I) Regional Interdependence: How Functional Pathology Limits Performance

Transcription

1 I) Regional Interdependence: How Functional Pathology Limits Performance Craig Liebenson, D.C. L.A. Sports and Spine Los Angeles, CA I) Medical Diagnosis is Important Rule out red flags Tumor Infection Fracture Medical Management Rule out red flags Investigations (e.g. imaging) Prescriptions Interventionist Management for nonresponders (injections/surgery) 1

2 The Scope of the Problem LBP more costly than heart disease 5% of US population permanently disabled More time missed from work than anything but common cold 7 years of poorer quality of life Most common LBP Shoulder Neck Knee Widespread DISABILITY EPIDEMIC Each year 5-10% of the population consults w/ a GP for LBP. A year later nearly 75% still have pain or disability a year later! The Disability Epidemic There is nothing to be done Patients report GPs don t take MSP complaints seriously Medication & Brief advice usual care does not match evidence-based care 2

3 Failures get expensive management/imaging Epidural Steroid Injections >400% MRI - >300% Lumbar Fusion Surgery - >200% Opiod Use More Imaging Centers A Good Thing? Researchers at Stanford University found (Baras): The more imaging centers The more MRI s ordered The more Surgeries Performed Does Structure Govern Function? 3

4 GAP Can We Bridge the Gap? INJURY CARE REHAB Bridge the Gap: The Continuum of Care (after Falsone) Training Continuum ATHLETIC DEVELOPMENT PERFORMANCE Can We Bridge the Gap? MD Diagnosis PT, ATC, DC Pain Mgmt S/C COACH Agility/Balance/Coord Pain Mgmt Manual Therapy Strength/Endurance Reassurance Stabilization Reassurance Speed/Power Motivation Recovery SKILL COACH Technique Equipment Strategy Psychology 4

5 What is the Role of Medical Dx? The medical diagnosis will give us contraindications to treatment rather than a treatment plan. Gray Cook, PT II) Regional Interdependence He who treats the site of pain is lost Karel Lewit, MD we must assess and treat dysfunction away from the patient s primary location of pain. Can Thoracic Spine Affect Other Areas? This refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with the patient s primary complaint. I don t touch a patient until I have examined everything. I want to know what is the relevant chain. I begin with a general picture, not a single lesion. K Lewit How About the Hip? 5

6 The Kinetic Chain Arm and Shoulder Scapula Thoracic and Lumbar Spine Hips and Pelvis Legs and Feet What Evidence is There? III) What Happens After Injury? Surprisingly, plenty R Wainner,

7 Guarding after an injury is normal Safe Mode after an injury tissues heal, but muscles learn, they readily develop habits of guarding that outlast the injury Janet Travell, MD White House Physician, President John F Kennedy According to Stanley Herring "signs and symptoms of injury abate, but these functional deficits persist... adaptive patterns develop secondary to the remaining functional deficits." Herring SA, Rehabilitation of muscle injuries. Med Sci Sports Exer 1990;22: Pain vs. Dysfunction pain & dysfunction, regardless of their origin, alter motor control. That is why initially we focus on training the most dysfunctional, non-painful pattern. 7

8 What is the #1 Risk Factor for Future Pain or Injury? Previous pain or injury Why? The influence of ankle sprain injury on muscle activation during hip extension Significant delay in onset of activation of the gluteus maximus on the injured side Bullock-Saxton JE, Janda V, Bullock MI: Int J Sports Med 15: , 1994 Is Compensation the Rule or Exception? Who are the Kings of Compensation? IV) Are There Rules? 8

9 Joint by Joint Approach The Shoulder - Mobility or Stability \ The Lumbar Spine - Mobility or Stability? I don t care how much the spine moves, I care how well it moves Pr Stuart McGill 9

10 What About the Thoracic Spine? Layer Syndrome Muscle Hypotrophy & If a muscle tests 5/5 does that guarantee normal function? Is the strongest person the best athlete? Stability enhances performance the brain thinks in terms of movements, not individual muscles 10

11 Prague School Rule Goal: Remediation of Faulty movement patterns Stretch tight muscles before strengthening weak ones Why? MOBILIZE/STABILIZE AE Homewood, D.C. We find things that are stuck and get them moving, and find things that are moving too much and tighten them." 11

