A Kinetic Chain Approach to Musculo-Skeletal Pain Combining Manual Therapies, Nutrition and...

A Kinetic Chain Approach to A Kinetic Chain Approach to Musculo-Skeletal Pain Combining Musculo-Skeletal Pain Combining Manual Therapies Nutrition and Manual Therapies Nutrition and

Corrective ExerciseCorrective Exercise

GEOFF LECOVIN DC ND LAc CSCSGEOFF LECOVIN DC ND LAc CSCS

ADAM RINDE ND ASCM-HFI ADAM RINDE ND ASCM-HFI CESCES

Integrative Approaches to Integrative Approaches to PainPain

This class is a synthesis of cutting-edge This class is a synthesis of cutting-edge chiropractic osteopathic naturopathic chiropractic osteopathic naturopathic massage nutrition and dry needling techniques massage nutrition and dry needling techniques and principlesand principles

Practitioners and students will learn the Practitioners and students will learn the different phases of pain and how to effectively different phases of pain and how to effectively assess and manage each phase with physical assess and manage each phase with physical medicine exercise nutrition and prescription medicine exercise nutrition and prescription drugsdrugs

Participants will refine their skills in soft tissue Participants will refine their skills in soft tissue and joint manipulative therapy and get exposure and joint manipulative therapy and get exposure to dry needling They will be able to effectively to dry needling They will be able to effectively manage the most common orthopedic and sports manage the most common orthopedic and sports medicine problems seen in private practicemedicine problems seen in private practice

Course ObjectivesCourse Objectives Understand the Understand the different phases of pain different phases of pain Differentiate between an orthopedic approach and Differentiate between an orthopedic approach and

Integrative approach to musculoskeletal painIntegrative approach to musculoskeletal pain Understand the significance in assessing the Understand the significance in assessing the

kinetic chainkinetic chain Learn about common distortion patternsLearn about common distortion patterns Understand the role of trigger points Understand the role of trigger points Understand the significance of perpetuating Understand the significance of perpetuating

factors factors Learn how to assess musculoskeletal conditionsLearn how to assess musculoskeletal conditions Learn how to decide which manual therapy or Learn how to decide which manual therapy or

modality is indicatedmodality is indicated Understand the role of corrective exercise as part Understand the role of corrective exercise as part

of the treatment plan and preventionof the treatment plan and prevention

PAINPAIN

ldquo ldquoAn unpleasant sensory and An unpleasant sensory and emotional experience associated emotional experience associated with actual or potential tissue with actual or potential tissue damage or described by the patient damage or described by the patient in terms of such damagerdquoin terms of such damagerdquo

International Association for the Study of PainInternational Association for the Study of Pain

3 PHASES OF PAIN3 PHASES OF PAIN

1 ImmediateNociceptive1 ImmediateNociceptive

2 AcuteInflammation2 AcuteInflammation

3 Chronic3 Chronic

IMMEDIATE IMMEDIATE NOCICEPTIVE PAINNOCICEPTIVE PAIN

Induced by extrinsic factors where Induced by extrinsic factors where there could be a threat of tissue there could be a threat of tissue damagedamage

Acute onset eg cut burn slapAcute onset eg cut burn slap Over 90 will recover within a few Over 90 will recover within a few

weeksweeks Pain messages are carried by A-Delta Pain messages are carried by A-Delta

and C Fibersand C Fibers Good prognosisGood prognosis

ACUTE INFLAMMATIONACUTE INFLAMMATION

Actual tissue damage eg strainsprainActual tissue damage eg strainsprain Recognized by signs of inflammation- redness Recognized by signs of inflammation- redness

increased local temperature and swellingincreased local temperature and swelling Occurs as a result of substances released by Occurs as a result of substances released by

damaged tissue cells (which are necessary damaged tissue cells (which are necessary for repair)for repair)

Pain messages are carried by C-fibersPain messages are carried by C-fibers Self limitingSelf limiting Responds to Naturopathic therapies or Responds to Naturopathic therapies or

NSAIDS analgesics and restNSAIDS analgesics and rest

CHRONIC PAINCHRONIC PAIN

11 Ongoing nociception or Ongoing nociception or inflammationinflammation

22 PsychologicalPsychological

33 NeuropathicNeuropathic-- functional and functional and structural alterations within the structural alterations within the Neuromusculoskeletal Neuromusculoskeletal systemsystem

Structure vs FunctionStructure vs Function Structure (Structure (orthopedic approach)- focuses orthopedic approach)- focuses

on the pathology of static structures on the pathology of static structures emphasizes diagnosis based on localized emphasizes diagnosis based on localized evaluation and special testsevaluation and special tests

FunctionFunction- recognizes the function of all - recognizes the function of all processes and systems within the body processes and systems within the body rather than focusing on a single site of rather than focusing on a single site of pathology pathology

The structural approach is necessary and The structural approach is necessary and valuable for acute injury or exacerbation the valuable for acute injury or exacerbation the functional approach is preferable when functional approach is preferable when addressing chronic musculoskeletal pain addressing chronic musculoskeletal pain

Traditional Orthopedic Traditional Orthopedic Approach Approach

Isolated joint kinematicsIsolated joint kinematics Uniplanar Uniplanar Isolated muscle strengthIsolated muscle strength Morphologically orientedMorphologically oriented

