Archive for the ‘therapy’ category

The Diaphragm and its Global Relationships

October 23, 2011

The diaphragm, being a centrally located muscle, when it becomes facilitated, its effects can be felt throughout the entire body. There are many reasons why the diaphragm becomes facilitated. One of these is emotional stress which causes the diaphragm to contract. Another is poor breathing habits. This results in chest breathing with the scalenes,serratus posterior inferior, quadratus lumborum, and the intercostals becoming overburdened. Regardless of the cause, let’s examine the effects of a facilitated diaphragm. The diaphragm, along with the upper trapezius, neck extensors, pectoralis minor,iliacus, and the jaw muscles, has the potential to be one of the most facilitated muscles in the body.

A great example of this is a client who played water polo and had a chronically tight diaphragm. Her parents took her to every respiratory expert in the area. No one could determine the exact cause of her discomfort. I examined her diaphragm with palpation and found it to be extremely tight and painful. I then began using the NeuroKinetic Therapy protocol to assess for muscle/function imbalance. I performed the manual muscle tests first by having her hold her breath and secondly with her breathing out. The muscles that were inhibited included the neck flexors, pectoralis major bilaterally, humeral flexors and extensors bilaterally, psoas bilaterally, rectus femoris bilaterally, gluteus maximus bilaterally, and several gait patterns which I will describe later. As you can see, the diaphragm was extremely overburdened. We then began the process of releasing her diaphragm and retesting all of the above muscles/functions. Over a process of several weeks the diaphragm progressively released and the inhibited muscles/functions became available. She was able to go back to playing water polo at a competitive level.

Because of the motions involved in playing water polo, I had to get creative with gait patterns. Not only were the normal gait patterns investigated, such as flexion and extension of the contralateral humeral and hip flexors and extensors, but also abduction and adduction of the humerus and femur. Rotational patterns were also examined such as bringing the right arm towards the left knee. Cleaning these up really helped to solidify the changes we were making in the motor control system. Of course after each session she was given exercises to do which mimicked what we did. Due to her discipline and hard work she was able to return to competition quickly.

The diaphragm, with its connections to the thoracic and lumbar erectors, quadratus lumborum, and the psoas, is considered a core muscle. It is also connected to the jaw muscles, abdominals, and the pelvic floor through the Valsalva maneuver. These are also considerations for inhibition when dealing with a facilitated diaphragm. It is most likely that the abdominals,psoas, and the pelvic floor muscles will be inhibited.

The diaphragm must be considered as a possible source of facilitation when dealing with global inhibition. Release of the diaphragm and reestablishing the neural pathways to the inhibited muscles/functions is critical in rehabilitation.

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The Pelvic Floor-Overactive or Underactive?

September 24, 2011

Weakness of the pelvic floor muscles is associated with lower back pain, incontinence, constipation, and sexual dysfunction. The use of Kegel exercises to correct this is commonplace and widely utilized by physical therapists and Pilates instructors. When employed correctly these exercises can strengthen the core, the lower back, and the pelvic organs. Problems occur when these muscles are overactive and are inhibiting associated core and lower back muscles. Asking overactive pelvic floor muscles to perform Kegel exercises can lead to pelvic floor pain and irritation of the pudendal nerve. The question is then how do we determine if the pelvic floor muscles are overactive or underactive?

A simple way to determine this is to use manual muscle testing. For example, if the pelvic floor muscles are weak, other associated muscles will have to compensate and thus become tight and painful. Let’s say the obturator internus remains tight and painful despite your best efforts to release it. Have your client do some Kegels and then reevaluate the obturator internus. If the OI has become more pliable you know you’re on the right track. This technique can be applied to the psoas, quadratus lumborum, gluteus maximus, sacroiliac area, and the hip joints.

But what to do if the pelvic floor is overactive? Start by evaluating the core and lower back muscles for weakness. For example, if the psoas tests weak have the client tighten the pelvic floor and retest. If the psoas now tests strong you know it is being inhibited by the pelvic floor muscles. This process can be applied to all associated muscles. If you are familiar with manual release of the pelvic floor it would be appropriate to do that. If you’re not there is a simple way to release the pelvic floor muscles. With the client supine, have them bend their knees and turn them out at a 45° angle so that the soles of their feet are touching. Then have them place their hands on their knees. Release of the pelvic floor muscles occurs when the hands resist a superior/diagonal movement of the knees. It is important that only light resistance is applied. This technique works very well as a home exercise program which would include this movement first followed by strengthening of the inhibited muscle.

Determining if the pelvic floor muscles are overactive or underactive is crucial in their treatment. Exercising an overactive pelvic floor can lead to serious pain and nerve irritation. Exercising an underactive pelvic floor can lead to vast improvements in core strength and lower back, sacroiliac, and hip joint function. It is truly a double-edged sword.

