for posterior jt mobs PRN
Sun Salutes with AAROM assist with right hand Performed at wall andor with wall assist PRN
Postural EducationAdditional Biofeedback
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
16
copy2014 Ginger Garner All rights reserved
Above 90 MVIC EMG amplitude UT MT and LT
Above 80 Supraspinatus Posterior Deltoid Middle Deltoid (Above 40 IS Tminor)
Correct form - Childrsquos Pose Reach Roll and
RiseIncorrect form
Extrapolated from Kibler et al 2013
RTC Periscapular Synergy
Acute to subacute progression(s)
1 Arm Spiral ndash TATD Breath myofascial release of upper quarter and chest
median n mob downtrain UT engage LT SA
2 Plank with push up plus ndash TATD breath postural alignment spinal neutral
under loading plus upper and lower subscapularis SSp IS pectoralis major
teres major LD
3 Press upScales ndash UT MT LT LS Rhomboids SA Pminor P major (84 +-
42) LD (55 +-27)
Kibler 2013 Kibler 2003 Garner 2015Modified arm spiral
copy2014 Ginger Garner All rights reserved
Activating the Posterior Cuff
IS and TMinorIn order of activation
1 Weight Shift in Four-Point Position (GRF on hand = 32 BW)
2 Plank with Chatarangawithout (34BW) with feet elevated (39BW)
3 Side Plank (1-armed push up) (60BW)
Questions
bull DDP (right)
bull Yogic mindful activation for neural patterning
Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
Garner 2015
Downward Dog Preparation
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
17
UE Synergy + Core Biofeedback
bullSub-Acute
Program -Pre-Asana
Shoulder
ldquoOpenerrdquo
Kibler 2013 Garner 2015
PMinor (flx) UT LT SA
Activation Sub-Acute Modifications
Top left to right Upward facing bow Cow Arms (scaption in full can and subscap Strength IR flexibility UT LT SA activation)
Bottom left to right Fish over bolster (pminor flx) Boat (LP control)
Seated Twist (myofascial release)
copy2014 Ginger Garner All rights reserved
Sub-Acute Progression - Top left to right Downward Facing Dog with strap
Strap-Assisted Plank Bottom left to right Dolphin Dive
Advanced Sub-Acute Progression
for UE Synergy amp Scapular
Kinematics
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
18
copy2014 Ginger Garner All rights reserved
Advanced Final Progression
Advanced Sub-Acute Progression
Left top to bottom Strap assisted dolphin NWB headstand prepMiddle Wall assisted NWB Headstand
Right left to right NWB Headstand Forearm balance
copy2014 Ginger Garner All rights reserved
Review
Neuromuscular Retraining amp Strength
bull Control and position during sport exercise and ADL function
bull Pre-position the body and upper extremity prior to initial ground contact
bull Stability amp integrity
bull Glenohumeral Lumbopelvic
bull RTC Scapular dyskinesis andor loss of coracoacromial arch space
Proprioceptive and Biofeedback Activities
bull Proprioceptive activities combined with decision-making
bull Balance agonistantagonist
bull Train joint mechanoreceptors
bull Upper extremity kinetic chain work employing joint stabilization requisites (in Modules 1-7PYT Volume 1 text)
Flexibility - Posterior capsule Latissimus dorsi Pectoralis major amp minor Myofascial amp neurovascular mobility and response (Lucas 2007)
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
copy2014 Ginger Garner All rights reserved
Program Impact
Pre-Test Results
bull Pre-test AROM ndash abduction to 45 deg without pain
bull PAS 710 with attempted activity
bull Special Tests
bull Positive Hawkinrsquos impingement
bull Positive Empty Can
bull MMT ndash 2+5 (flexion abd
ERIR)
Post-Test Results
bull Post-test AROM ndash full pain-free abduction
bull PAS 010 with full activity
bull Special Tests ndash negative
painfree
bull MMT ndash 55 painfree
bull Able to return to full ADLrsquos and activity without pain
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
19
copy2014 Ginger Garner All rights reserved
Resources
bull Quick Dash Outcome Measure httpdashiwhoncasystemfilesquickdash_questionnaire_2010pdf
bull Nutrition amp Orthopaedicscourse httpswwwalliedhealthedcomblogcourse2100
bull Yoga Couch TATD Breath Abdominal Breath Sleeping Positions ndashwwwmedicaltherapeuticyogacom
bull Beth Israel Deaconess Medical Center ScapaularDyskinesis Guidelines httpwwwbidmcorgCentersandDepartmentsDepartmentsOrthopaedicSurgeryServicesandProgramsSportsMedicineForPatients~mediaFilesCentersandDepartmentsOrthopaedicSports20MedicineRehab20ProtocolsScapular20Dyskinesisashx
Selected Sources (1)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res2010 Jun24(6)1696-704
bull Croft P Soft-tissue rheumatism In Sillman AJ Hochberg MC Eds Epidemiology of the Rheumatic Disease Oxford England Oxford University Press 1993375ndash421
bull Glockner SM Shoulder pain a diagnostic dilemma Am FamPhysician 1995511677-87ndash1690-2
