This is a chapter 1 summary of “Recognizing and Treating Breathing Disorders” by Leon Chaitow. It’s Been A While I know it has been a while for some Therapy Notes (©™®#zacistheshizzy), but I decided to revisit some Chaitow as I read his new edition. The chapters have changed quite a bit so far, and many new things have been added. Here is the updated chapter one. A Lotta History Hyperventilation disorders have been through the ringer, and to this day are hardly diagnosed. Some of the biggest classifications in my eyes arrived in 1908-09 from phsyiologists Haldane, Poulton, and Vernon. These fellows classified symptoms of overbreathing to include: Numbness Tingling Dizziness Muscular hypertonicity. This symptom cluster occurred with respiratory alkalosis. In 1977, Lum, Innocenti, and Cluff developed assessment and treatment programs for breathing disorders in the UK, which spearheaded breathing disorder literature. Despite these scientific advancements, many physicians do not diagnose hyperventilation as a legitimate problem. Some of these patients even go so far as to being accused as malingering. Hearing this problem is quite unsettling, as I am seeing more and more people who overbreathe; and possibility correlating, more and more people with chronic pain. A future post is in order to show how I think the two are connected. Breathing Pattern Disorders (BPD) and Symptoms So many symptoms could occur with BPDs. The most extreme of these symptoms is hyperventilation syndrome, defined by the following: Breathing in excess of metabolic requirements. Reducing CO2 concentrations in the blood below
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The Post Wonderful Time of the Year: Top Posts of 2013
The Best…Around Time is fun when you are having flies. It seems like just yesterday that I started up this blog, and I am excited and humbled by the response I have gotten. Hearing praise from my audience keeps me hungry to learn and educate more. I am always curious to see which pages you enjoyed, and which were not so enjoyable; as it helps me tailor my writing a little bit more. And I’d have to say, I have a bunch of readers who like the nervous system 🙂 I am not sure what the next year will bring in terms of content, as I think the first year anyone starts a blog it is more about the writing process and finding your voice. Regardless of what is written, I hope to spread information that I think will benefit those of you who read my stuff. The more I can help you, the better off all our patients and clients will be. So without further ado, let’s review which posts were the top dogs for this year (and some of my favorite pics of course). 10. Lessons from a Student: The Interaction This was probably one of my favorite posts to write this year, as I think this area is sooooooo under-discussed. Expect to be hearing more on patient interaction from me in the future. 9) Clinical Neurodynamics Chapter 1: General Neurodynamics Shacklock was an excellent technical read. In this post we lay out some nervous system basics, and
Read MoreTreatment of Shredded Cheese of the Hip: A Case Report and Rant
A Long Day I officially eclipsed my longest work day ever. Started seeing patients at 7:30 am and finished training my last client at 10 pm. So exhausting, but the bright side is my new schedule prevents me from waking up that early ever again! Hooray for sleeping in…sort of. I figured while I had some time in the airport before my next course, I would write a little something about a patient I evaluated right before my lunch break on this long day. Needless to say, I didn’t get much of a break. Her Story This lovely lady is a nurse with a history of chronic left hip pain. She has predominately been treated surgically via labral repairs and muscle reattachment. Her most recent symptom exacerbation involved putting on her socks about a month prior. She heard a pop as she bent over and could not walk. She initially saw two ortho docs. One specializes in total hips, the other in scopes. Since she was not appropriate for a total hip, this doc referred this lady to his associate. After some imaging was done, she found out that she could not have surgery because she had several muscle tears. Or in the language that the doctor used: “I have nothing to work with. Your hip is shredded up like cheese.” This lady knew no other treatment but surgery, and hearing this news was devastating for her. Thoughts of a brutish life and an end to her fulfilling job flooded
Read MoreChapter 4: Biomechanical Influences on Breathing
