nhpc calgary 2013 stretching for chronic conditions

Stretching for

Chronic conditions

2 day workshop

This workshop will take you through some of the more common chronic conditions seen by the therapist and how to affectively treat them with stretching. Stretches can be used to lengthen muscle, tendon, myofascia, and the connective tissue that houses the peripheral nervous system.

Learn to assess which type of stretch will produce the most effective outcome; PNF, MET, passive, active and neural tethering techniques will be demonstrated and practiced to normalise soft tissue length.

Student HandbookFirst Edition

Paula Nutting, BHSc MST, Dip REMReg Nurse, Cert IV in Fitness

Stretching for Chronic Conditions NHPC Spring Conference Calgary Alberta 2013

Table of contents

Definition of Stretching 3

– Stretch & Tendon Reflexes 4– Indications and Contraindications

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Proprioceptive Neuromuscular Facilitation 6 – 7

Muscle Energy Techniques 8

MET diagram 9

Assisted Stretching 11

Neural Tethering 11

Conditions for discussion

– Tension and Cervicogenic Headaches

11

oTreatment options

12 - 14

– Shoulder Impingement/tendinopathy 1 4 -

15

oTreatment options

16 – 19

– Pelvic Rotations and Torsions

19

o Treatment options

20 – 23

– Hamstring Tendinopathy

24

Paula Nutting – PNHands On BHSc MST(TEAC) Dip Rem Mass, Reg Nurse, Cert IV Fitness

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o Treatment options

24 – 25

– ITB Friction Syndrome

26

o Treatment options

26 – 27

Bibliography 28

Definition

What is chronic pain and how does it apply to the manual therapist?

Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain,[ though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months. A popular alternative definition of chronic pain, involving no arbitrarily fixed durations is "pain that extends beyond the expected period of healing." Wikipedia

Chronic pain is that which lasts a long time (over six months) and is not relieved by standard medical management. Chronic pain may result from a previous injury long since healed. Or it may have an ongoing cause, such as arthritis, cancer, nerve damage, or chronic infection. With chronic pain, normal lifestyles can be restricted or even impossible. Many people suffer with chronic pain, unaware that


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http://en.wikipedia.org/wiki/Chronic_pain#cite_note-Turk1-0%23cite_note-Turk1-0

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Acute


there are a variety of treatment options that can help them live more normal lives. Drudgel (which is a pharmacological site)

Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years. Department of Health and Senior Services

Although chronic musculoskeletal pain significantly affects populations of working age there is clear evidence that musculoskeletal pain, in particular, increases with age with an ageing population it is therefore likely that musculoskeletal pain in the community will increase. But there are also other factors that may lead to an increasing burden of musculoskeletal

pain. These include the association of musculoskeletal pain with obesity—an epidemic of which is occurring around the world. In both sexes, self-reported work-restricting pain in the neck and back area and in hip, knee and ankle joints Oxford Journals Rheumatology

Chronic conditions most commonly occur because of overuse, misuse, disuse, abuse, which most often is of a repetitive nature. Depending on the type of movement patterns will produce strain on soft tissue or bony tissue; we can discover through appropriate history what is the most common structures affected.

Chaitow and DeLany discuss at length both Upper and Lower Cross Syndromes and how common poor postures can create a myriad of muscle imbalances which will compromise the homoeostasis of the human system. Muscles and tendons change their resting length and the muscle tension curves are altered in such a way that muscles loose strength, length, tonus, firing capabilities and hypertonic fascicles bundle to create trigger points.

The therapist can use skills to treat Tendon, Ligaments, muscles, joints and nerves. We will be practicing on techniques that will alleviate stresses on the body by returning soft tissue lengths to ease compression or distraction at the joints and the peripheral nervous system. Our profession works at a hands on level and through effective study we can define where we can be most effective.

What is Stretching

Simply put Stretching is any therapeutic manoeuvre designed to increase mobility of soft tissue and subsequently improve ROM. This is done by elongating structures that have adaptively shortened and have become hypomobile over time.

Physiology of the Stretch Reflex


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It is a monosynaptic reflex arc which lowersthe antagonist tone (reduces motor stimulation). It occurs as the result of a neurological loopwhere the muscle spindle of the agonist isstimulated and sends an afferent signal to the CNS. It operates as a feedback mechanism tocontrol muscle length by causing musclecontraction.

Physiology of the Tendon Reflex

This operates as a feedback mechanism to control muscle tension by causing muscle relaxation. The Golgi tendon organs (GTO) detect and respond to changes in muscle tension. The feedback system protects tendons and their associated muscles from excessive tension thereby reducing muscle damage.