bull Hudson VJ PhD DPT MBA ATC Evaluation Diagnosis and Treatment of Shoulder Injuries in Athletes Clinics in Sports Medicine Volume 29 Issue 1 Pages 19-32 January 2010
bull Isabel de-la-Llave-Rincoacuten Ana Puentedura Emilio J Fernaacutendez-de-las-Pentildeas Ceacutesar Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Journal of Manual amp Manipulative Therapy Volume 19 Number 4 2011 pp 201-211(11)
Sources (2)
bull Kolber MJ Beekhuizen KS Cheng MS Hellman MA Shoulder injuries attributed
to resistance training a brief review J Strength Cond Res 2010 Jun24(6)1696-
704
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing
Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention
Blackwell Publishing International Olympic Committee 2009
bull Lamberts H Brouwer HJ Mohrs J Reason for Encounter- Episode-and Process-
Oriented Standard Output From Transition Project Part I Amsterdam Department of
General PracticeFamily Medicine University of Amsterdam 1991
bull Lucado Ann1 Kolber Morey2 Cheng M Samuel2 Echternach John3 Subacromial
impingement syndrome and lateral epicondylalgia in tennis players Physical Therapy
Reviews Volume 15 Number 2 April 2010 pp 55-61(7)
bull Lucas K 2007 Effects of latent myofascial trigger points on muscle activation
patterns during scapular plane elevation PhD Thesis School of Health Sciences
RMIT University
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
20
Sources (3)
bull Bayam L Ahmad MA Naqui SZ Chouhan A Funk L Pain mapping for common shoulder disorders Am J Orthop (Belle Mead NJ) 201140(7)353-358
bull Krogsgaard MR Safran MR Rheinlaedner P and Cheung E Ch 9 Preventing Shoulder Injuries Bahr R and Engebretson ed Sports Injury Prevention Blackwell Publishing International Olympic Committee 2009
bull Kibler WB Ludewig PM McClure PW Michener LA Bak K Sciascia AD Clinical implications of scapular dyskinesis in shoulder injury The 2013 consensus statement from the scapular summit Br J Sports Med 201347(14)877-885 doi 101136bjsports-2013-092425 101136bjsports-2013-092425
bull WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
Sources (4)
bull Garner G Medical Therapeutic Yoga prospectus for publication Handspring Pub Ltd Scotland UK 2015
bull Escamilla RF Yamashiro K Paulos L Andrews JR Shoulder muscle activity and function in common shoulder rehabilitation exercises Sports Med 200939(8)663-685
bull Parsons IM Apreleva M Fu FH Woo SL The effect of rotator cuff tears on reaction forces at the glenohumeraljoint J Orthop Res 2002 May20(3)439-46
bull Tate AR et al Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletesJOSPT2008384-11
Sources (5)
bull Seitz AL McClure PW Lynch SS Ketchum JM Michener LA Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation Journal of Shoulder and Elbow Surgery 201221(5)631-640
bull Ludewig PM et al Motion of the shoulder complex during multiplaner humeral elevation J Bone Joint Surg Am200991378-389
bull Kibler WB et alQualitative clinical evaluation of scapular dysfunction a reliability study J Shoulder Elbow Surg200211550-556
bull W Ben Kibler and John McMullen Scapular Dyskinesis and Its Relation to Shoulder PainJ Am Acad Orthop Surg MarchApril 2003 11142-151
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
1
Spinal Kinematics
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 2
bull Case Scenario
bull Epidemiology
bull Spinal Kinematics
bull Integrated PT Application via
yoga
bull Guidelines Indications
Contraindications
Objectives
bull Describe how the simultaneous application of yoga Ayurveda and spinal kinematics can influence and improve overall systemic health and wellbeing
bull Identify the ways spinal osteokinematics and arthrokinematics can operationalize the biopsychosocial model of assessment
bull Analyze 12 yogic postures and their symbiotic effect on spinal functional mobility GI motility and overall health
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
2
ProblemAn individual with back pain comes
to you after having been to a
physician to rule out structural and
systemic issues and to a physical
therapist for conventional low back
pain rehabilitation Her pain persists and she wants to know if alternative
methods of rehabilitation (ie yoga)
may work
bull Think about how you will answer her questions
In order to answer her question you must know
bull 80 of Americans experience back pain
bull Back pain is the most common
bull neurological ailment after headache in the US
bull cause of job-related disability and lost days from work
bull in the third decade of life
After ruling out systemic and structural GI issues one must also consider GI triggers
bull Gastrointestinal dysfunction is one of the most common hospital admissions in the United States today (AHRQ 2006)
bull The Cleveland Clinic cites lack of exercise as a shared risk factor in both functional GI disorders (constipation IBS) and back pain