Integrative Functional Integrative Functional ApproachApproach

Focuses on all kinetic chain components Focuses on all kinetic chain components (muscular articular neural)(muscular articular neural)

Optimum acceleration deceleration and Optimum acceleration deceleration and dynamic stabilization in multiplanar (saggital dynamic stabilization in multiplanar (saggital frontal transverse) movementsfrontal transverse) movements

Enables synergistic production and reduction of Enables synergistic production and reduction of force and dynamic stabilizationforce and dynamic stabilization

Maintains optimum length-tension and force-Maintains optimum length-tension and force-couple relationships of agonists and antagonists couple relationships of agonists and antagonists

Allows optimum joint arthrokinematics and Allows optimum joint arthrokinematics and neuromuscular efficiencyneuromuscular efficiency

Regional Regional InterdependenceInterdependence

Seemingly unrelated impairments in Seemingly unrelated impairments in a remote anatomical region may a remote anatomical region may contribute to or be associated with contribute to or be associated with the patientrsquos primary complaintthe patientrsquos primary complaint

Wainner et al JOSPT 2007Wainner et al JOSPT 2007

Optimum AlignmentOptimum Alignment

Alignment of the musculoskeletal Alignment of the musculoskeletal system allowing posture to be system allowing posture to be balanced with center of gravitybalanced with center of gravity

Ability of the Ability of the neuromuscular systemneuromuscular system to perform functional tasks with the to perform functional tasks with the least amount of energy and stress on least amount of energy and stress on the kinetic chainthe kinetic chain

Optimum muscle Optimum muscle length-tension length-tension relationshipsrelationships at which a muscles are at which a muscles are capable of developing maximal tensioncapable of developing maximal tension

KINETIC CHAIN KINETIC CHAIN CONCEPTSCONCEPTS

Proprioception- Proprioception- the cumulative neural input to the cumulative neural input to the CNS from mechanoreceptors (specialized the CNS from mechanoreceptors (specialized neural structures that convert mechanical neural structures that convert mechanical information into electrical information that is information into electrical information that is relayed to the CNS)relayed to the CNS)

Length-Tension Relationship- Length-Tension Relationship- the optimal the optimal length at which a muscle can produce the greatest length at which a muscle can produce the greatest forceforce

Force-Couple Relationship- Force-Couple Relationship- the synergistic the synergistic action of muscles to produce movement around a action of muscles to produce movement around a jointjoint

Arthrokinematics-Arthrokinematics-The ability of a joint to move The ability of a joint to move through its biomechanical range of motion through its biomechanical range of motion

Optimal Neuromuscular Optimal Neuromuscular ControlControl

Normal length tension relationshipsNormal length tension relationships Normal force couple relationshipsNormal force couple relationships Normal arthrokinematicsNormal arthrokinematics

Optimal sensorymotor integrationOptimal sensorymotor integration

Optimal neuromuscular efficiencyOptimal neuromuscular efficiency

Optimal tissue recoveryOptimal tissue recovery

Example of Kinetic Chain Example of Kinetic Chain Dysfunction and PainDysfunction and Pain

Excessive pronation-Excessive pronation- metatarsalgia bunion PF metatarsalgia bunion PF neuromaneuroma

Excessive tension in tibialis posterior and Excessive tension in tibialis posterior and peroneous longus- peroneous longus- shin splintsshin splints

Knee stress-Knee stress- tendonitis injury susceptibility tendonitis injury susceptibility Lateral thigh tension- Lateral thigh tension- tight hamstrings ITB TFL (eg tight hamstrings ITB TFL (eg

PFS)PFS) Abnormal L-P rhythm-Abnormal L-P rhythm- anterior pelvis rotation anterior pelvis rotation Increased lumbar lordosis-Increased lumbar lordosis- tight psoas erector spinae tight psoas erector spinae

and latissimus dorsi- Lumbagoand latissimus dorsi- Lumbago Downward traction of the scapula with shoulder Downward traction of the scapula with shoulder

movementmovement Excessive tension in outer shoulder musclesExcessive tension in outer shoulder muscles Neck and shoulder painNeck and shoulder pain

MUSCLE ACTION MUSCLE ACTION CLASSIFICATIONSCLASSIFICATIONS

Agonists- Agonists- prime movers prime movers AntagonistsAntagonists - - act in direct opposition to act in direct opposition to

prime moversprime movers SynergistsSynergists - - assist prime movers during assist prime movers during

functional movement patternsfunctional movement patterns Stabilizers- Stabilizers- support or stabilize the support or stabilize the

body while the prime movers and the body while the prime movers and the synergists perform the movement patternssynergists perform the movement patterns

NeutralizersNeutralizers-- muscles that counteract muscles that counteract the unwanted action of other musclesthe unwanted action of other muscles

Functional Muscle Functional Muscle DivisionDivision

Stabilization GroupStabilization Group Movement GroupMovement Group

Stabilization GroupStabilization Group(Local MusclesInner Unit)(Local MusclesInner Unit)