This is a chapter 4 summary of “Multidisciplinary Approaches to Breathing Pattern Disorders” by Leon Chaitow. The second edition will be coming out this December, and you can preorder it by clicking on the link or the photo below. Loose-Tight Chaitow likes to use the loose-tight concept as a way of visualizing the body’s three-dimensionality while assessing. He likes to look at comparing structures as tight or loose relative to one another. Those areas which are loose are often prone to injury and more likely to be nociceptive. If we try to see which muscles have a tendency towards tightness or looseness, stabilizers tend towards laxity and mobilizers to increased tone. Obviously, all muscles function in both capacities, and some even stay more towards the middle (scalenes). But the tendency depends on which function is more dominant. Posture and Respiration (Not PRI, Peepz) Taking the previous concepts, Janda’s crossed syndromes can have a role in ones breathing function. With an upper crossed posture, the slumped upper body position negatively influences breathing function. Lower crossed syndrome will put the diaphragm in an anterior facing position, thus affecting diaphragm length-tension and breathing function. Facilitation Facilitation is an osteopathic term for a process involved in neural sensitivity. There are at least two forms of facilitation: spinal (segmental) and local (trigger points). Once facilitation occurs, any additional stress the individual undergoes can increase neural activity in the segment. There are several ways to observe facilitated segments. You can observe these via palpation: Goose flesh
Read MoreChapter 12: Lower Limb
This is a Chapter 12 summary of “Clinical Neurodynamics” by Michael Shacklock. Piriformis Syndrome Piriformis syndrome often involves the fibular tract of the sciatic nerve. It has the capacity to create symptoms from the buttock down to the anterolateral leg. Testing the neurodynamics with a fibular nerve bias is essential. To attempt to isolate this problem, we must best differentiate interface from neurodynamic components. Using Cyriax principles –palpation, contraction, and lengthening –can be beneficial in this regard. Keep in mind that below 70 degrees hip flexion the piriformis produces external rotation, and above 70 degrees it is an internal rotator. When treating this problem, the goal is to change pressure between the piriformis muscle and the sciatic nerve. Level 1a – Static opener VID – KF, ER Level 1b – Dynamic opener VID – Passive ER Level 2a – Closer mobilization using passive IR. VID – Passive IR Level 2b – We finish with a passive piriformis stretch VID – Tailor stretch If there is a neurodynamic component to things, slightly modify things by using sliders. We start things off with the same opener as the interface above. As the patient progresses, you can add proximal or distal components eventually finishing with a fibular nerve-based slump. VID – Building the slump To combine interface and neural treatments, contract-relax can be utilized. Sciatic Nerve in the Thigh Oftentimes with hamstring strains, sciatic nerve sensitivity can increase. The slump and straight leg raise tests can be utilized to help differentiate a pure
Read MoreChapter 11: Lumbar Spine
This is a Chapter 11 summary of “Clinical Neurodynamics” by Michael Shacklock. Physical Exam The slump is the big dog for assessing lumbar spine complaints. Deciphering which movements evoke the patient’s symptoms can tell you a lot about the nervous system’s dysfunction: Neck flexion increases symptoms – Cephalid sliding dysfunction. Knee extension/dorsiflexion increases symptoms – Cauded sliding dysfunction. Both neck flexion and knee extension increase symptoms – Tension dysfunction. The straight leg raise is another important test that can help determine the nervous system’s state. Treatment The treatment parallels similar tactics as previous body areas. For reduced closing dysfunctions We start level 1 with static openers, progress to dynamic openers, then work to close. For opening dysfunctions, we progress toward further opening/contralateral lateral flexion. Neural Dysfunctions We treat these mechanisms based on which dysfunction is present. For cephalid sliding dysfunctions, we approach with distal to proximal progressions; and for caudad sliding dysfunction, we work proximal to distal Tension dysfunctions are started with off-loading mvoements towards tensioners Complex Dysfunctions Sometimes you can have interface dysfunctions that simultaneously have contradictory neurodynamic dysfunction. There are several instances of the case. Reduced closing with distal sliding dysfunction – Treat by combining closing maneuvers while perform active knee extension. Reduced closing with proximal sliding dysfunction – Address by closing maneuver with neck flexion. Reduced closing with tension dysfunction – This is treated with adding closing components to tensioners Reduced opening with distal sliding dysfunction – Here we add a dynamic opener along with leg movements. Reduced
Read MoreChapter 10: Upper Limb
