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
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Chapter 5: Interaction of Psychological and Emotional Effects with Breathing Dysfunction
This is a chapter 5 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. Intro This chapter is dedicated to showing the connection between the body and consciousness; how our psyche is influenced by breathing and vice versa. This chapter was easily my favorite out of the entire book. Breathing Strategies Optimal breathing involves moderate abdominal expansion, some intercostal involvement, and minimal involvement of accessory muscles. Conversely, chest breathing is dominated by accessory muscle use. These two breathing styles are merely end points on a continuum rather than discrete categories. In terms of which strategy is used, chest breathing is often the preferred route for consciously mediated intentional breathing; whereas abdominal breathing is the main route for relaxed, automatic breathing. One reason you would want to override automatic breathing is to prepare for sudden action. At the onset of exercise, ventilation immediately jumps. This change occurs via three phases, with the first phase occurring independent of exercise load. This phase is a conscious exercise preparatory action. The other increases occur as exercise demands increase. When we are in an emergency situation, these breathing phases change. Prior to the initial pre-action deep breath comes a breath holding phase, which helps increase sensory organ stability. These preparatory breathing changes are great for imminent danger or action, but problematic when threats are non-physical and in the future. While
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 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 MoreOnline Consult with The Manual Therapist
The Rundown My good friend Erson Religioso of The Manual Therapist fame recently contacted me to do a consult for some back/leg trouble he has been having. It was a very interesting eval for many reasons. Online consults are a completely different animal, as you cannot do any hands-on testing. Moreover, when you have a therapist who is initiated into pain neuroscience, you don’t have to go so much the Explain Pain route 🙂 So with this eval, we looked at things a lot through a PRI lens, and were able to get him strategies to modulate his pain experience. The eval runs a smidge over 1 hour, so here are some vids with a quick rundown. Subjective – Getting paresthesia down the R LE that began 2 weeks ago after a car ride…has peripheralized since initial event. – Symptoms are aggravated with static sitting or standing…onset ranging from seconds to minutes. – Has tried loading/unloading MDT strategies, neurodynamics, Mulligan techniques, IASTM, compression wrapping, etc…all to no avail. Objective (major findings) – Limited B Apley’s scratch (1 per FMS scoring) – Negative slump and ASLR – Painful lumbar motions of extension, right rotation and sidebend. R sidebend was limited. – Negative thomas test on left, positive on right – Slight limitations in active seated hip IR B, R>L. – Adduction lift scores 1/5 B. My Impression If I were to classify Erson, it seems his symptoms would seems to be more dominant as peripheral nociceptive ischemic and central sensitivity (he stated he has
Read MoreChapter 6: Planning the Physical Examination
This is a Chapter 6 summary of “Clinical Neurodynamics” by Michael Shacklock. Observe When assessing the patient, you must look at the following information: Symptom location, extent, quality, and behavior. Movement resistance. Range of motion. Compensatory patterns. Breathing quality. Tone of voice. Facial expression Protective muscle tone. Avoidance. When planning the exam, you can tier to what extent you ought to assess someone. Level 0: neurodynamics are contraindicated for physical or psychosocial reasons. Level 1: Limited exam where symptoms are minimally provoked. Full neurodynamic tests are not performed, and are tested separately from musculoskeletal structures. The neurodynamic tests are performed with relieving-based structural differentiation. Level 1 is indicated when… Symptoms are easily provoked and take a long time to settle after movement. Severe or latent pain is present. Potential pathology. Neurological deficit. Progressive worsening prior to exam. Level 2: Standard examination in which neurodynamics, interfaces, and innervated tissue are tested separately. Standard neurodynamic sequences are used and symptoms can more readily be brought on. Level 2 is indicated when… Less severe, latent, or easily provoked symptoms. Absent/minor neurological symptoms. Stable problem that is not rapidly deteriorating. Level 3: It’s gettin’ real. Here we see greater force localization and sequences that start at the problem. Sensitizers are often used as well. Level 3 is indicated when… Level 2 exam is normal or provides insufficient information. Symptoms are not severe or easily provoked. Problem is stable. No evidence of pathology. There are four examination types here: 3a) sensitizers are added. 3b) Begin
Read MoreChapter 5: Diagnosis with Neurodynamic Tests
This is a Chapter 5 summary of “Clinical Neurodynamics” by Michael Shacklock. Neurodynamic Tests In neurodynamic tests, there are two movement types: 1) Sensitizing: Increase force on neural structures. 2) Differentiating: Emphasizing nervous system by moving the neural structure as opposed to musculoskeletal tissue. The reason why sensitizers are not considered differentiating structures is because they also move musculoskeletal structures. Examples of sensitizing movements include: Cervical or lumbar spine contralateral lateral flexion. Scapular depression Humeroglenoid (HG) horizontal extension HG external rotation Hip internal rotation Hip adduction Interpreting The ability to interpret neurodynamic findings is crucial when determining the nervous system’s involvement. Findings such as asymmetry, symptoms, and increased sensitivity are all important. But to implicate neurodynamics, structural differentiation ought to be performed. Just because there is a positive test does not mean that it is relevant to the patient’s complaints. There are several ways to classify findings: Negative structural differentiation: Implicates musculoskeletal response. Positive structural differentiation: Implicates neurodynamic response. Neurodynamic responses can have different interpretations: Normal: Fits normal responses per literature. Abnormal: Differ from normal responses. Can be broken down further into… Overt abnormal responses: Symptoms reproduction. Covert abnormal response: No symptoms, but may have other subtle findings such as asymmetry, abnormal location, and/or different resistance. From here, one must determine if the findings are relevant or irrelevant to the condition in question. You may also come across subclinical findings, in which the neurodynamic test is related to a minor problem that may become major at some point.