The Importance of Functional Lats

September 3, 2011

There are very few muscles in the body whose functionality is as important as the lats. Because it connects the thoracolumbar fascia to the humerus, inhibition of the latissimus dorsi can cause compensations in the neck, shoulder, elbow, lower back, and gait. This article will detail these compensation patterns and how to resolve them. This information is important for all massage therapists, Pilates instructors, personal trainers, physical therapists, etc. because inhibition of a muscle that is centrally located causes global responses. Understanding how these patterns are formed and relate to each other  is essential in resolving long-standing and difficult presentations.

First, let’s start with the neck and shoulder. The lat via its attachment to the humerus is capable of scapular depression. It is opposed by the elevators of the scapula including the upper trapezius and the levator scapula. After palpating tight spots in the neck extensors, upper traps, and levator scapula I will then test the function of the lat by asking the client to hold their palm against their hip. If this is a weak test I then therapy localize tender spots on the aforementioned muscles while testing the lat  to see if they strengthen the test. Whichever one makes the tests the strongest is the one I release first. If that does not completely resolve I then proceed to the next tenderest spot and continue on until the test is strong. If the lat tests strong to begin with, I will challenge it by having the client shrug their shoulder or turn their head to the opposite side. One of these will usually inhibit the lat. When the lat tests strong and can withstand the challenges, I consider that a reprogramming of the motor control system. I will then assign a home program of  first stretching the neck/shoulder muscles followed by strengthening of the lat. It is crucial that the client follows this protocol exactly in order to successfully reprogram the motor control system. When the reprogramming occurs it is stored in the short-term memory. By constant repetition the reprogramming is then shifted to long-term memory.

Now let’s talk about the elbow. When the body perceives an instability in a joint it will very often either compress that joint or a nearby joint. I find very often with difficult to resolve cases of medial or lateral epicondylitis that the elbow is compressing to stabilize for the shoulder joint. Inhibition of the lat will often result in either of these situations. I will test the lat by having the client either holding their pinky against their hip with the palm up for medial epicondylitis or with the thumb against the hip with the palm down for lateral epicondylitis. If the test is weak I will then therapy localize spots around the epicondyles and then proceed with the NeuroKinetic Therapy protocol. A home program would be releasing the areas around the epicondyle followed by strengthening of the lat.

Finally the lower back. The latissimus dorsi  is contiguous with the thoracolumbar  fascia. Any inhibition of the lat will cause muscles/functions in that area to compensate. These include the ipsilateral erector spinae group, the quadratus lumborum, the gluteus maximus, and the gluteus medius.  This may also cause a contralateral rotational compensation, including the piriformis. Follow the NKT protocol, identify the facilitated muscles/functions using therapy localization, challenge the reprogramming, and assign the appropriate home program.

Gait can also be affected by inhibition of the lat. The lat is also an extensor of the humerus. Start by testing humeral extension with contralateral straight leg hip extension. If the extension of the humerus is inhibited check for tender spots in the opposite glute, hamstring, calf, and plantar foot muscles. Use the NKT protocol. Extension of the humerus may also be tested against flexion of the opposite humerus or flexion of the ipsilateral leg.

Functionality of muscles/functions that are centrally located are essential in maintaining healthy global relationships. The latissimus dorsi with its attachments to both the upper body and lower body is a muscle whose function is crucial in maintaining balance. A strong functional lat =  a happy body.

The Psoas Muscle and its Global Relationships

July 31, 2011

There continues to be a a lot of discussion about strengthening the core muscles. In this article I will discuss functional relationships that will inhibit the core muscles from being strengthened. Due to dysfunctional movement/coordination patterns, even the best of core strengthening programs will not be successful unless these dysfunctional patterns are reprogrammed. My approach, using NeuroKinetic Therapy, is to identify the muscles/functions that are inhibiting the core muscles. This can be easily accomplished through therapy localization. The spot (or spots) is then released using whatever techniques you already know and then the core muscles are retested to see if they are now facilitated. If the core muscles now test strong challenge them against the ones that were inhibiting them in the first place to see if your reprogramming protocol has been successful. If yes, then assign that sequence to your client as homework.

Let’s consider the psoas muscle as our first example. Any inhibition of a muscle that is centrally located will cause the motor control system to go into action to compensate for it because these muscles are crucial in all movements of the extremities and in spinal stabilization. A common pattern that I see is the psoas inhibited by the quadratus lumborum. Ipsilaterally this is considered an antagonistic relationship. Using the NKT protocol, first manually muscle test the psoas, and let’s assume it tests weak. Then find a tender spot on the quadratus lumborum and while holding it, retest the psoas. If the psoas now tests strong you know exactly which spot to release on the quadratus lumborum. After releasing the quadratus lumborum retest the psoas. If it now tests strong, then challenge it by testing the quadratus lumborum and retesting the psoas. If the psoas is able to withstand the challenge, you have successfully reprogrammed that dysfunctional pattern.