NIH 2003 Hoy et al 2010 Rahman et al 2010 Hoy et al 2010 (3)
Is this very common
Is this serious
bullIn order to answer her questions you must consider
bull Musculoskeletal systembull Degenerative Disease
bull RheumatologicalDisease States
bull Skeletal anomalies
bull Organicsystemicbull Metabolic Bone Disease
bull Gastrointestinal
bull Reproductive
bull Vascular (aortic aneurysm)
bull Oncological
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
2008 Consumer Guidelines for Low Back Pain published by The American Chronic Pain Association
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
3
How did this happen
The Mayo Clinic cites
the following risk factors for low back
pain
bull Anxiety
bull Depression
bull Obesity
bull Older age
bull Being female
bull Physically
strenuous work
bull Sedentary work
bull Stressful job
bull Smoking
copy 2012 Ginger Garner Living Well Inc excerpt from PYT Texts copy2001-2012 All rights reserved
How can you be sure the two
problems are related In order to answer her question you must know The most common GI functional disorders carry similar risk factors
bull Poor nutrition
bull Being overweight or obese
bull Being sedentary
Patients with persistent back and abdominal pain that have been differentially diagnosed may feel
bull Patterns of pain related to eating and digestion or specific movements or exercise
bull Concurrent lower abdominalback pain
bull Stiffness or loss of ROM amp flexibility
bull Inability to complete ADLrsquos
Anatomy amp Physiology
bull Atlasaxis
bull C3-7
bull T1-T12
bull L1-L5
bull Sacrum and
coccyx
Figure 511 amp 12 Axial Skeleton
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
4
Spinal Biomechanics
Arthrokinematics amp Osteokinematics
Arthrokinematics determine osteokinematics
ldquoThree joint complexrdquobull Smooth cartilage
surfaces
bull Flexible ligament capsule
bull Synovial jointfluid
Clinical Biomechanics
bull Facet joint orientation
bull Torsional stiffness
ldquoKnowledge of 3 dimensional spine coupling characteristics is important for treating patients with
spinal painrdquo ~Sizer et al 2007
Kapandji 2008 Sizer et al 2007 White amp Panjabi 1990 Image Donatelli and Thurner 2014
Coupled vs Uncoupled Movement amp Definition of ldquoNeutral Spinerdquo
bullAn uncoupled movement is defined as a motion that occurs in absence of another osteokinematicrange of motion and can occur independently (Norkin and Levangie 1992)
bullRotation and side bending however occur in conjunction as coupled movements For example if side bending occurs to the right the spinousprocesses will rotate to the left
bull There are ligamentous and bony checks to flexion side bending and rotation while extension is limited mostly by the spinousprocesses themselves
bull It is important to note that osteokinematic and arthrokinematic motion can be functionally limited by musculoskeletal dysfunction or poor postural habits Coupled motions can also widely vary dependent on age and posture (Edmonston et al 2005)
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
5
Fryettersquos ldquoLawsrdquo of Physiologic Motion
bull Lovett ndash 1905
bull Fryette ndash 1957
bull Basic principles (at left)
bull Evolving principles (slides
which follow)
bull Yogic context
Somatic Dysfunction
Accordionpranayama fold
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type I
Table 52 Lateral variation of wide angle forward seated bend or upavista konasana (Left to righttop to bottom progression)
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
6
Recalibrating
Fryettersquos ldquoLawsrdquo ndash Type II
Table 53 Revolved
head to knee or parivritta janusirsasana
Cranium amp Cervical Spine Kinematics
CraniumC1
bull Plane joint 10 deg flexion 20 deg extension 15 deg SB
C1C2 ndash Atlasaxis
bull Pivot joint No disc 30-45 deg or 50 rot Combined skullC1 and C1C2 motion closer to 36 deg
C2-C7 - Remaining 15-30 degrees of rotation
bull Type II movement
Cook et al 2006
CraniumC-spine Application
Cranium-C1 Movement
bull Mild chin lock or Mild jalandharabandha
bull Slippage of head on atlas
C2-C7 Rotation
bull Cam action of first 30-45 degrees of rotation at C1-C2
bull Rotation becomes more limited with increasing head rotation which further supports cervical rotation as a nonlinear motion
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
7
Thoracic Spine Kinematics
Thoracic Spine Movements
bull Flexion and Extension
bull T1-T6 ndash limited flexionextension
bull T9-T12 ndash most available
bull Rotation and Side Bending
bull 75 sidebending
bull Upper T spine - rotation easiest
bull Lower T spine ndash less available
bull Rotation limited by rib cage age pliability
bull Force couples conflict in literature
Sizer et al
2007
Yoga example ndash Threading the needle
(unloaded)
Thoracic Spine Coupling
SB as primary motion = SB + Rot
bull T1-T4 - 21 ratio
