Thoracic Dysfunction & Groin Pain When to Look Beyond the Hip

Transcription

1 Thoracic Dysfunction & Groin Pain When 2018 Dr. Linda-Joy Lee This is a resource document only. All rights reserved. No part of this document may be reproduced, distributed, or transmitted in any form or by any means, including photocopying or other electronic or mechanical methods without expressed written consent from Dr. Linda-Joy Lee.

2 Thoracic Dysfunction & Groin Pain When to A Whole Person Approach to Groin Pain Linda-Joy (LJ) Lee, PT, PhD Groin Pain a Challenge Common in sports involving sprinting, kicking, and twisting motions e.g. soccer, ice hockey, running, tennis, AFL Also common postpartum, especially as mums return to activity, postpartum athletes returning to high level sport Previously poor agreement on diagnostic criteria à Recent Doha agreement (2015) Classification based on Clinical Examination of Structures in the Groin Slide on classifications Weir A, Brukner P, Delahunt E, et al. Br J Sports Med 2015;49:

3 Doha Agreement - Classification 1. Defined entities: Adductor related Iliopsoas related Inguinal related Pubic related 2. Hip related groin pain (from the hip joint) 3. Other causes/ conditions (referred pain, hernia, serious pathology) Weir A, Brukner P, Delahunt E, et al. Br J Sports Med 2015:49: Say Good-bye to. Sports groin, sportman s groin Sports hernia, sportman s hernia Gilmore s groin Hockey groin Adductor/ iliopsoas tendinopathy/ tendinitis Osteitis pubis Athletic groin pain Athletic pubalgia Groin Pain a Challenge Often in the same patient there are multiple origins of groin pain 42% of patients (Holmich 2007) 27% (Lovell 1995) But - Why are these 44% (Weir, A structures 2017) becoming painful? Weir A, Brukner P, Delahunt E, et al. Br J Sports Med 2015:49:

4 Common Clinical Finding Loss of Centred Femoral Head/ Optimal Axis of Motion Common w/ Adductor-related & Iliopsoas-related Groin Pain Hip-related Groin Pain Altered neural drive to muscles around the hip some muscles overactive, others underactive (altered resting tone/ activity) Strength Imbalances, Fascial and capsular changes Courtesy of Andrew Wallis, Melbourne Changes axis of joint motion and alters distribution of joint loading forces Assessing Femoral Head Control During Functional Movement Meaningful Task Analysis (Lee LJ 2008) Altered axis of femoral head motion à overload of multiple structures bone, labrum, muscle, tendon excessive compression and/or tensile forces à multiple painful tissues due to Exhausted Adaptive Potential Hip Driven Groin (EAP) (Pettman, E) Pain Femoral head palpation: Lee & Lee 2004, Sahrman, Johnston & Smidt 1969 Current Evidence Treatment High quality studies are lacking Active programs improve treatment success vs passive programs Multimodal programs including some manual soft tissue work can facilitate faster return to play but not higher treatment success compared to active physical training program Recommended Rehab programs are focused on restoring abdominal wall, pelvic girdle, and hip muscle function Serner A, van Eijck CH, Beumer BR, et al. Br J Sports Med 2015;49:81 3

5 Elite Runner 1500 m Diagnosis of right adductor strain deep insertional pain at pubic bone injured during altitude training camp 2 nd week of intensity, fullness & pressure in groin, no inguinal hernia à Need to consider whole body movement strategy & the role of the thorax in trunk control The Thorax A Key Part of the Trunk & the Whole Body Largest region of the vertebral column ~ 20% of overall body length (vs. lumbar spine 12%, cervical spine 8%) (Gray s anatomy, 2008) Up to 35% of body mass (Winter 2009) Thorax - complex arrangement of vertebrae, ribs, cartilage, sternum/manubrium plus internal cavity (Gray s anatomy) Thorax = Thoracic Spine + Ribcage Thoracic Ring Approach Evidence for the Ring Strong anatomical attachments between thoracic spine & ribcage at all levels 5 th ring = T4-T5, right and left 5 th ribs, anterior attachments to sternum 4

6 Thoracic Ring Approach Evidence for the Ring Biomechanical studies Location of axis of rotation for thoracic spine only measures on specimens with intact rib cage slice were accurate (Molnar et al, Spine 2006) Changes in sagittal posture (slump, millitary) result in 3-D changes in Ring shape (Lee LJ et al, Respir Physiol Neurobiol 2010) Myth the thoracic spine and ribs function independently Functional Spinal Unit = Ring Vertebra-disc-vertebra, 2 Need ribs Ways (left and to right), Assess & Treat the anterior attachments to Thoracic Ring sternum Fact à The thoracic spine and ribcage function in a very integrated manner Thoracic Ring Techniques Developed in the Context of Functional Movement Analysis à Meaningful Task Analysis (Lee LJ 2008) Pain-Free Thoracic Ring Dysfunction à alters loading at distal sites Elite Runner with Recurrent Adductor-Related Groin Pain 5