This is a Chapter 10 summary of “Clinical Neurodynamics” by Michael Shacklock. Thoracic Outlet Syndrome (TOS) When discussing TOS pathoneurodynamics, you must talk about breathing. The brachial plexus passes inferolaterally between the first rib and clavicle. When inhalation occurs, the plexus bowstrings over the first rib cephalidly. So breathing dysfunctions can contribute to one’s symptoms. Excessive scapular depression can also contribute because the clavicle approximates the plexus from above. Clinically, TOS often presents as anteroinferior shoulder pain, with some cases passing distally along the course of the ulnar nerve. A resultant upper trapezius/levator scapula hyper or hypoactivity can occur that may affect the neural elements. Treating the Interface Level 1 – Static Opener with breathing Level 2 – Static opener with rib mob during exhalation; progressing with scapular depression. Level 3 – Rib depression with sliders and tensioners. Pronator Tunnel Syndrome This syndrome consists of pain in the anteromedial forearm region with or without pins and needles. Symptoms are usually provoked by repetitive activities such as squeezing, pulling through the elbow, and pronation movements. From an interface perspective, pronator syndrome deals with excessive closing. So we will use openers to treat. Level 1 – Static opener combining 60-90 degrees of elbow flexion with forearm pronation Level 2 – Dynamic opener Treating neural components depends on the present dysfunction. There are the following possible dysfunctions: Distal sliding dysfunction – symptoms decrease with contralateral cervical flexion. Proximal sliding dysfunction – Symptoms increase with contralateral cervical sidebend and finger flexion. Tension dysfunction –
Read MoreChapter 9: Cervical Spine
This is a Chapter 9 summary of “Clinical Neurodynamics” by Michael Shacklock. Physical Exam The key tests you will want to perform include: Slump test. MNT 1. You can tier your testing based on one’s dysfunctions, such as opening or closing, as well as using sensitizers for less severe problems. Reduced Closing Dysfunction Level 1a – Static opener to increase space and decrease pressure in the intervertebral foramen. In the picture below, we would open the right side by combining flexion, contralateral sidebend, and contralateral rotation. Level 1b to 2b Reduced Opening Dysfunctions For these impairments, they are treated just the same as closing dysfunctions. The major difference is rationale. In closing dysfunction, the goal is to reduce stress on the nervous system. With opening dysfunctions, however, we are trying to improve the opening pattern. Static openers will generally not be used because these treatments could potentially provoke symptoms. Neural Dysfunction The gentlest technique is the two-ended slider, in which an ipsilateral lateral glide and elbow extension are performed. For tension dysfunctions, we go through the following progression:
Read MoreChapter 8: Method of Treatment: Systematic Progression
This is a Chapter 8 summary of “Clinical Neurodynamics” by Michael Shacklock. Let’s Treat the Interfaces The two main ways to treat interfaces involve opening and closing techniques. These treatments involve either sustained or dynamic components. We will discuss which techniques work best in terms of dysfunction classification. – Reduced Closing Dysfunction – Given static openers early in this progression, continuing to increase frequency and duration. Eventually you move to more aggressive opening techniques, while finishing with closing maneuvers. – Reduced Opening Dysfunction – Start with gentle opening techniques working to further increasing the range. – Excessive Closing and Opening Dysfunctions – Work on improving motor control and stability. How About Neural Dysfunctions The main treatments are sliders and tensioners; each can be performed as one or two-ended. Sliders ought to be applied when pain is the key symptom. Sliding may milk the nerves of inflammation and increase blood flow. These techniques could also be used to treat a specific sliding dysfunction. Sliders can be performed for 5 to 30 reps with 10 seconds to several minute breaks between sets. Increased symptoms such as heaviness, stretching, and tightness is okay, but pain should not occur afterwards. Typically sliders are performed in early stages, and in acute situations should occur away from the offending site. Tensioners are reserved for higher level tension dysfunctions. The goal is to improve nerve viscoelasticity. Some symptoms are likely to be evoked, but this occurrence is okay as long as symptoms do not last. Tensioners are
Read MoreChapter 4: Diagnosis of Specific Dysfunctions