bull T4-T8 11
bull T8-T12 ndash 31bull Ipsilateral SB + Rot (Type II motion)
bull 47 of subjects at T1-T4
bull 83 of subjects at segments T4-T8
bull 68 of subjects at segments T8-T12
bull Remaining subjects experienced Type I motion (contralateral rotation) with SB
Rot as primary motion = SB + Rot
bull T1-T4 ndash 18
bull T4-T8 ndash 99
bull T8-T12 ndash 93
bull Ipsilateral SB + Rot (Type II motion)
bull Remaining subjects experienced Type I motionSizer et al 2007 Willems et al 1996 Theodoridis and Ruson 2002
Revolved Triangle Entry
Thoracic Spine Coupling
Regional Interdependence
Theodoridis amp Ruston
bull Initiation of thoracic coupling via UE
elevation in 25 female subjects
bull 92 ipsilateral thoracic SB + rot in
UE flexion
bull 8 contralateral
bull 76 ipsilateral coupling in scaption
bull 24 contralateral coupling
D Theodoridis S Ruston The effect of shoulder movements on thoracic spine 3D motion Clin Biomech(Bristol Avon) 17 (2002) pp 418ndash421
Revolved Triangle Final (parivritta trkonasana)
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
8
Lumbar Spine Movements
bull Vertebrae large facets suggest stability over mobility
bull Rotation - 13 contribution
bull Side bending L1-S2 about 27 degrees
bull Flexion or reversal or lordosisExtension ndash L4-S1
bull Importance of normative values of L spine motion in question
bull AMA hierarchy
bull Anthropology of lumbar motion differs between races
bull ldquoDifferent criteria should be usedhelliplumbar spine mobility forhellipgroupsrdquo (2010)
Modified sage pose or maricyasana A
Lumbar Spine Kinematics
Hands to big toe or padangusthasana
Trudelle-Jackson et al 2010 Intolo et al 2009 Chung and Wang 2009 Van Herp
et al 2001 McGregor et al 1995 Dvorak et al 1995 Sullivan et al 1994
bull Lumbosacral Junction
bull Reciprocal movement ndash L5 flexes and S1 extends L5 rotates right and S1 rotates left L5 side
bends right and S1 will side bend
left
bull Sacroiliac joint 3 planar motion Type II movement which can occur unilaterally or bilaterally
bull Flexion and extension of sacrum
bull Right or left rotation of sacrum
bull Right or left sidebending of sacrum
bull Torsion a combination of the three Bow and arrow pose or akarnadhanurasana
Kinematics ndash Sacroiliac Joint
Extended side angle or uttitaparsvokonasana
Fryettersquos Laws ndash Type III
Table 54 Revolved forward seated bend or
parivritta paschimottanasana
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
9
Intervention amp PrescriptionEvolving Yoga
Three Pronged Theory based on currentbiomechanical ldquoabsolutesrdquo and theory recognized in medicine
1 Yoga postures for mobilization of the spine are not universally applicable
2 Yoga posture prescription for spinal mobility must consider not just medical condition and age but race and gender
3 Yoga postures for the spine especially those using the higher risk movements of flexion and rotation should be prescribed and not taught as a general modality for all populations
bullNote that yoga postures are the primary physical context of yoga but do not represent a complete MTYPYT prescription based on the conceptual model
Modified Noose
(Pasasana)
Fig 2 The six subsystems of movement
Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6
2013 692 - 697
httpdxdoiorg101016jmehy201302006
Prior to Medical Therapeutic
Yoga Posture Prescription 1 Identify bony landmark idiosyncrasies
(static or dynamic) in spine2 Teach TATD breath first3 Consider myofascial or neurovascular
involvement
Safe Prescription of Postures
depends on bull Employing TATD breath during all non-
restorative postures especially during transitions
bull Application of spinal mechanical theory bull Introducing planar movements one
degree of freedom at a timebull Follow the primary FMA bull Emphasize slow performance speed
General Indications
Indications Compression amp
Torque Consider compression amp torque in posture prescription
Compression
bull Hemodynamic perfusion of abdominal organs via manual massage and mobilization
bull Gravity dependent postures and spinal flexion
bull Abdominal massage action increases GI motility reduces GI related pain amp decreases overall GI related symptoms (Sinclair 2010 Lamas et al 2009 Ernst 1999)
Torque
bull Applied force and a distance between the applied force and its axis of rotation
bull Spinal rotation
bull Caution when combining with axial compression flexion and rotation (Shirazi1989)
Modified noose pose or pasasana
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
10
Safety can be provided through the PYT precepts (Module 1)
bull Breath before pose (3)
bull Abdominal breath before TATD breath
bull Then TATD breath for all poses except restorative (2)
bull Stability before mobility (4)
bull Lumbopelvic stability provides foundation for all other stability (7)