7 Thoracic Ring Palpation Palpation via Anterolateral, Lateral, Posterolateral Ribs Identify Non- Optimal Behaviour for the Task Compression, Loss of Dissociation, Loss of Ring Dance assess 3D integrated function of the Ring - due to strong anatomical attachments the lateral palpation reflects the vertebral motion Inter-ring movement occurs during function new component Need dissociation between rings Visible on X-ray & MRI What is Optimal Behaviour of the Thoracic Rings? Rotation & Sidebending largest neutral zones Conjunct Lateral Translation of Ring Ant & Post translation Flex/ Extension (smallest neutral zone) Vertical loading capacity The Thorax is the Centre of Trunk Rotation 6-22 rotation per segment 2-4 flex-ext per segment Compare to 1-3 in the lumbar spine Ring Dance (LJ Lee 2002) Lateral translation of entire Ring, conjunct with Rotation and Lateral Flexion, conjunct with anterior/posterior rotation of ribs & vertebral rotation motion occurs at all joints of the ring and relative to the rings above and below 6

8 Meaningful Task Analysis - Thoracic Ring Palpation to Assess for Non-Optimal Behaviour during Functional Tasks Strategy Task Mismatch Not matching the correct strategy to task demands NOLT = Non-optimal Behaviour Relative to the Task being Performed Reference What is Optimal Ring Function for the Task? Non-Optimal Neuromuscular Patterns in the Thorax Impact the Rest of the Trunk, the Structures involved in Athletic Groin Pain, & the Rest of the Body Optimal strategies for function & performance require coordinated activity of all the muscles of the trunk Thoracic ring dysfunction affects optimal trunk muscle recruitment & can drive low back, PGP, and multiple types of groin pain Thoracic Driven Pelvic Girdle Pain & Groin Pain What exactly is a Correction? Diagnostic Test Temporary Optimization of the Functional Behaviour & Neural Representation of that Region in order to predict the impact of treating that Region on the whole person The how-to of a correction is to manually create and support optimal Alignment, Movement & Control first in the starting position and then through the Meaningful Screening Task 7

9 Left Trunk Rotation with and without Thoracic Ring Correction Left Rotation à Right Ring Translation What is If it is truly stiff how can it change so quickly? underlying impairment? Left Translation of 8 th Thoracic Ring = Optimal for Right Trunk Rotation but Non-Optimal for Left Rotation How Many Movement/ Control Options Does this Patient Have for the 8 th Ring? One Strategy used across all tasks left translation/ right rotation of the 8 th ring Loss of Options & Movement Variability at this region of the thorax Strategy Task mismatch for anything other than right trunk rotation activities Myth The Thorax is Inherently Stiff & Stable due to its Form The Thorax is Inherently Flexible 13 joints per typical ring = 136 joints that move & thus require neuromuscular control 8

10 The Thoracic Ring Approach New View of the Thorax Flexible Stack of Rings with Need for Neuromuscular Control & Muscle Balance to Support Multiple Movement Options Multiple Non-Optimal Patterns Possible Consider all the muscles around the thoracic rings and their connections What is the Impact of Muscle Imbalances and Altered Motor Control around the Thoracic Rings? Runner unable to perform plank due to LBP, head feels like going to explode Thoracic Driven LBP 9

11 Thoracic Rings Common Driver for Asymmetrical Oblique & RA Function, Inability to Train Synergistic Abdominal Wall Function Without Thoracic Ring Correction Asymmetrical IO/EO & Inability to Recruit Transversus Abdominis on the Right Side With Thoracic Ring Correction Symmetrical Contraction LJ Lee 2002 Thorax & Abdominal Function Thorax provides attachment & innervation to all abdominals Dysfunction in thorax is common driver for dys-synergies of deep and superficial abdominal muscles The Functional Thorax & Gravity Zazulak et al 2007 ACL Injury & Lateral Trunk Control Lateral Translation is Component of Normal Behaviour of Each Thoracic Ring Need Options Adjustor for COM/BOS postural equilibrium esp. to lateral perturbations Hip Thorax Strategy Needed to Maintain Body over Base of Support 10

12 If lose options for both L/R Translation of each Ring à affects WB position over BOS Chloe 13 y.o. elite tennis player trains 5-6 days/ week Insidious onset left inguinal hernia, painfree surgery Jan Coach referral athlete no concerns, was given some abdominal training ball roll-outs, planks Post-Sx - Tenderness to palpation exists below incision at medial PS and along medial inguinal ligament Net COM over BOS Left In Serve stays left & Increases left Thorax Initiates Left Translation with all Tasks at 5 th Ring Initial Assessment & Post-Rx #2 11

13 Thoracic Dysfunction can create imbalances between Intra-Thoracic & Intra-Abdominal Pressures High Potential for Future Injury Groin, Pelvis, Pelvic Floor Non-optimal Strategies Create Excessive Intra-Abdominal Pressure (IAP) Pressure Belly à Excessive Fascial Load & Facilitate Herniation Likely Multiple Mechanisms for Thoracic Driven Hernias, Incontinence & Prolapse Kyphosis & Lordosis are Not due to Excessive Flexion-Extension but AP Translation my mom is always telling me I have bad posture effortless change in posture 2 Treating the Rings 3-Dimensionally treatments to Corrects AP Posture Thoracic Ring Driver 12