12 Mobility vs Stability Faulty Hip Extension Pattern - mobility vs stability SFMA In general, reduced movements seen in passive assessments suggest that mobility problems are likely. A stability problem might be likely when active movement is limited in loaded or unloaded positions, or both, and when passive testing is normal. Is a Mobility Problem Always Primary? Acc to Janda, Increased muscle tone can be due to a # of different factors Muscle Spasm- A Proposed Procedure for Differential Diagnosis. J Man Med 1991;6:

13 1. Dysfunction of the limbic system 2. Impaired function at the segmental (interneuron) level 3. Impaired coordination of muscle contraction (trigger points) 4. Response to pain irritation 5. Overuse (which is usually combined with changed elasticity of the muscle and usually described as muscle tightness) Clinical Audit Process (CAP) Find what works the patient should experience the results Within-session reassessment was shown to predict between-session improvement If post-tx audit of MS showed improvement those pts were at least 3.5X more likely to have between session improvement Hahne A, Keating JL, Wilson S. Australian Journal of Physiotherapy 2004;50: Assess/Correct/Re-assss Gray Cook (p115) The system in a nutshell: 1. Set a movement path baseline assess 2. Locate and observe the movement problem prioritize 3. Use corrective measures aimed at the problem treat 4. Revisit the baseline Re-assess V) Management 13

14 When vs What Not a question so much of WHEN to mobilize or stabilize As WHAT to mobilize or stabilize Why? Tightness is often compensatory - protective Tension related - emotional Steps 1. Reassurance - cortisol, apical breathing 2. Recovery - de-inflamme, re-set 3. Rehab - faulty movement patterns (mobilize/stabilize) (myelinate) 4. Reconditioning - (S & C) (power) 1. Reassurance: Impairment/pathology does not = disability 2. Recovery Local manual treatment, even when effective, may address the acute symptoms but often cannot correct the underlying cause, which is altered control of the postural motor program 14

15 3. Rehab Postural-Motor Program 1. Upright Posture 2. Core/Respiration 3. 1 Leg Stance Assess/Assess/Assess Time spent in assessment will save time in treatment V Janda Every Exercise is a Test Every Exercise is a Test 15

16 The Hip Hinge p304, 645 ROS Faulty Biomechanical Movement Pattern - Running Ideal Upright Mechanics Faulty Slouched Posture Faulty Biomechanical Movement Pattern - Stepping Faulty Pelvic Unleveling Ideal Posture Faulty Biomechanical Movement Pattern - Reaching Ideal arm raising w/ shoulder relaxed Poor pattern due to shrugging the shoulder up 16

17 What is Goal? Acc to Cook, the goal is fastest to 14, not 21 Acc to Lewit, the goal is not to teach perfect movement patterns, but to correct the key fault that is causing the trouble. John Wooden "The importance of repetition until automaticity occurs cannot be overstated. You Haven't Taught Until They Have Learned by Gallimore & Nater Stages of Learning Unaware of Dysfunction - Most people Aware of Dysfunction - Start Aware of Correction - Fatiguing Subcortical Correction - Goal/new engram " minimize the conscious awareness phase and find something the patient does well automatically as soon as possible V Janda To enhance myelination of CNS pathways TRAIN at the limit of patient s capability to automatize in the subconscious a new motor program 17

18 Core Stability The spinal column w/out muscles buckles at a load of 90 N (20 lbs) This large load carrying capacity is achieved by the participation of wellcoordinated muscles surrounding the spinal column M Panjabi Joint System Muscle System Central Nervous System Stable to unstable Uniplaner to triplaner Isolated to integrated Non-weight bearing to weight bearing Progressions Passive modelling Active assistance Active Resistance 4. Re-Conditioning Stability to Performance The Athlete s Goals: Power & Performance 18

19 Skills Pyrelli Tyre Faulty Biomechanical Movement Pattern - Landing a Jump 19

20 POWER Million-dollar question" - FINE LINE BETWEEN BUILDING & BREAKING The objective of injury prevention strategies is to ensure that tissue adaptation stimulated from exposure to load keeps pace with, and ideally exceeds the accumulated tissue damage. Stuart McGill, Ph.D. Sacred Cows: Science Explores Hypothesis Muscle activation vs Spine load during exercise 20

21 Sed Elite Sports Capacity should exceed demand! Triple Flexion for Triple Extension Developmental Kinesiology 21

22 Punctum Fixum What enhances performance prevents injury Ball & Socket Joints Require a Fixed Core "Usually, working out is about aesthetics sixpack abs and biceps and pecs instead of true functionality. True function has a different aesthetic appeal."