The psoas can also be inhibited by the hip flexors in a synergistic relationship. Muscles that I find that are commonly inhibiting the psoas in this group are the TFL, the proximal portion of the rectus femoris, the iliacus, and the adductors (especially the pectineus). Use the same NKT protocol to treat.

There are also core relationships to deal with. Inhibition of the psoas can cause facilitation, tightness, and pain in the lumbar spine and the sacroiliac joint. Because the psoas attaches to the lumbar intervertebral discs, it is crucial in the management of low back pain to deal properly with these dysfunctional relationships.

The last category of relationships to consider involves kinetic chains. It is not uncommon to find the psoas inhibited by the ipsilateral scalenes, the contralateral pectoralis minor, and the ipsilateral tibialis anterior. I find many unresolved cases of neck pain alleviated by addressing the relationship of the psoas to the scalenes. This can also contribute to TOS and other neurological problems involving the brachial plexus.

It is important to remember that just because the psoas is tight that doesn’t mean it needs to be stretched or worked deeply. The question you have to ask is why is it tight? If it is weak and tight the worst thing you can do is to stretch it. A weak muscle does not like to be stretched. It will cause a panic in the motor control system and the body will rebound by tightening it even more. When a muscle is weak it protects itself by shortening. It is crucial to first test a tight psoas to determine if it is weak or strong. If it is strong you can go ahead and stretch it. If it is weak you must first figure out why it is so and then rehabilitate it. When the psoas is strong then you can go ahead and stretch it.

In future blogs, we will discuss other core muscles and their global relationships, such as the transverse abdominis, the diaphragm, and the pelvic floor.

 

Cervical Dystonia/Torticollis

June 20, 2011

When I was researching standard treatment for cervical dystonia, mostly what I found was that there was no cure and the usual treatment is Botox injections. The Botox is generally injected into the “overworked” SCM and Splenius Capitus. This may provide some temporary relief of symptoms but certainly is no cure. What is not explored much in the literature are the motor control issues associated with this condition. Clearly the brain is sending dysfunctional signals to the muscles of the neck. But what can be done to change that?

There are four basic patterns associated with this condition. The first is a rotation of the head to one side. The second is a lateral side bending of the head to one side. The third is forward flexion. The fourth is extension. What is commonly seen is a combination of these patterns. The most frequent of these would be rotation of the head with contralateral side bending. Let’s examine each of these and the possible treatment protocols. With rotation of the head to the left, the most active muscles would be the right SCM and the left Splenius Capitus. First test the “connectivity” of the left SCM and the right Splenius Capitus. Does inhibiting the right SCM and the left Splenius Capitus facilitate the other two muscles? This would be an example of a functional correction. Of course there are many more muscles/functions involved in turning the head to the left. The left longus colli, scalenes, and the suboccipital muscles must also be examined. Testing for right thoracic rotation and left lumbar rotation is also crucial. These would be the most common compensatory rotations for a left cervical rotation. Re-firing the muscles that create left thoracic rotation and right lumbar rotation will greatly improve your treatment.

In lateral side bending of the neck the ipsilateral upper trapezius dominates with help from the levator scapula and the posterior scalene. The ipsilateral longus colli and neck extensor group must also be considered. The implications for a kinetic chain start with the latissimus dorsi, obliques, hip abductors, and peroneals. Testing the contralateral kinetic chain for inhibition and making corrections again will greatly enhance your outcomes.

In flexion of the neck, the SCMs,longus colli, suprahyoid muscles, and neck extensors must all be thoroughly examined. Check the kinetic chain from the pectoral muscles, the diaphragm, the abdominals, the hip flexors, the knee extensors, and the ankle extensors. These may be inhibiting the muscles involved in the extension kinetic chain.

In extension of the neck, the same muscles that are involved in the flexion pattern must be resolved but with the opposite emphasis. Check the kinetic chain from the trapezius, levator scapula, rhomboids, Multifidi, quadratus lumborum, gluteals, hamstrings, calf muscles, and the muscles of the sole of the foot.

With a combination pattern of rotation and side bending you must mix and match the most active muscles along with their associated kinetic chains. This requires a great deal of assessment, testing, and treatment, but the results will be worth it.

Client compliance is crucial in resolving cervical dystonia. Exercises which emphasize stretching the overworked muscles followed by strengthening the inhibited muscles produce excellent results. There are many other options such as eye tracking exercises. One of my clients when looking down always turns his head to the left. Retraining of that pattern is crucial in the resolution of this condition.

In conclusion, the treatment of cervical dystonia is a complicated assessment and treatment process that requires strict client compliance with assigned exercises. Therapies which reconfigure dysfunctional motor programs in the cerebellum are likely to be the most successful.