PeronealsPeroneals Tibialis posteriorAnteriorTibialis posteriorAnterior VMOVMO Gluteus MediusGluteus Medius Pelvic floor musclesPelvic floor muscles Transverse AbdominusTransverse Abdominus Internal ObliqueInternal Oblique MultifidusMultifidus Deep erector spinaeDeep erector spinae Transversospinalis groupTransversospinalis group DiaphragmDiaphragm Serratus anteriorSerratus anterior MiddleLower TrapeziusMiddleLower Trapezius RhomboidsRhomboids Teres MinorTeres Minor InfraspinatusInfraspinatus Posterior deltoidPosterior deltoid Lomgus ColiCapitusLomgus ColiCapitus Deep cervical StabilizersDeep cervical Stabilizers

Movement GroupMovement Group(GlobalOuter Unit)(GlobalOuter Unit)

GastocnemiusSoleusGastocnemiusSoleus AdductorsAdductors HamstringsHamstrings Gluteus MaximusGluteus Maximus PsoaPsoa TFLTFL Rectus FemorisQuadricepsRectus FemorisQuadriceps PiriformisPiriformis Erector SpinaeErector Spinae QLQL Rectus abdominusRectus abdominus External obliqueExternal oblique Pectoralis MajorMinorPectoralis MajorMinor Latissimus DorsiLatissimus Dorsi Teres MajorTeres Major Upper TrapeziusUpper Trapezius Levator ScapulaeLevator Scapulae SCMSCM ScalenesScalenes

FUNCTIONAL MOVEMENT DIVISION SUMMARY

Stabilization System (inner core)1048707 Local muscles for joint support and posture1048707 Being prone to weakness and inhibition1048707 Less activated in most functional movement patterns1048707 Fatigue easily during dynamic activities1048707Predominantly slow twitch Movement System (outer core)1048707 Global muscles for movement1048707 Being prone to developing tightness1048707 Readily activated during most functional movements1048707 Overactive in fatigue situations or during new movement

patterns1048707 Compensate (synergistic dominance) during fatigue statesCompensate (synergistic dominance) during fatigue states1048707 Predominantly fast twitch

Low Back PainLow Back Pain Chronic low back pain represents 85-95 of Chronic low back pain represents 85-95 of

the populationthe population Lack of appropriate neuromuscular response Lack of appropriate neuromuscular response

of the muscles stabilizing the LPHCof the muscles stabilizing the LPHC Patients unable to preferentially recruit the Patients unable to preferentially recruit the

inner unit musculature of the LPHCinner unit musculature of the LPHC Recruitment of motor units from the outer Recruitment of motor units from the outer

unit leading to synergistic dominance unit leading to synergistic dominance altered normal force couple relationships altered normal force couple relationships length-tension relationships joint kinematics length-tension relationships joint kinematics and neuromuscular controland neuromuscular control

CAUSES OF MUSCLE CAUSES OF MUSCLE IMBALANCESIMBALANCES

Pattern overloadPattern overload AgingAging Decreased recovery and regeneration Decreased recovery and regeneration

following an activityfollowing an activity Repetitive movementRepetitive movement Lack of core strengthLack of core strength ImmobilizationImmobilization Cumulative traumaCumulative trauma Lack of neuromuscular controlLack of neuromuscular control Postural stressPostural stress

Postural Distortion Postural Distortion PatternsPatterns

Altered Reciprocal Inhibition- Altered Reciprocal Inhibition- The process whereby a The process whereby a tight or overactive agonist inhibits its functional tight or overactive agonist inhibits its functional antagonist This results in altered force couple antagonist This results in altered force couple relationships and synergistic dominance and leads to the relationships and synergistic dominance and leads to the development of faulty movement patterns and poor development of faulty movement patterns and poor neuromuscular controlneuromuscular control

Synergistic Dominance-Synergistic Dominance-The process whereby synergists The process whereby synergists compensate for a weak or inhibited prime mover in compensate for a weak or inhibited prime mover in attempts to maintain force production and functional attempts to maintain force production and functional movement patterns This causes faulty movement patterns movement patterns This causes faulty movement patterns which leads to tissue overload decreased neuromuscular which leads to tissue overload decreased neuromuscular efficiency and injuryefficiency and injury

Arthrokinetic Dysfunction-Arthrokinetic Dysfunction- A biomechanical dysfunction A biomechanical dysfunction in two articular partners resulting in abnormal joint in two articular partners resulting in abnormal joint movement (arthrokinematics) muscle inhibition and movement (arthrokinematics) muscle inhibition and proprioception disturbance proprioception disturbance

Myofascial dysfunctionMyofascial dysfunction (trigger points) (trigger points) CNS changesCNS changes

MYOFASCIAL PAIN MYOFASCIAL PAIN SYNDROMESSYNDROMES

A myofascial trigger point is a A myofascial trigger point is a highly localized and highly localized and hyperirritable spot in a palpable hyperirritable spot in a palpable taut band of skeletal muscle taut band of skeletal muscle fibersfibers