bull Spine receives priority over extremities (7)
bull No weight bearing inversions are taught or used in PYT (12)
bull No chin lock (jalandhara bandha) for populations with C1 or C2 instability or cervical fusion
bull No flexion + rotation for osteoporosis population
bull Flexion postures can be performed with rotation for compression but should be avoided in populations where flexion is contraindicated
bullPostures are practiced and applied for program planning in the shoulder and cervical spine lumbopelvic course and Module 14 on-site course
Cautions amp Contraindications
Selected Sources
bull Cook C Coupling behavior of the cervical spine A systematic review of the literature J Manipulative Physiol Ther 200629(7)570
bull Donatelli RA Thurner MS The young Athletersquos spinal mechanics In Spinal injuries and conditions in young athletes Springer 201417-25
bull Sizer PS Coupling behavior of the thoracic spine A systematic review of the literature J Manipulative Physiol Ther 200730(5)390 390-399 399
bull JM Willems G Jull J Ng An in-vivo study of the primary and coupled rotations of the thoracic spine Clin Biomech 11 (1996) pp 311ndash316
bull Hoffman J Gabel P Expanding Panjabirsquos stability model to express movement A theoretical model Medical Hypotheses Volume 80 Issue 6 2013 692 ndash 697
bull Garner G Medical Therapeutic Yoga 2015 (tent)Handspring Pub Ltd Scotland UK (PYT Volumes III 2001-2014)
Sources (2)
bull Hoy D Brooks P Blyth F Buchbinder R The Epidemiology of low back pain Best Pract Res Clin Rheumatol 2010 Dec24(6)769-81 Review PubMed PMID 21665125
bull Rahman Shiri Jaro Karppinen Paumlivi Leino-Arjas Svetlana Solovieva and Eira Viikari-Juntura The Association Between Obesity and Low Back Pain A Meta-Analysis Am J Epidemiol (2010) 171(2) 135-154 first published online December 11 2009 doi101093ajekwp356
bull Hoy DG Protani M De R Buchbinder R The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 Dec24(6)783-92
bull Adam Goode Eric J Hegedus Philip Sizer Jr Jean-Michel Brismee Alison Linberg and Chad E Cook Three-Dimensional Movements of the Sacroiliac Joint A Systematic Review of the Literature and Assessment of Clinical Utility J Man Manip Ther 2008 16(1) 25ndash38 PMCID PMC2565072 2008
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
1
Clinical Update on
Integrated Care
of the Elbow
For Professional Yoga Therapist candidates
This CE corresponds to Module 10 Part 2
Part 3
bull Lateral Epicondylitisndash Epidemiology amp Case Study Integrated Care
bull Yoga in America Trends and Cultures
bull Evaluating Existing Yoga Programs
bull PYTS Paradigm ndashShifting the Learning Experience
copy2014 Ginger Garner All rights reserved
Objectives
bull Review the current evidence base and epidemiology concerning the most common elbow injuries
bull Identify elbow rehabilitation or injury prevention methods in integrated treatment of lateral epicondylitis
bull Describe safe application and appropriate use of integrated care for the elbow through understanding indications and contraindications
bull Analyze a case study format in evaluation and management of a common elbow diagnosis
bull Evaluate yoga programs for safety and efficacy
bull Describe how medical yoga can improve health care and its delivery in the US
copy2014 Ginger Garner All rights reserved
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
2
Case Scenario
ProblemYou have to inform your patient a
construction worker that he will miss
a minimum of 2 weeks of work
because he has developedhelliphellip
Think about how you will answer his
questions
copy2014 Ginger Garner All rights reserved
Is this very common
In order to answer his question you must know
bull Epicondylitis is a disorder of the arm that commonly affects working-age individuals in the general population
bull Occurrence not influenced by gender
bull Lateral epicondylitis is more prevalent than medial epicondylitis (ME)
Reported 5-10 times more common than ME
Annual incidence 1-3 of the population
Shiri et al 2006 Walz DM et al 2010 Calfee et al 2008 Mellor 2003 Bisset et al 2005 Johnson et al (AAFP presentation)
copy2014 Ginger Garner All rights reserved
What is epicondylitis
In order to answer his question you must know
epicondylitis is defined as Inflammation and subsequent
degeneration of the muscles on the medial or lateral condyle
of the humerus caused from repeated
bull Pronation
bull Supination
bull Gripping flexion medially or laterally in the forearm
copy2014 Ginger Garner All rights reserved
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
3
How can you be sure the problem is in my elbow
In order to answer his question you must know
bullPatients with epicondylitis might experience pain with the following actions
Wrist extension
Gripping
Gripping with supination (lateral)
Wrist flexion
Gripping and pronation (medial)