 

Reactive Muscles and the Kinetic Chain

May 21, 2011

The concept of reactive muscles was introduced by David Walther in his book “Applied Kinesiology”. When two muscles are in relationships such as synergistic or antagonistic, one muscle has the ability to compensate for the other. Although the muscles may manually test strong or facilitated by themselves, in relationship one muscle may inhibit the other. This is called a “reactive pair”. Understanding this dynamic is crucial in working with dysfunctional movement patterns. A good example would be a client presenting with lower back pain. First test the transverse abdominis and it tests strong. From this you might assume that this muscle is working just fine and is not contributing to the problem. Then test the lumbar erectors. Let’s say they test strong. Then retest the transverse abdominis. Now you find that it tests weak. This reactive relationship clearly is contributing to the lower back pain. Using the NeuroKinetic Therapy protocol, the lumbar erectors are released so that the transverse abdominis becomes facilitated. This can be the underlying reason for unresolved lower back pain. This is a classic example of a reactive antagonistic relationship.

When we use our muscles in concert with each other there is a natural flow of effort transmitted from one muscle to the other. A good example of this is picking up a glass of water and drinking it. First you need to grasp the glass, requiring intrinsic and extrinsic muscles of the hand. Then the wrist and elbow must bend, requiring muscles of the forearm and humerus. Then the shoulder must flex and finally the mouth must open. This is a complex action which normally requires no conscious thought. In other words, it has become a motor program. However, if there has been an injury or a long-standing postural distortion, this normally effortless action becomes compromised. We can call this a synergistic reactive relationship. Any muscle in this chain of action can inhibit another. A tight jaw could cause a weak grip. Check this out by first testing the grip. Is the client clenching his/her jaw? If so, release the involved jaw muscles before retesting the grip. You will find that the grip now tests strong. I have found the scalenes in this kind of reactive relationship to 13 different muscles further down this chain. Is it any wonder that the client was diagnosed with thoracic outlet syndrome?

Knowing how to work with reactive muscle relationships is an essential element in rehabilitative therapy. This powerful tool can help you unlock the secrets of dysfunctional movement and coordination patterns.

Ankle Sprains and the Kinetic Chain

April 22, 2011

An ankle sprain can be a fairly serious injury. Estimates for recovery range from three months to a year. We know that ligaments heal slowly and the tissue surrounding them must be strengthened in order to regain complete functionality. But what is often ignored is the effect of the unstable ankle on the rest of the body. Understanding how kinetic chains work is essential in unwinding complicated compensation patterns from acute or chronic injuries. The motor control center in the cerebellum will create a dysfunctional coordination pattern based on the information it is getting from the ankle and the rest of the body. This pattern will persist until it is reprogrammed with a new functional one. Long-standing aggravations to the knees, hips, lower back, and neck can be traced to dysfunctional movement patterns created by an ankle sprain.

Almost all ankle sprains are caused by a twisting of the foot which overstretches and tears the ligaments around the lateral malleolus (inversion sprain). What happens next is very interesting. It becomes very difficult to put weight on the outside of the foot because that causes pain. The foot then tends to be more comfortable in eversion, placing more weight on the inside of the foot. This causes the lower body to lean to the opposite side. What muscles must engage to make that happen? The evertors of the foot, adductors of the ipsilateral hip, abductors of the contralateral hip, the contralateral quadratus lumborum, the contralateral obliques, and the ipsilateral lateral neck flexors(upper body leaning ipsilaterally to counterbalance lower body). This will cause strain to the medial portion of the ipsilateral knee (medial meniscus strain), to the lateral portion of the contralateral knee (ITB syndrome), tightening of the contralateral quadratus lumborum and obliques (hip and shoulder level differences and leg length discrepancy), and tightening of the ipsilateral upper trapezius (neck problems such as persistent subluxations).

Clearly the dysfunctions along the kinetic chain must be addressed. I have seen neck problems of many years traced back to an ankle sprain. Changes in gait resulting from such a sprain can cause knee, hip, and lower back injuries. How would you treat this? I use the NeuroKinetic Therapy protocol to assess and treat such conditions. First I would manual muscle test the strength of the ankle and find what muscles/functions are compensating for that weakness. Then I would release the compensating muscles and retest the weak/inhibited ankle function. The same process can be applied to the knee, hip, lower back, and neck. I often find that when I asked my client to laterally flex their neck to the opposite side as the sprained ankle, it will inhibit many functions along that kinetic chain. Conversely, because the lateral neck flexors are bracing for those weak functions they can never relax. Each client will present a different combination of the above, so proceed slowly and investigate with great detail all the possibilities.

Having a global approach to injury is a very crucial aspect of successful rehabilitation. Treating injuries myopically can only lead to further dysfunction. Understanding how an injury can affect an entire kinetic chain is the key to unraveling the mysteries of chronic pain.