Travell and SimonsTravell and Simons

TRIGGER POINT TRIGGER POINT SYMPTOMSSYMPTOMS

1 Onset after micro or macro trauma1 Onset after micro or macro trauma2 Local or referred pain (RPP)2 Local or referred pain (RPP)3 Pain with muscle contraction3 Pain with muscle contraction4 Muscle stiffness and restricted joint motion4 Muscle stiffness and restricted joint motion5 Muscle weakness5 Muscle weakness6 Paresthesia and numbness6 Paresthesia and numbness7 Proprioceptive disturbance- dizzy lack of balance7 Proprioceptive disturbance- dizzy lack of balance8 Autonomic dysfunction- pilomotor reflex8 Autonomic dysfunction- pilomotor reflex9 Edema and celllulite- decreased circulation and 9 Edema and celllulite- decreased circulation and

waste accumulationwaste accumulation10 Sleep disturbance10 Sleep disturbance

PathogenesisPathogenesis

Over stretchingover shortening Overloading of tissue Micro-trauma Destruction of sarcoplasmic

reticulum Release of calcium++ Sustained muscle contraction

Physical Findings of Physical Findings of MTrPsMTrPs

Taut bandTaut band Tender and painful nodule to palpationTender and painful nodule to palpation Patient pain recognitionPatient pain recognition Local twitch responseLocal twitch response Limited range of motionLimited range of motion Muscle weaknessMuscle weakness Positive stretch sign- pain of mechanical or Positive stretch sign- pain of mechanical or

neural origin exhibited during myofascial neural origin exhibited during myofascial stretching that can be improved with trigger stretching that can be improved with trigger point therapy to the musclepoint therapy to the muscle

Classification of Trigger Points Classification of Trigger Points

SatelliteSatellite AttachmentAttachment ActiveActive Limit ROMLimit ROM WeaknessWeakness Local amp Referred painLocal amp Referred pain LatentLatent Limit ROMLimit ROM WeaknessWeakness Pain only with compressionPain only with compression

Classification of Trigger pointsClassification of Trigger points

Active TPActive TPLimit ROMLimit ROMWeaknessWeaknessLocal amp ReferredLocal amp ReferredPainPain

Latent TPLatent TPLimit ROMLimit ROMWeaknessWeaknessPain only with compressionPain only with compression

TRIGGER POINTS ARE TRIGGER POINTS ARE KNOWN TO CAUSEKNOWN TO CAUSE

HeadachesHeadaches Neck and jaw painNeck and jaw pain Low back painLow back pain Carpal tunnel Carpal tunnel

syndromesyndrome Joint pain (arthritis Joint pain (arthritis

tendonitis bursitis tendonitis bursitis ligament injury)ligament injury)

Tennis elbowTennis elbow Contributing cause of Contributing cause of

scoliosisscoliosis

EarachesEaraches DizzinessDizziness NauseaNausea HeartburnHeartburn False heart painFalse heart pain ArrhythmiaArrhythmia Genital painGenital pain Sinus paincongestionSinus paincongestion Colic and bed wettingColic and bed wetting Depression CFS Depression CFS

lowered resistance to lowered resistance to infectioninfection

Kinetic Chain Kinetic Chain ImbalancesImbalances

Imbalances in muscle lengthImbalances in muscle length Altered normal length-tension Altered normal length-tension

relationshipsrelationships Abnormal force-couple relationshipsAbnormal force-couple relationships Altered reciprocal inhibition of the Altered reciprocal inhibition of the

functional antagonistfunctional antagonist Synergistic dominance Synergistic dominance Faulty movement patternsFaulty movement patterns Initiation of the cumulative injury cycleInitiation of the cumulative injury cycle

Cumulative Injury CycleCumulative Injury Cycle

Adhesions

Muscle imbalance

Cumulative injury cycle

Altered neuromuscularcontrol

Tissuetrauma

Inflammation

Muscle spasm


When a chain reaction evolves in When a chain reaction evolves in which some muscles shorten and which some muscles shorten and others weaken in predictable others weaken in predictable patterns of imbalancepatterns of imbalance

JandaJanda

11 Upper crossed syndromeUpper crossed syndrome

22 Lower crossed syndromeLower crossed syndrome

Looking at the Body joint-by-joint From Looking at the Body joint-by-joint From the Bottom Upthe Bottom Up

Ankle mobility (particularly sagittal)Ankle mobility (particularly sagittal) Knee stabilityKnee stability Hip mobility (multi-planar)Hip mobility (multi-planar) Lumbar Spine stabilityLumbar Spine stability Thoracic Spine mobilityThoracic Spine mobility Gleno-humeral stability Gleno-humeral stability (The joints alternate mobility and (The joints alternate mobility and

stability) stability) bull Injuries relate closely to proper joint Injuries relate closely to proper joint

function function bull Problems at one joint usually show up as Problems at one joint usually show up as

pain in the joint above or belowpain in the joint above or below

Patient HistoryPatient HistoryOPQRSTOPQRST

OO- Onset- OnsetPP-palliativeprovocative-palliativeprovocativeQQ-quality-qualityRR-radiation-radiationSS-severity-severityTT-temporal factors-temporal factorsFAOMASHFAOMASH (family hx accidents other (family hx accidents other

meds allergies surgical history meds allergies surgical history hospitalizations)hospitalizations)

The patient will tell you whatrsquos wrong The patient will tell you whatrsquos wrong if you know how to askif you know how to ask

