Question: Why deal with the extremities?

Transcription

1 Build/review foundation of: Why, When, Where & How Marni Capes, DC, CCEP, CCSP Keith G. Rau, DC, CCEP, CCSP Life University 2015 Fall CE Welcome Back All Y alls! Learn/review assessment skills for extremities Safety, Stability and Subluxation Learn/ review extremity adjusting to apply upon your return Monday morning Answer: Kinetic Chain Optimization Question: Why deal with the extremities? Begin with the why Whether care is prompted by: An injury or An understanding of the impact of the kinetic chain on: The rest of the kinetic chain The spine Injury prevention Performance 1

2 Kinetic Chain What makes up the kinetic chain? ACTIVE tissue- muscles PASSIVE tissue- ligaments, tendons, fascia CONTROL tissue- Nervous system How does it work? One link connects to another Proper function of one impacts proper function of others How does the Kinetic Chain work? Upper Extremity NS from C-spine Open kinetic chain- think load Forces transmitted proximal to distal (forces produced) Lesser impact on spine Symptoms often distal to problem/source S causes E causes W/H Suspended structures Stability- muscle driven Used by selection Lower Extremity NS- Lumbar spine Closed kinetic chain- think ground reaction forces Forces transmitted distal to proximal (ground reaction) Huge impact on spine Symptoms often proximal to problem/source F/A causes K causes H causes LB causes UE Bolted on structures Stability- ligament driven Used by default Why? Source of problem is often not where pain is located Localization does not preclude other sources or concurrent conditions Pain is not a good indicator of dysf(x) The doctor that treats the site of pain is lost. Karl Lewit Why? General Consideration For spine problem, consider looking at the extremities. Consider the impact of the spine on the extremities For extremity problem, consider looking at the spine. Consider the impact of the extremities on the spine 2

3 Impact of spine on extremities Nerve supply comes from spine Origin of muscles is often on spine Same muscles that move the extremities move the spine Spine serves as the axis of rotation Stable spine and core necessary for efficient extremities Aberrant patterns in the spine will feedback to extremities Impact of extremities on spine Act as levers upon the spine Muscle attachments Transmit forces to the spine via Ground reaction forces via LE Muscle attachments from UE and LE Aberrant stresses from or aberrant patterns of movement in extremities can perpetuate or cause spinal problems. Chiropractic Tx of LE Conditions: A Lit Review. Hoskins, W. et al. JMTP Oct :8 the demarcation of spine & periphery is often nebulous, for e.g., peripheral injuries such as hip & shoulder conditions commonly masquerade as spinal conditions, whereas peripheral injuries & dysf(x) have the potential to create spinal pain & dysf(x) through kinetic & kinematic biomechanical relationships. p 660 Core? Consider the core in every situation Functions best w feedforward neuromuscular control It is all about the NS! Consider rechecking your findings while patient does abdominal bracing 3

4 Question: When (and when not) do I adjust the extremities? Foundational apply the why just discussed and Decisions driven by assessment and experience 1. Assess safety of area of injury / chief complaint (CC) Is it safe to adjust? 2. Assess stability of area of injury / CC Is it stable enough to adjust? 3. Assess area of injury / CC for presence of subluxation / fixation Is the joint subluxated Management Criteria- Safety? Is there: Frank contraindications? Fracture Dislocation Pathology Underlying condition Reservations/Precautions What is the pt s pain tolerance? What is your comfort level? 4

5 Safety- Mechanism of Injury (MOI) Consider closely the MOI- 3 Considerations: 1. Forces involved 2. Position of joint a. Closed pack or Open pack b. Open or closed kinetic chain 3. Time of episode a. Quick / short b. Slow / insidious / gradual c. Long period of time Management Criteria- Stability? HOPS History Observation Palpation Special tests- Perform orthopedic evaluation of injured area or areas of pain Orthopedic Considerations If patient has- ROM Tenderness in or around joint Weakness on strength test (+) orthopedic test (with exceptions) it may be an indication to perform RMT and eval to consider adjusting (+) Orthopedic test Contraindication or indication to adjust? Referral for orthopedic surgeon consult & possible imaging You decide whether it is a good idea or not to adjust 1. Frank injured joint and/or region 2. Symptomatic- NAI, indirect injury 3. Asymptomatic but accommodating Evaluation guides care and we tend to only find what we look for 5

6 Management Criteria- Subluxation? How do you assess the need to adjust a particular extremity or the kinetic chain in general? Manual muscle testing based on the mechanoreceptor theory which is based on Hilton s Law For most of the lower extremity we also assess joint motion. Question: What is the role of subluxation? KEY! Based on the following model Lephart, Fu, Downes Potential/re-injury Injury 4 Ligamentous Injury 5 Instability 6 VSC Proprioceptive Deficit 1 Question: How do we manage patients with extremity problems? Functional Instability 3 Decreased neuromuscular control 2 It is as easy as 6

7 1, 2, 3 Paradigm- design-driven management paradigm 1. Neurological 2. Joint Motion 3. Soft Tissue Optimized? Perfect results? Complete healing? What would happen if 1, 2 and 3 were optimized? Is what you do the starting or ending point? Do not forget SAID!!! Local, Regional or Global Injury to a specific joint- Local Region impacted by injury or nature of activities/sport- Regional Impact of any problem on the rest of the system- Global Are you looking at the big picture or only the little one? Kevin Hearon, DC 4 Books- Field Manuals 1. What You Need to Know About Extremity Adjusting 2. Advanced Principles of Upper Extremity Adjusting 3. Advanced Principles of Lower Extremity Adjusting 4. Foot, Gait and Orthotics Wall charts, DVD s through Consider the CCEP program offered at Life U and other sites around the world Performance for Life (PFL Method) John Downes, DC Tom Michaud, DC Human Locomotion- Textbook 7

8 Free Podcasts BJSM Chiropractic Biophysics The Gait Guys Podcast Gray Cook Radio JBJS Physioedge Podcasts from the Cochrane Library Stop Chasing Pain 8