Indications for Use in Chronic conditions

ROM decreased due to adhesions, contractures, and scar tissue formation Restricted motion n structural deformities Muscle weakness and shortening of same or opposing tissue Fascial or neural adhesions

Contraindications to Stretching

Joint motion decreased by a bony block Recent fracture Acute inflammatory or infectious process Hematoma or other tissue trauma Shortened soft tissues

o creating joint stability o creating functional abilities

Hypermobility – stiffy’s flippy’s floppy’s


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Types of Stretches applied this weekend

o Proprioceptive Neuromuscular Facilitationo Muscle Energy Techniqueso Assisted Stretchingo Neural tethering adaption’s

Proprioceptive Neuromuscular Facilitation

Originally used for neuromuscular re-education in stroke victims in the 40’s and 50’s by Knott and Voss. Later clinically useful for rehab in children with cerebral palsy (Levine et al 1954). This lead to applying PNF to wide ranges of orthopedic conditions.

Philosophy of PNF

Philosophy of care is whole body, simulates basic movement patterns (Alder et al 1993), it has a Neuro-developmental origin and used for functional activities i.e. swimming, climbing, throwing etc. It is useful due to the resisting movements in multiple planes simultaneously.

PNF applied to the target muscle or group occurs by instigating a stretch which is passive or passive assisted followed by the use of strong isometric contraction. The contraction phase is approximately 5 -6 seconds and the stretch is held for 30 seconds. PNF can be more affective by utilizing the Reciprocal Inhibition of a


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muscle where reflex relaxation occurs after isometric contraction of the agonist a neurological loop contract-relax and antagonist contract (CRAC).

Types of PNF Stretches for chronic conditions

1. Hold - Relax (HR)

Isometric technique used to increase ROM and to facilitate relaxation on one side of the joint (due to muscle tightness) when pain is present.

Consists of an isometric contraction of all components of the range-limiting or antagonistic mm groups. Pattern is elicited in non-painful range at point of limitation of the available ROM. Let isometric build slowly, and then ask for complete relaxation. Move limb actively (pt) or passively (therapist) through newly gained ROM to new point of limitation. Technique is repeated several times.

2. Contract Relax (CR)

Combination of an isotonic contraction of the rotary component and a maintained isotonic contraction of the other 2 components of the antagonistic pattern, used to increase ROM and facilitate relaxation when there is decreased ROM on one side of the joint. Patient's intent will be to move, therapist however allows only rotational motion. Pt then relaxes and moves or is moved into new ROM. The difference between HR and CR:- with HR, intention is to hold, not move.-build up/release of resistance in more abrupt with CR, gradual with HR.- CR is not used in the presence of pain.

3. Control-relax with agonist contraction - pre-stretch isometric contraction followed by a concentric contraction

PNF variations

o Repeated contraction is the repetitive use of the stretch reflex to initiate a muscular response, or to strengthen a pre-existing contraction. Several applications: a. very weak muscle at lengthened range to initiate pattern b. moderate weak muscle to keep contraction strong

throughout ROM c. muscle with unequal strength in different parts of the

ROM - use where weakness exists

o Repeated dynamic contractions followed by repeated stretches followed by resistance to a weak agonist


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o Reversal of antagonists, designed to facilitate coordinated reciprocal contractions. Alternating, slow, rhythmical concentric contractions of all the components of agonist and antagonistic patterns are performed without relaxation between reversals.USES - improve coordination and ability to smoothly reverse

directions, improve strength, increase ROM, prevent or relieve fatigue.

Sherrington’s Law of successive induction, which states that an agonist is facilitated by the preceding contraction of its antagonist. On applications, increased resistance to the stronger pattern will facilitate

a more forceful contraction in the weaker.

The benefits of PNF include:

Develops muscular strength and endurance, facilitate stability, mobility, neuromuscular control and coordinated movementsLays a foundation for the restoration of functionThe down side is post The down side is post treatment soreness treatment soreness when done too when done too aggressivelyaggressively

Muscle Energy Techniques

History

MET owes most of its development to osteopathic clinicians such as Fred Mitchell Snr1967 and more recently Karel Lewitt 1986, Vladimir Janda 1989 and Leon Chaitow 1996. These techniques though mostly linked to the osteopathic profession, have a strong tie to the physiotherapeutic fields with the introduction of Proprioceptive Neuromuscular Facilitation.

Guiding principles for MET Guiding principles for MET


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It is thought that Golgi tendon organs are stimulated during the isometric contraction, which then facilitates the post-isometric relaxation (PIR). (Chaitow, 2000, p 35)

The PIR period is thought to last for ‘in excess of 15 seconds’ (Chaitow, 2000, p 142), during which the tissues can be elongated with less resistance. The antagonist of the target muscle will be reciprocally inhibited during the isometric contraction.