Read MoreCourse Notes: Mobilisation of the Nervous System
I Have an Addiction It seems the more and more that I read the more and more and read the more and more addicted I become to appreciating the nervous system and all its glory. To satisfy this addiction, I took Mobilisation of the Nervous System with my good friend Bob Johnson of the NOI Group. This was the second time I have taken this course in a year’s span and got so much more value this time around. I think the reason for this enrichment has been the fact that I have taken many of their courses prior and that I prepared by reading all the NOI Group’s books. A course is meant to clarify and expand on what you have already read. So if you are not reading the coursework prior, you are not maximizing your learning experience. What made this course so much more meaningful was being surrounded by a group of like-minded and intelligent individuals. As many of you know, I learned much of my training through Bill Hartman. Myself, Bill, the brilliant Eric Oetter and Matt Nickerson, my good friend Scott, and my current intern Stephanie, all attended. When you surround yourself with folks smarter than you, the course understanding becomes much greater. This course was so much more with the above individuals, so thank you. Try to attend courses with like-minded folks. Here are the highlights of what I learned. If you would like a more in-depth explanation of these concepts, check out my
Read MoreLessons from a Student: The Brain
Oh It’s On Believe it or not, I currently have someone interning with me for the next 12 weeks which is has led me to thinking about many things: 1) People trust me with the youth of America? 2) I have to justify what I am doing now? 3) I hope I can teach her something. It has been a great and even nostalgic experience thus far. I remember just a couple years ago being in this young lady’s shoes having the same successes, failures, and questions she has now. I think working with me may have been quite a difference from the scholastic framework that she was accustomed to. This difference is because our common theme for the week was wait for it…………………………………….The Brain. Most schools, especially in the orthopedic realm, teach about developing physical therapy diagnoses and treating various pathologies. However, we had a couple different cases in which we didn’t necessarily nail down a pathology yet got fantastic results. Case 1 The first patient we saw was a lovely middle-aged woman who was classic for the biopsychoscial treatment model I espouse. She comes into seeing us with chronic low back pain over the past 3 years, has had several TIAs, been diagnosed with an eating disorder, and generally lives a stressful life. Our comparable sign for the day was flexion which was at 50% range and painful (or DP for you functional movement folks out there). We discuss what we think is going on and the first
Read MoreExplain Pain Section 6: Management Essentials
This is a summary of section 6 of “Explain Pain” by David Butler and Lorimer Moseley. Management 101 The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain. Tool 1: Education Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery. Here are some important concepts to be known about explaining pain. Anyone can understand pain physiology. Learning about pain physiology reduces pain’s threat value. Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life. Tool 2: Hurt ≠ Harm It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay. Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take
Read MoreExplain Pain Section 5: Modern Management Models
This is a summary of section 5 of “Explain Pain” by David Butler and Lorimer Moseley. So Many Clinicians There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain. Here are some general guidelines for someone dealing with pain. Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination. Make sure any prescribed help makes sense and adds to your understanding of the problem. Get all your questions answered. Avoid total dependence on any practitioner. Make sure your goals are understood by you and the clinician. The clinician’s ultimate job is to assist you in mastering your situation. Models of Engagement There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain. The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro. The Onion Skin Model – Helps describe all the factors that go into the pain experience; including nociception, attitudes and beliefs, suffering, pain escape behaviors, and social environment. Fear-based models – Fear of pain and reinjury are major forces
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