bullJohnson et al 2007 Walz et al 2010 Calfee et al 2008 Levin et al 2005 Jobe et al 1994
bullPatients with epicondylitis can present with the following signs and symptoms
Ho pain at elbow with recreationaloccupational activities that require repetitive action
Insidious onset
Pain reproduced with resisted supination andor wrist extension
Point tenderness over origin of common extensor tendons (LE)
copy2014 Ginger Garner All rights reserved
How did this happen
In order to answer his question you must know risk factors for epicondylitis include
bull Smoking
bull Working age
bull Repetitive movements
bull Obesity
bull Forceful activities or heavy physical load
bull Fault mechanics or ergonomics
bull Other comorbiditiesShiri et al 2006 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Despite identifiable high risk populations At issues
are considerably preventable Epicondylitis can fall into two broad categories
bull Intrinsic Risk Factors
bull Extrinsic Risk Factors
Activities related to injury include Construction
Autoworkers
Chefscooks
TeachingEducation Childcare
copy2014 Ginger Garner All rights reserved
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
4
What would happen if I kept playing
In order to answer his question you must know
that continued use of her elbowforearm could result in
bull Microtears leading to chronic epicondylitis
bull Tendinopathy from collagen degeneration
bull Angiofibroplastic proliferation
bull Full thickness tear requiring surgery
bullJohnson et al 2007 Hudak et al 1996
copy2014 Ginger Garner All rights reserved
Anatomy Review
copy2014 Ginger Garner All rights reserved
Injury Prevention
In order to prevent epicondylitis it is critical that you identify
Intrinsic Factorsbull Weakness in forearms
bull Musculoskeletal imbalance
bull Repetitive stress source
bull Lack of flexibility and ROM in forearm and related joints
bull Poor postural habits
bull Obesity
bull Smoking
bull Diabetes
Extrinsic Factorsbull Training or activity execution
errors ie overgripping
bull Environmental factors in sport and activity bull Ergonomic setup
bull Stressful work environment
bull Poor trainingbull Lack of cross training
bull Lack of rest
bull Faulty equipment
copy2014 Ginger Garner All rights reserved
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
5
Medical Management
Johnson et al 2007 Burke 2010 httpwwwpri-medcomPMODigitalAssetsShared20FilesSyllabus20Files_Fall
202010AccessAtlantaSession205-Extremities-Access20Atlanta-ONLINEpdf
copy2014 Ginger Garner All rights reserved
WHO ICF Model
WHO ICF 2002 International Classification of Functioning Disease and Health Geneva Switzerland
45 yo active male right lateral epicondylitis no remarkable PMH
Does house projects such as building walls
hanging sheetrock and painting who co of forearm pain amp inability to complete ADLrsquos after a weekend of caring for
his 24 pound 7 month old
Insidious onset of lateral elbow pain that now prevents patient from
completing ADLrsquos
Reports almost constant discomfort
in right (dominant) elbow pain increases on holding and caring for infant especially
while multi-tasking ie holding infant and cooking dinner Patient is very active loves to hike
climb surf and rappel Conscious about diet eats mostly organic
Right lateral epicondyle tender to
palpation at insertion point of extensor muscle mass positive lateral epicondyle test
MMT 45 and painful reduced grip strength
Good support system low stress
able to commit to PT motivated and educated with high health literacy
copy2014 Ginger Garner All rights reserved
copy2014 Ginger Garner All rights reserved
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
6
Acute Management
bull Physical therapy supported to offer mid-to-long range
relief
bull Supervised programs superior to HEP
bull Medical management with corticosteroid injections show
no relief after 6 weeks
bull Mixed data on bracing
bull Short term relief
bull Possibly inferior to corticosteroids or NSAIDS
Barr et al 2009 Stasinopoulos et al 2009 Johnson et al 2010 Johnson et al 2007
copy2014 Ginger Garner All rights reserved
Integrated MTY
Lateral Epicondylitis Algorithm
copy2014 Ginger Garner All rights reserved
ldquoPre-posturesrdquo and postures to address strength and facilitate conscious relaxation and meditation include Top Prayer HandsShoulder Lock Left Middle Row Arm Spiral Downward facing dog prep Bottom Eagle Arms
(with flexed and extended elbows) Left bottom ndash incorrect form Right bottom ndash correct form
Acute
Shoulder LockDDPEagle Arms
copy2014 Ginger Garner All rights reserved
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
7
Acute
Figure 8
1 5 clockwisecounterclockwise directions
2 Loose hold no gripping of finger
3 30 second hold (stretch)
bull Breath receives priority
bull Stability over mobility