Patient ExaminationPatient ExaminationIPPIRONELIPPIRONEL

I-inspectionI-inspectionPP--palpationpalpationP-P-percussionpercussionII-instrumentation-instrumentationR-range of motion (active and passive)R-range of motion (active and passive)O-orthopedic testsO-orthopedic testsN-neurological tests ie motor sensoryN-neurological tests ie motor sensoryEE-extra tests eg x-ray MRI CT-extra tests eg x-ray MRI CTLL-lab-lab

PosturePosture

DynamicDynamic Structural efficiencyStructural efficiency Neuromuscular efficiencyNeuromuscular efficiency Balance and equilibriumBalance and equilibrium Functional strengthFunctional strength

Static Posture LandmarksStatic Posture Landmarks

Side An imaginary line should run slightly anterior to the lateral malleolus through the middle of the femur center of shoulder and middle of the ear

Posterior An imaginary line should run from between the medial malleoli up through the spine and center of the head

Anterior An imaginary line should run from between the medial malleoli up through the sternum and center of the head

Common Dysfunctional Common Dysfunctional PatternsPatterns

AnkleFoot- AnkleFoot- PronationTurns outPronationTurns out Knee- Knee- HyperextendedMoves in or outHyperextendedMoves in or out Hip- Hip- Uneven Uneven LumbarPelvisHip- LumbarPelvisHip- LordosisscoliosisLordosisscoliosis Thoracic- Thoracic- kyphosisscoliosiskyphosisscoliosis Scapulae- Scapulae- UnevenabductedUnevenabducted Cervical- Cervical- LordosisscoliosisLordosisscoliosis Head- Head- ForwardForward

Observing Dynamic PostureObserving Dynamic Posture

Relates to the basic functions- Relates to the basic functions- squatting pushing pulling and squatting pushing pulling and balancingbalancing

Shows muscle and joint interplayShows muscle and joint interplay Can uncover postural distortions and Can uncover postural distortions and

imbalances in anatomy physiology imbalances in anatomy physiology and biomechanics that can lead to and biomechanics that can lead to injury injury

Movement assessmentMovement assessment

11 Identifies movements that consistently causes painIdentifies movements that consistently causes pain22 Identifies altered motor control abnormal length-Identifies altered motor control abnormal length-

tension relationships relative flexibility and faulty tension relationships relative flexibility and faulty movement patterns that can cause pain and can lead movement patterns that can cause pain and can lead to pathology eg arthritisto pathology eg arthritis

33 Movement impairment is classified by the direction Movement impairment is classified by the direction of movement that causes painof movement that causes paineg movement classifications in the spine flexion eg movement classifications in the spine flexion extension rotation flexionrotation extension rotation flexionrotation extensionrotationextensionrotation

44 Testing is performed sitting standing side-lying Testing is performed sitting standing side-lying prone supine and in a quadruped position bilaterally prone supine and in a quadruped position bilaterally and unilaterallyand unilaterally

55 Reproducing the pain is the key to both identifying Reproducing the pain is the key to both identifying the problem and effective treatment through therapy the problem and effective treatment through therapy and corrective exercisesactivities and corrective exercisesactivities

Kinetic Chain Check PointsKinetic Chain Check Points (anteriorposteriorlateral)(anteriorposteriorlateral)

FootAnklendash Straight ahead w neutral position at the ankle

Kneendash Straight ahead in line w 2nd and 3rd toes

Lumbo-Pelivic-Hip Complexndash Neutral spine with abdominals drawn in

Shoulder and cervical spinendash Neutral center of shoulder in line with center of hip joint

Headndash Neutral center of ear in line with center of shoulder

Dynamic InspectionDynamic Inspection(Overhead Squat)(Overhead Squat)

SPECIAL IMAGINGSPECIAL IMAGINGHelp or HindranceHelp or Hindrance

Lumbar MRIrsquos were done on 98 people Lumbar MRIrsquos were done on 98 people with no hx of back or leg pain 36 had with no hx of back or leg pain 36 had normal discs at all levels 52 had normal discs at all levels 52 had bulging discs at one or more levels bulging discs at one or more levels 27 had a disc protrusion and 1 had 27 had a disc protrusion and 1 had an extrusion an extrusion

ldquoldquoThe discovery by MRI of bulges or The discovery by MRI of bulges or protrusions in people with low back protrusions in people with low back pain may frequently be pain may frequently be coincidentalrdquocoincidentalrdquo(NEJM1994)(NEJM1994)

GOAL OF TREATMENTGOAL OF TREATMENT

11 Control the pain and break the pain cycleControl the pain and break the pain cycle22 Break chemical and Mechanical feedback Break chemical and Mechanical feedback

loop that maintains muscle contractionloop that maintains muscle contraction33 Increase circulation that has been Increase circulation that has been

restricted by contracted tissuerestricted by contracted tissue44 Lengthen shortened musclesLengthen shortened muscles55 Reconditioning and strengthening weak Reconditioning and strengthening weak

musclesmuscles66 Correct movement patternsCorrect movement patterns77 Prevention of recurrence through an Prevention of recurrence through an

appropriate exercise programappropriate exercise program

TREATMENTTREATMENT

ProvocativeProvocative ActiveActive ResistedResisted FunctionalFunctional ProprioceptiveProprioceptive