Isometric contractions are typically kept to ‘light’ – e.g. starting at 20% available strength – as suggested by clinical experience and the theory that a lighter (sustained) contraction will recruit more of the postural (type I) fibres. (Chaitow, 2000, p 143).

The use of ‘completing the breath’ has been found to be helpful to augment the post-isometric relaxation.

- Inhale during the isometric contraction and holding the breath

- Release the breath while slowly releasing the contraction

- Patient asked to have a complete breath (inhale/exhale) and instructed to ‘let go completely’ (Chaitow, 2000, p 143)

Use of eye movements can also assist in increasing/decreasing tone of target muscle in the head and neck regions.

Variations in using MET – see table below

- More commonly MET is used to lengthen chronically shortened myofascia of postural muscles, whereby a comfortable, but definite stretch is felt by the patient. When this is repeated 3 – 5 times on each muscle there is little risk of treatment soreness if the stretching (lengthening) has been ‘comfortable’.

- This ‘chronic’ variation of MET for shortened postural muscles is commonly used.

-Contraindications

If pathology is suspected, no MET should be used until an accurate diagnosis has been established

Pathology’s such as osteoporosis, arthritis etc needs to be established so that the dosage of application can be modified, amount of effort, number of repetitions, stretching included or not.

MET should be a painless treatment style so if it causes pain then it is to be stopped until the pain is investigated further.

The ‘barrier’ or ‘bind’.The ‘barrier’ or ‘bind’.

The barrier used in MET is a first sign of resistance barrier, when you first feel the ‘bind’ while passively lengthening the muscle.Ease is the state of lack of tension in the soft tissueBind is the point where the therapist feels the tension is taken up but well before the client feels a stretch


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MET is applied at the point of bind and NOT at the point where the client feels the stretch. This is so for acute muscle conditions whereas MET is applied short of the barrier in chronic conditions.

Assisted stretches

The client/patient gets into a position of muscle stretch and the therapist applies overload to the point that the end-of-range is felt. This degree of stretch is not manageable by the client due to the pain-feedback system The client can apply antagonist contraction to induce reciprocal inhibition of the target muscle group


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Neural tethering

The active stretch in which the therapist releases the peripheral nerves from the fascial adhesions some of the larger muscle combinations such as the Hamstrings, Gastrocnemius and foreflexors of the arms.

This is not to be confused with the Nerve Facet Joint tethering, which occurs when the ascending facet joint (Superior Facet) is found densely attached to the exiting nerve root. Irritation and sensitisation of the nerve root is encountered over the segment of tethering. Whilst filamentous congenital ligaments (Goswami and Knight 2001) are to be encountered in anatomy, this tethering is dense, tough, attached to the facet joint margin and the apex of the facet joint capsule, and may contain osteophytes. The scarring may draw the exiting nerve medially in to the anterior pathway of the ascending facet joint

The greatest release is noted between the medial and lateral hamstring groups, the medial and lateral portions of the Gastrocnemius and the flexors and extensors of the forearms.

The client is placed supine and hip flexion so to illicit a neural stretch (SLR), then instructed to perform rapid isometric plantarflexion of the ankle. Changes to the tension within the joint capsule of the ankle, the motility of the nerves within the ankle as well as attempting to free the Sciatic, Sural and/or Peroneal nerves bound between the most superficial layer of fascia that surround these Phasic muscles.

Tension and cervicogenic headaches

TENSION HEADACHES


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o 90% of all headaches; progress from episodic to chronic

o Caused by stress, reading and are benign. 3:1 females

o Treated with medicationo Clinically – bilaterally, diffuse, dull and persistent, mild photophobia, mild

phonophobia, nausea (e.g. hangover)o Pathogenesis - ?? most likely the cervicogenic theory

o Management – analgesics work best, limit predisposing factors e.g. alcohol, working 15 hour days etc. high risk of habitual reliance of medications

CERVICOGENIC HEADACHESo First thoughts of studied in 1983 in Scandinavia. Studied again in 1987 –

all patients reported relief from typical “tension” symptoms. 1988 – 1997 – most studies said rubbish; so the term remains controversial, but remedial therapy relieves tension HA symptoms

o syndrome characterized by chronic hemicranial pain that is referred to the head from either bony structures or soft tissues of the neck

o its presenting characteristics occasionally may be difficult to distinguish from primary headache disorders such as migraine or tension-type headache

o The pain is likely referred from one or more muscular, neurogenic, osseous, articular, or vascular structures in the neck.

o The prevalence of cervicogenic headache in the general population is estimated to be between 0.4% and 2.5%, but in pain management clinics, the prevalence is as high as 20% of patients with chronic headache. The mean age of patients with this condition is 42.9 years, and cervicogenic headache is four times more prevalent in women.