bull Identification ofchange for faulty movement patterns
bull Contrast repetitive stress contributors with yoga program design
bull Proprioceptive activities combined with decision-making
copy2014 Ginger Garner All rights reserved
AcuteThree Tier ldquoYoga Couchrdquo amp Cow Arms
copy2014 Ginger Garner All rights reserved
Arm Spiral
copy2014 Ginger Garner All rights reserved
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
8
Subacute
Top Shoulder Opener and
eccentric wrist extflexion (weighted and nonweighted)
Left Inversions ndash Strap Assisted
Downward Facing Dog
Right ndash Inversions - NWB
Headstand
Advanced sequencing for safe progression is taught in Module 8 and 14 copy2014 Ginger Garner All rights reserved
bullLeft Hand Balances
bull Use hand balances such as crane (at
right) scales or plank to reinforce new
motor patterns for preventing RSS
bull These should be added last when
there are no symptoms remaining
bullBottom Staff
bull With and without liftoff
bull good posture strength flexibility
Sub-Acute Progression
ldquoIn all postures teach progressive relaxation for
biofeedback for conscious
dissociation and releaserdquo
copy2014 Ginger Garner All rights reserved
Chronic Considerations
bull Marma Point Massage
(kurpara) to the extensor or
flexor muscle mass
bull Followed by a directed stretch
to the area
bull Ice massage to minimize
localized inflammation
bull TFM MWM Protocol
Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisation with movement and exercise
corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939copy2014 Ginger Garner All rights reserved
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
9
Contraindications
A patient is unable to perform pre-
asanapostures with safety and self-correction because of the following
bull Lack of motor control and awareness
bull Performing asana quickly and without proper biomechanical
alignment
bull Not introducing low level force loads
for dynamic stability during asana
bull Returning to activity before adequate healing and strengthening
AVOID Yoga postures that cause co-contraction or gripping of the forearm musculature in the acute phase such as
bull Plank Side plank
bull Downward facing dog prep Downward facing dog
bull Bounding transitions from hands
bull Forearm balances Headstand (NWB)
bull Similar closed kinetic chain (WB) upper extremity postures
copy2014 Ginger Garner All rights reserved
Program Impact
Post-Test Results (3 months fu)
bull Negative lateral epicondyle test
bull MMT 55 and painfree
bull No tenderness to palpation over extensor muscle mass
copy2014 Ginger Garner All rights reserved
Yoga in America Trends and Culture
bull 16 million practitioners aged 35-54
bull 6 billion spent annually
bull 2008 - 494 reported that they started practicing yoga to improve their overall health
bull 2003 - 56
bull Almost 50 - reported yoga would be beneficial if they were undergoing treatment for a medical condition
Source 2008 Harris Interactive Service Bureau on behalf of Yoga Journal
copy2014 Ginger Garner All rights reserved
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
10
Evaluating Existing YogaYoga
Therapy Programs
bull Yoga ndash YA wwwyaorgbull Voluntary Registry
bull Self-reportingOversightbull Registry Levels
bull Trade
bull IAYT ndash wwwiaytorgbull Self-proposed Educational Standards and Regulation 2012bull Proliferation of Programs 2006-2008
bull Trade to undergraduate
bull PYT ndash Medical Therapeutic Yoga wwwprofessionalyogatherapyorgbull Medical amp third party oversight legal scope of practicebull Pre-requisites
bull Consumer Risk and Safetybull Graduate post-graduate CECME
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
Medical Therapeutic Yoga
Model for Integrated Interdisciplinary Care
copy2014 Ginger Garner All rights reserved
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
11
Interdisciplinary Support for
OT
CAM can be used as a provision of OT services when it is used as ldquopreparatory method or purposeful activity to facilitate the ability of clients to engage in their daily life occupationsrdquo (AOTA 2011 p S27)
ldquoCAM may be used responsibly by OTrsquos as part of a comprehensive approach to enhance engagement in occupation by people organizations and populations to promote their health and participation in liferdquo (AOTA 2011 p S26)
ldquoCAM practices systems and products may be appropriately incorporated into OT practice to encourage a clientrsquos engagement in meaningful occupationsrdquo(AOTA 2011 S29)
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA CAM Position Paper 2011
Aspects of OT Domain
Areas of
Occupation
Client
factors
Performanc
e skills
Performanc
e patterns
Context and environment
Activity
demands
-ADLrsquos-IADLrsquos-Rest and sleep-Education-Work-Play-Leisure-Socialparticipation
-Values beliefs and spirituality-Body functions-Body structures