Effective Treatment OptionsEffective Treatment Options Ischemic compressionIschemic compression Injection techniquesInjection techniques Dry needlingDry needling Soft tissue manipulationSoft tissue manipulation Muscle energy technique (MET)Muscle energy technique (MET) Joint manipulationJoint manipulation Friction massageFriction massage UltrasoundUltrasound Spray and StretchSpray and Stretch Contrast therapyContrast therapy Corrective exerciseCorrective exercise Supportive taping Supportive taping Diet and nutrition to aid in repairDiet and nutrition to aid in repair

Progressive Pressure Progressive Pressure Release TechniqueRelease Technique

Apply progressive pressure to point of tissue Apply progressive pressure to point of tissue resistance for 45-60 seconds Hold until resistance for 45-60 seconds Hold until resistance dissipates Repeat procedure 3-4 resistance dissipates Repeat procedure 3-4 times each time moving to a deeper barriertimes each time moving to a deeper barrier

Pressure is to patient tolerance Pressure is to patient tolerance Have patient deep breatheHave patient deep breathe Release pressure quickly to produce Release pressure quickly to produce

vasodilation and elimination of the local vasodilation and elimination of the local ischemiaischemia

Identify and treat satellite trigger points Identify and treat satellite trigger points Follow by stretching (30 sec) and breathing Follow by stretching (30 sec) and breathing Post treatment heat or cold applicationsPost treatment heat or cold applications

SOFT TISSUE RELEASE SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)TECHNIQUE (NMR- 97112)

Specific contact is made on the muscle Traction is applied to the tissue in

order to trap the lesion The muscle is moved either actively or

passively through the line of injury The stretch is held for 1-2 seconds Repetitions are done in different

positions and planes of motion (8-10 times)

EFFECTS OF SOFT TISSUE EFFECTS OF SOFT TISSUE RELEASERELEASE

1 STR stretches and softens scar 1 STR stretches and softens scar tissueadhesionstissueadhesions

2 Pain input messages to limbic 2 Pain input messages to limbic system are reprogrammedsystem are reprogrammed

3 Muscle length flexability and 3 Muscle length flexability and memory are regainedmemory are regained

Manipulation Manipulation ConsiderationsConsiderations

11 Doctors positionDoctors position22 Patients positionPatients position33 Doctors contactDoctors contact44 Patients contactPatients contact55 Line of driveLine of drive66 Joint type and normal motionJoint type and normal motion77 RespirationRespiration88 Patientrsquos eye positionPatientrsquos eye position99 Psycho-somatic influencesPsycho-somatic influences1010 Distraction techniques Distraction techniques

ACTIVE ISOLATED ACTIVE ISOLATED STRETCHING (Mattes)STRETCHING (Mattes)

Myofascial stretching of isolated Myofascial stretching of isolated muscles which avoids activating the muscles which avoids activating the protective myotatic reflex protective myotatic reflex contraction contraction

11 Stretch through anatomical plane of Stretch through anatomical plane of attachmentsattachments

22 Contract the antagonistic muscle to Contract the antagonistic muscle to facilitate a release in the stretched facilitate a release in the stretched muscle (reciprocal inhibition)muscle (reciprocal inhibition)

33 Ten repetitions for two secondsTen repetitions for two seconds

HYDRATION amp HYDRATION amp RESPIRATIONRESPIRATION

11 The connective tissue matrix is an The connective tissue matrix is an important water storage important water storage compartmentcompartment

22 Hydration promotes smooth non-Hydration promotes smooth non-friction mechanical movement and friction mechanical movement and effective nerve conductioneffective nerve conduction

33 Respiration expedites water Respiration expedites water absorptionabsorption

Tissue PressureTissue Pressure

LengtheningLengthening Stretching used to increase the Stretching used to increase the

extensibility of muscle and extensibility of muscle and connective tissue resulting in connective tissue resulting in increased range of motion at a jointincreased range of motion at a joint

11 StaticStatic- passive - passive 22 ActiveActive- using agonists and synergists- using agonists and synergists33 NeuromuscularNeuromuscular- PNF- PNF44 FunctionalFunctional- using the bodyrsquos - using the bodyrsquos

momentummomentum55 NeurodynamicNeurodynamic- neural structures- neural structures

ActivateActivate Isolated (intramuscular) Isolated (intramuscular)

StrengtheningStrengthening Exercises used to Exercises used to isolate a particular muscle in order to isolate a particular muscle in order to increase the force production increase the force production capabilities through concentric-capabilities through concentric-eccentric muscle actions eg Scaption eccentric muscle actions eg Scaption exercisesexercises

Strengthening exercises to start after a Strengthening exercises to start after a 70 of the normal range of motion has 70 of the normal range of motion has been achieved (empirical observation)been achieved (empirical observation)

IntegrateIntegrate

Integration Techniques Integration Techniques (Intermuscular) (Intermuscular)