14 Gait & Thorax Driven Foot Pain tendinopathy, fasciosis, etc Foot Can Also be a Common Secondary Driver to the Thoracic Rings Groin can be Victim in between Thorax & Foot A Healthy Thorax has Options & Space Retrieved from motorcyclesuperstore.com Trunk spring for compressive loads, Give in the system, Energy storage for recoil SNS Fight, Flight or Freeze Heart palpitations (medical workup clear) GI function smooth muscle facilitation Anxiety, emotional lability Immune system relationships SNS sensitization distinct entity from PNS & CNS sensitization 13

15 Broadening Our View Consider the Connections Throughout the Body When to treat the Hip? When to look beyond the Hip? Need a whole body, whole person assessment & treatment framework Consider more than pain evaluate all areas for dysfunction during movement à use clinical tests to relate presence of dysfunction to symptoms & predict response to treatment Need a robust clinical reasoning process Which whole body tasks are chosen? The power of the Meaningful Task Meaning Construct Incorporates Emotional and Cognitive Aspects, Contextual aspects 14

16 Meaningful Task Analysis (MTA) Assessment Framework to Find Drivers (Lee LJ 2008) Multiple Signs of Non-Optimal Strategy Where to input to make most efficient change? Meaningful Task Analysis (MTA) Assessment Framework to Find Drivers (Lee LJ 2008) You ll make his right hip feel better, but he ll get pain somewhere else or change will be temporary Correcting the Right Hip Makes the Upper Thorax Translate Left/Rotate Right, and Makes the Left Foot Loading Non-Optimal Correct The Primary Driver Other Areas of Non-Optimal Load Transfer, Experience & Task Performance Improve 4 th / 3 rd Ring Correction Fully Corrects Hip à Thorax Driven Hip The Thoracic Ring Approach 15

17 What is A Driver? A region of the body that is in dysfunction perhaps because of an old Injury, movement habits over time, or a new injury A Driver is not a specific impairment in a system It is the way in to make the biggest change in symptoms & movement the underlying cause, not just the victim A Driver may or may not be painful but it is not functioning in an optimal way to support performance of your meaningful task Manual correction of the Driver creates neurophysiological changes throughout the body Find the Driver to Prioritize Where to Assess for System Impairments to Direct Treatment Treatment Focused to Impairments of the Driver & Relevant Psychosocial Influences Correct the Driver & Assess Impact on Meaningful Tests Moderate to Severe OA Changes on Imaging Correct Rings 3/4 à Significant Increases in ROM esp. ADD & IR 16

18 How do we Change Strategies? It Depends on what is Driving the Non-Optimal Strategy Neck? The Drivers are the Way In to the Nervous System to Change Strategies & Experiences In Pelvis? Thorax-Driven Cases, Treating the Thoracic Rings Lumbar is the Key to Unlock Change in Spine? Patient Experience & Strategies Foot? Right Foot Driven Right Hip Impingement Pain & Decreased ROM Right Foot Correction Fully optimizes both Right and Left Hip Function à treat the foot to rehab the Hip Cervical Driven Hip Impingement To Restore Hip Function Treat the Neck It s All Connected. 17

19 Athletic Groin Pain Future Directions Also for Knee Pain, Tendinopathy etc. Perhaps in our focus on the individual injury sites, we have lost sight of the larger view, and we suggest that, in the future, research into AGP should spend less introspective focus on trying to subclassify into anatomically painful structures but on the resolution of painful propagative movements in rehabilitation and injury prevention Franklin-Miller A, Richter C, King E et al, Br J Sports Med 2017; 51: Connectedness Essential for Optimal Health Experience: My right catch is weak when I swim Primary Driver: Foot A Broader Framework to Assess & Treat the Thoracic Spine & Ribcage Clinical reasoning framework to determine when and when not to treat the thorax to restore optimal function and performance for whole body tasks When is the thorax the Primary Driver for distal pain & whole body function? à these principles became part of the ISM (Lee & Lee 2007) & were further evolved in ConnectTherapy 18

20 Whole Person Clinical Reasoning Models Developed using a systematic process in the clinic, evidence-informed: determine the connections between non-optimal movement strategies, dysfunctional regions, and symptoms/ undesired experience & lack of function Incorporate emotional & cognitive features à Meaning Construct biopsychosocial models Use corrections & clinical reasoning algorithm to predict who will respond to treatment in one area vs. another rather than by trial and error, pattern recognition, or intuition Need to consider more than pain, more than regional impairments, more than psychosocial features To Change Strategies & Create Positive Experiences Need to Understand How Everything is Connected Thank You! If I have seen further it is by standing on the shoulders of giants Isaac Newton,

21 Thank You! All my patients and mentors who share their journeys and challenge us all to keep learning, thinking, feeling and questioning so that we can help our patients do the things they love 20