-Sensory perceptual skills-Motor and praxis skills-Emotionalregulation skills-Cognitive skills-Communication skills
-Habits-Routines-Roles-Rituals
-Cultural-Personal-Physical-Social-Temporal-Virtual
-Objects used and their properties-Space demands-Socialdemands-Sequencing and timing-Required actions-Required body functions-Required body structures
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
Intervention Approaches
Intervention approaches Examples of using yoga as intervention
Create promote (health promotion) Create and promote Transversus Abdominis Thoraco-diaphragmatic breathing (yoga breath) with goal of facilitating a clear mental state and core stabilization
Establish restore (remediation) Restore range of motion in shoulder after injury for effective overhead reach
Maintain Maintain core and trunk stability for postural alignment and ultimate upper body motion
Modify (compensation adaptation) Modify yoga practice through use of props to support performance
Prevent (disability prevention) Prevent stress and pain through incorporating meditative and mindfulness techniques
Biggins K OTD PYT Capstone Using Yoga in OT 2013 AOTA 2008 2nd ed OT Practice Framework
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
12
Purposeful Movement through Yoga
Exercise-Purposeful activity Continuum through Biomechanical Frame of
Reference incorporating yoga (adapted from Dutton 1989)
Movements more easily achieved through
exercise (preparation)
Yoga examples(preparation)
Movements more easily achieved through purposeful activity
Yoga examples(purposeful
simulation)
Isolated movement
Rhythmical movement
Linear movement
Reciprocal movement
Increase in range of
motion
Excessive resistance for strength
-Mountain pose with TATD breath
-Sun salutation
-Forward fold
-Warrior and reverse warrior
-High lunge for
hip flexors
-Down dog for shoulder complex
Coordinated movement
Arrhythmical movement
Diagonal movement
Asymmetrical movement
Maintenance of range of motion
Maximal repetitions for endurance
-Mudras
-Isolatedmovements of a posture
-Triangle
-Twist
-Cow face pose
-Vinyasa
Biggins K 2013 OT and Yoga AOTA 2008 2nd ed OT Practice Framework
Resources
wwwprofessionalyogatherapyorg
Spine Stabilization Foundations (distance learning)
bull Module 6
bull Module 7
Spine Lab (on-site)
bull Module 8
bull Module 14 (spine GI) and 15 ndash (all physiological movements including inversions)
Related Spine Courses
bull Cervical Spine Course
bull Lumbopelvic Spine Course
bull Sacroiliac Joint Course
copy2014 Ginger Garner All rights reserved
Sources
bull Shiri R Viikari-Juntura E Varonen H and Heliovaara M Pervalance and Determinants of Lateral and Mediail Epicondylitis A Population Study Am J Epidemiol (2006) 164 (11) 1065-1074
bull Walz DM Newman JS Konin GP Ross G Epicondylitis Pathogenesis imaging and treatment Radiographics 201030(1)167-184
bull Stasinopoulos D Stasinopoulos I Pantelis M Stasinopoulou K Comparison of effects of a home exercise programme and a supervised exercise programmefor the management of lateral elbow tendinopathy Br J Sports Med 201044579-583 Published Online First 3 November 2009
bull American Journal of Occupational Therapy (2011)Complementary and Alternative Medicine Supplement 65(6) S26-31
bull World Health Organization Towards a common language for functioning disability and health ICF the international classification of functioning Geneva World Health Organization2002
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK
13
Sources (2)
bull American Occupational Therapy Association(2008) Occupational therapy practice framework Domain and process (2nd ed) American Journal of Occupational Therapy 62 625-683
bull Bisset L Paungmali A Vicenzino B Beller E A systematic review and meta-anaylsis of clinical trials on physical interventions for lateral epicondylalgia Br J Sports Med 200539411-42210
bull Bisset L Beller E Jull G Brooks P Darnell R Vicenzino B Mobilisationwith movement and exercise corticosteroid injection or wait and see for tennis elbow randomised trial BMJ 2006 333939
bull Barr S Cerisola FL and Blanchard V Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis A systematic review Physiotherapy Volume 95 Issue 4 December 2009 Pages 251-265
Sources (3)
bull Calfee RP Patel A DaSilva MF Akelman E Management of lateral epicondylitis Current concepts J Am Acad Orthop Surg 200816(1)19-29
bull Levin D Nazarian LN Miller TT et al Lateral epicondylitis of the elbow US findings Radiology 2005237(1)230-234
bull Biggins K OTD OTRL CHT PYT The use of yoga as a modality to treat varied diagnoses of the upper extremity An evidence-based educational workshop Rocky Mountain University of Health Professions 2013
bull Garner G Medical Therapeutic Yoga (PYT I-IV Manuals 2001-2014) Prospectus for publication 2025 UK