Re-educating the nervous system on Re-educating the nervous system on movement patterns and muscle movement patterns and muscle synergies in a dynamic manner synergies in a dynamic manner (eccentric isometric concentric)(eccentric isometric concentric)

eg Squat to roweg Squat to row

PERPETUATING FACTORSPERPETUATING FACTORS

11 Mechanical StressesMechanical Stresses

22 NutritionalDietary factorsNutritionalDietary factors

33 Metabolic and Endocrine Metabolic and Endocrine InadequaciesInadequacies

44 Psychological factorsPsychological factors

55 Chronic InfectionChronic Infection

66 Other Other (allergy sleep improper (allergy sleep improper breathing dehydration smoking breathing dehydration smoking caffeine medications visceral disease)caffeine medications visceral disease)

MECHANICAL STRESSMECHANICAL STRESS

11 Structural-Structural- body asymmetry and body asymmetry and disproportion eg leg length disproportion eg leg length discrepancy long second metatarsal and discrepancy long second metatarsal and short first metatarsalshort first metatarsal

22 PosturalPostural eg poor posture poorly eg poor posture poorly fitting furniture poorly adjusted glasses fitting furniture poorly adjusted glasses ergonomicsergonomics

33 Constriction of musclesConstriction of muscles eg poor eg poor fitting clothingfitting clothing

44 Degenerative joint diseaseDegenerative joint disease

NUTRITIONAL FACTORSNUTRITIONAL FACTORS(VITAMINS AND (VITAMINS AND

MINERALS)MINERALS) Nutritional inadequacies cause impairment of Nutritional inadequacies cause impairment of

energy cell metabolism and function which energy cell metabolism and function which reduces the ability of the muscle to meet extra reduces the ability of the muscle to meet extra demands and metabolic stressdemands and metabolic stress

Nutrients Play a role in the synthesis of Nutrients Play a role in the synthesis of neurotransmitters protein carbohydrate and fat neurotransmitters protein carbohydrate and fat metabolism DNA synthesis collagen synthesis metabolism DNA synthesis collagen synthesis and proper nerve and muscle functionand proper nerve and muscle function

Low levels should be treated as they may not be Low levels should be treated as they may not be adequate for optimum healthadequate for optimum health

Deficiency increases irritability of trigger points Deficiency increases irritability of trigger points and nervesand nerves

NUTRITIONAL NUTRITIONAL DEFICIENCYDEFICIENCY

B1B1- important for energy and synthesis of - important for energy and synthesis of neurotransmitters Potentiates the effectiveness of thyroid neurotransmitters Potentiates the effectiveness of thyroid hormonehormone

B6B6- important in lipid and protein metabolism and the - important in lipid and protein metabolism and the synthesis of neurotransmitterssynthesis of neurotransmitters

B12B12- essential for energy and DNA synthesis and in fat - essential for energy and DNA synthesis and in fat carbohydrate and protein metabolismcarbohydrate and protein metabolism

Folic Acid-Folic Acid- Important for synthesis of DNA cell Important for synthesis of DNA cell metabolism and for normal brain function and metabolism and for normal brain function and developmentdevelopment

CC- important in collagen synthesis and synthesis of - important in collagen synthesis and synthesis of serotonin and norepinephrineserotonin and norepinephrine

Calcium Magnesium Potassium and Iron-Calcium Magnesium Potassium and Iron- Important Important in muscle contraction and functionin muscle contraction and function

Naturopathic Approaches to Naturopathic Approaches to InflammationInflammation

Antioxidants A E C Se Zn CoQ10Antioxidants A E C Se Zn CoQ10 CBioflavonoids- 1000mg 3xdayCBioflavonoids- 1000mg 3xday Magnesium (citrate)- 300mg 2xdayMagnesium (citrate)- 300mg 2xday Fish Oil (18 EPA amp 12DHA)- 10g per day (at least Fish Oil (18 EPA amp 12DHA)- 10g per day (at least

3g EPA)3g EPA) Bromelain- 1000-2000 MCU 4xday away from foodBromelain- 1000-2000 MCU 4xday away from food Quercetin- 500mg 3xdayQuercetin- 500mg 3xday Boswellia- 400mg 3xdayBoswellia- 400mg 3xday Glucosamine and Chondroitin Sulphate- 500mg of Glucosamine and Chondroitin Sulphate- 500mg of

each 3xdayeach 3xday Topical DMSOTopical DMSO Topical BiofreezeTopical Biofreeze HydrotherapyHydrotherapy Guided imagerysystematic relaxationhypsosisGuided imagerysystematic relaxationhypsosis

Dietary Factors in Dietary Factors in InflammationInflammation

Phytonutrients- vegetables and fruitsPhytonutrients- vegetables and fruits GreenBlack teaGreenBlack tea Garlic Ginger Turmeric Cinnamon etcGarlic Ginger Turmeric Cinnamon etc Consume low glycemic load carbohydrates (insulin Consume low glycemic load carbohydrates (insulin

connection)connection) Eat small frequent meals to ensure glycemic Eat small frequent meals to ensure glycemic

regulationregulation Omega 6Omega 3 should be lt41 Omega 6Omega 3 should be lt41 Decrease meat dairy shellfish and refined Decrease meat dairy shellfish and refined

carbohydratesfatscarbohydratesfats Decrease caffeine and alcohol Decrease caffeine and alcohol Optimize digestion and bowel habitsOptimize digestion and bowel habits Identify food reactionsIdentify food reactions