This is a Chapter 4 summary of “Clinical Neurodynamics” by Michael Shacklock. Mechanical Interface Dysfunction In early stages of closing dysfunctions, symptoms present as aches and pains. This presentation is due to the musculoskeletal tissues being more affected than the neural tissue. As severity increases, neurological symptoms such as pins and needles, tingling, and burning are more likely to occur. The severest end of the spectrum includes numbness and weakness; indicating further compromise to the neurovascular structures. Interface dysfunctions behave with changes in posture and movement. Oftentimes cardinal signs of inflammation can be present, along with night pain/morning stiffness. Typically you will see a painful arc throughout movement. During the physical exam, patients will show an inability to move in opening or closing directions. You can also find altered pain production, soft tissue thickening, or hypermobility/instability. Neurological changes will usually be present only in severe interface dysfunction. There are four basic types of interface dysfunctions 1) Reduced closing 2) Excessive closing 3) Reduced opening 4) Excessive opening In reduced closing dysfunction, closing movements such as squeezing or cervical extension provoke symptoms. Assessment may show a protective deformity developing in the opening direction so pressure is reduced on the nervous system. Symptoms will often not be reproduced unless neurodynamic testing is combined with interface testing. Excessive closing is when, well, interfaces are closing too much. An example of this dysfunction is excessive lumbar lordosis present with low back pain that increases with standing, walking, and running. A patient’s history will often show
Read MoreChapter 3: General Neuropathodynamics
This is a Chapter 3 summary of “Clinical Neurodynamics” by Michael Shacklock. What it is General neuropathodynamics are abnormalities consistent throughout the nervous system, with specific referring to local abnormalities. These changes may lead to a neurogenic pain experience, in which pain is initiated by a primary lesion, dysfunction, or transitory perturbation in the nervous system. This definition means that dysfunction in the nervous system, it’s surrounding tissues, and innervated tissues can all be related to neurogenic pain. Definitions of Clinical Problems When discussing dysfunction, there are several descriptors: 1) Optimal/desirable: When the neuromusculoskeletal system behaves well and does not create symptoms in situations of high stress. 2) Suboptimal: Imperfect neuromusculoskeletal behavior which results in potential symptom increasing if an adequate trigger occurs. 3) Normal: Function of neuromusculoskeletal system is within normal values. 4) Abnormal: Neuromusculoskeletal system is outside of the normal range. 5) Relevant: When pathodynamics are linked to the clinical problem. 6) Irrelevant: When pathodynamics are not linked to the clinical problem. You will oftentimes have multiple of these components in a clinical situation. Mechanical Interface Dysfunction These dysfunctions deal with abnormal or undesirable forces on the nervous system. There are two main categories with their own subcategories. 1) Closing dysfunctions – Altered closing mechanisms of the movement complex. Can be reduced (protective response) or excessive (hypermobility/instability). 2) Opening dysfunctions – Altered opening mechanisms of the movement complex. Can be reduced which creates impaired pressure reduction, or excessive leading to tissue traction. Pathoanatomical Dysfunction This type of dysfunction is
Read MoreChapter 2: Specific Neurodynamics
This is a Chapter 2 summary of “Clinical Neurodynamics” by Michael Shacklock. Intro Specific neurodynamics include local effects of body movements on the nervous system. So today we will go through each body region discussing these. The Spine Here are some interesting tidbits regarding the spine and neurodynamics. When we flex the spine, the spinal canal elongates by about 9 cm. Neck flexion creates significant tension to the lumbosacral nerve roots. Neural structures slide relative to the bony interface differently depending on the location and the movement used. Flexion increases tension, but reduces compression. Extension adds compression, but reduces tension. Lateral flexion increases tension on the convex/contralateral side of the spine. This situation occurs by interface and neural tissue elongation and increased distance between the spine and periphery. Rotation closes on the ipsilateral side and opens on the contralateral side. The spinal cord tends to move towards various specific segments. These areas are termed zones of convergence, and these areas include C5-6 and L4-5. For example, tissues above C5-6 will slide toward this zone, as will tissues below this segment. The midpoint at which tissues diverge is at T6. At this point, tissues below T6 will converge towards L4-5, and tissues above T-6 will converge to C5-6. Gravity can also play a role in neurodynamics. For example, if you perform a SLR in sidelying, the downward side usually has less mobility. This difference occurs because the neural contents are convex on the downward side and convex on the upper side,
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