METABOLIC AND METABOLIC AND ENDOCRINEENDOCRINE

When energy metabolism of the When energy metabolism of the muscle is compromised as a result of muscle is compromised as a result of metabolic or endocrine imbalance it metabolic or endocrine imbalance it perpetuates trigger point activity perpetuates trigger point activity egeg

11 HypoglycemiaHypoglycemia

22 HypothyroidHypothyroid

33 MenopauseMenopause

44 HyperuricemiaHyperuricemia

AllergyInfectionAllergyInfection

Can perpetuate trigger point Can perpetuate trigger point activity possibly due to histamine activity possibly due to histamine releaserelease

PSYCHOLOGICAL FACTORSPSYCHOLOGICAL FACTORS

There is a decrease in brain serotonin There is a decrease in brain serotonin which causes increased sensitivity which causes increased sensitivity and low oxygenation of the tissues and low oxygenation of the tissues egeg

11 StressStress

22 DepressionDepression

33 AnxietyAnxiety

44 Insomnia Insomnia

55 FatigueFatigue

Tension Myositis SyndromeTension Myositis Syndrome The mind body connectionThe mind body connection

Conscious or Repressed Unconscious EmotionsConscious or Repressed Unconscious Emotions

StressStress

Abnormal Autonomic ActivityAbnormal Autonomic Activity

Reduced Local Circulation of BloodReduced Local Circulation of Blood

Mild Oxygen DeprivationMild Oxygen Deprivation

Muscle PainMuscle Pain Nerve painNumbnessTinglingWeaknessNerve painNumbnessTinglingWeakness

Tendon PainTendon Pain

Practical ApplicationsPractical Applications

Evaluation and TreatmentEvaluation and Treatment

Cervical spineCervical spine Thoracic spineThoracic spine Lumbo-Pelvic-Hip complexLumbo-Pelvic-Hip complex Upper frac14 - Shoulder elbow wrist Upper frac14 - Shoulder elbow wrist

handhand Lower frac14 - knee ankle footLower frac14 - knee ankle foot

Practical FormatPractical Format

Common patterns of dysfunction Common patterns of dysfunction Functional anatomy and Functional anatomy and

biomechanicsbiomechanics AssessmentExaminationAssessmentExamination TreatmentTreatment

Trigger point releaseTrigger point release Muscle release therapyMuscle release therapy Friction massageFriction massage Joint manipulationJoint manipulation StretchingStretching Corrective exercise (inhibit lengthen Corrective exercise (inhibit lengthen

activate integrate)activate integrate)

ReferencesReferences NASMNASM Leon Chaitow ND DCLeon Chaitow ND DC Warren Hammer DCWarren Hammer DC Vladimir Janda MDVladimir Janda MD Craig Liebension DCCraig Liebension DC Paul ChekPaul Chek Shirley SarhmannShirley Sarhmann Peter Levy DCPeter Levy DC Stuart Taws LMPStuart Taws LMP SLACK Hands on seminarsSLACK Hands on seminars Chan Gunn MDChan Gunn MD Stuart McGillStuart McGill Gray Cook PTGray Cook PT

Integrative Approaches to Integrative Approaches to PainPain

This class is a synthesis of cutting-edge This class is a synthesis of cutting-edge chiropractic osteopathic naturopathic chiropractic osteopathic naturopathic massage nutrition and dry needling techniques massage nutrition and dry needling techniques and principlesand principles

Practitioners and students will learn the Practitioners and students will learn the different phases of pain and how to effectively different phases of pain and how to effectively assess and manage each phase with physical assess and manage each phase with physical medicine exercise nutrition and prescription medicine exercise nutrition and prescription drugsdrugs

Participants will refine their skills in soft tissue Participants will refine their skills in soft tissue and joint manipulative therapy and get exposure and joint manipulative therapy and get exposure to dry needling They will be able to effectively to dry needling They will be able to effectively manage the most common orthopedic and sports manage the most common orthopedic and sports medicine problems seen in private practicemedicine problems seen in private practice







PAINPAIN






3 Chronic3 Chronic






































































































scoliosisscoliosis








Adhesions

Muscle imbalance



Tissuetrauma

Inflammation

Muscle spasm



JandaJanda














PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress






















PAINPAIN






3 Chronic3 Chronic






































































































scoliosisscoliosis








Adhesions

Muscle imbalance



Tissuetrauma

Inflammation

Muscle spasm



JandaJanda














PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress



















3 Chronic3 Chronic






































































































scoliosisscoliosis








Adhesions

Muscle imbalance



Tissuetrauma

Inflammation

Muscle spasm



JandaJanda














PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress





















































































































scoliosisscoliosis








Adhesions

Muscle imbalance



Tissuetrauma

Inflammation

Muscle spasm



JandaJanda














PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress





















Adhesions

Muscle imbalance



Tissuetrauma

Inflammation

Muscle spasm



JandaJanda














PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress


















JandaJanda














PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress



























PosturePosture


































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress
















































TREATMENTTREATMENT




































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress


















































IntegrateIntegrate
















































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress




























































11 StressStress


33 AnxietyAnxiety


55 FatigueFatigue



StressStress


















StressStress
















A Kinetic Chain Approach to Musculo-Skeletal Pain Combining Manual Therapies, Nutrition and...

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