o Patients with cervicogenic headache will often have altered neck posture or restricted cervical range of motion. The head pain can be triggered or reproduced by active neck movement, passive neck positioning especially in extension or extension with rotation toward the side of pain, or on applying digital pressure to the involved facet regions or over the ipsilateral greater occipital nerve. Muscular trigger points are usually found in the suboccipital, cervical, and shoulder musculature, and these trigger points can also refer pain to the head when manually or physically stimulated. There are no neurologic findings of cervical radiculopathy, though the patient might report scalp paresthesia or dysesthesia.

o Osteopathic manipulative techniques such as craniosacral, strain-counter strain, and muscle energy techniques are particularly well suited for the management of cervicogenic headache

Treatment options


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Suboccipital releasePatient spine with head relaxed, therapist places fingers under the occiput and distracts the head into forward flexion. The patient opens the eyes and looks to the toes for 10 sec, the therapist gently distracts further. The eyes then look to the top of the head 10 sec whilst the therapist maintains the pressure. The eyes go to normal rest for 10 sec and the therapist finds new end of range in the gapping. The process is repeated x 3.

Upper Trapezius MET anterior, middle and posterior fibres

Levator scapular assisted stretch


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Have the client lying supine and resting there head and neck along your forearm. Lock down their shoulder with your opposite hand and use your forearm to elevate the neck/head till they feel a moderate stretch of the target muscle. Instruct the client to actively draw their chin to the armpit/nipple regions whilst you continue to take up any ease of the muscles. Hold for minimum of 60 seconds.

Isometric SCM activation

Have client apply pressure to their chest to fixate the ribs and sternum. Use your hand and forearm to ensure there are isometric contractions when the patient tries to flex and rotate their head from side to side. Apply 6 second rotations for 30 sec and then re-test the scalene tension.

Respiratory techniques for the Scalenes


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Compress the Scalenes down onto the 1st rib with the fingers so that the muscle is elongated. Then instruct the patient to inhale fully and hold the breath for 6 seconds. As they forcefully exhale, depress the rib further to take up any slack created by the lengthening scalene. Repeat x 3.

Shoulder impingement and tendinopathies

ROTATOR CUFF TENDINOPATHY

The Rotator cuff muscles include the Teres Major Teres Minor, Supraspinatus and Subscapularis; the tendons may become swollen and this condition can take on a primary or secondary pathology. Primary is due to overuse or faulty biomechanics, whereas the secondary cause is from excessive load due to altered shoulder mechanics or impingement from above or below.

SUPRASPIINATUS TENDINOPATHY

The tendinitis results usually from chronic wear and tear of the Supraspinatus tendon as it passes under the acromion. This may be in sports-people and people that do a lot of overhead work though it may occur in any person.Anatomical factors such as the shape of the acromion or a tight subacromial space due to a thickened ligament may be predisposing factors.

Tears in the tendon of the Supraspinatus or other rotator cuff muscles (commonly occur together) often result from a fall on the shoulder, usually in older people. They can also result from attrition –which is the gradual degeneration with wear and tear, or other inflammatory disorders such as rheumatoid arthritis.

When treating either of these conditions, as a Remedial Massage Therapist, we can work in conjunction with anti-inflammatory drugs and cryogenic/thermogenic therapy. Our assessment of the muscle length and strength of the muscles that


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http://www.virtualmedicalcentre.com/diseases.asp?did=503


attach to the shoulder and humeral complex will assist us in developing a valuable stretching regime to induce correct capsular patterning. This regime should include the rotator cuff muscles as well as the anterior muscles of the chest.

SHOULDER IMPINGEMENT

Results from mechanical impingement of the rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flexed and internally rotated position.

There are 3 stages in the spectrum of rotator cuff impingement: Stage 1, commonly affecting patients younger than 25 years, is depicted by acute inflammation, oedema, and haemorrhage in the rotator cuff. This stage is usually reversible with non-operative treatment. Stage 2 is a progression of stage 1 and affects patients aged 25-40 years, with the rotator cuff tendon progressing to fibrosis and tendonitis. The 3rd stage commonly affects patients older than 40 years which usually results in surgery - anterior acromioplasty and rotator cuff repair is commonly required. Impingement and rotator cuff disease are frequently seen in the repetitive overhead athlete. The increased forces and repetitive overhead motions can cause changes in the distal part of the rotator cuff tendon, which can be preventably treated with correct muscle length and alignment.

The treatment offered by the therapist should include various types of strength and flexibility of the muscles of the shoulder girdle to ensure “normal” joint biomechanics. This allows for optimum soft tissue tension and therefore oxygen perfusion to the tissues which assists in the bodies healing.

Muscles treated include rotator cuff, Pectoralis Major and Minor, Upper Trapezius Scalenes, SCM, and should

also include Latissimus Dorsi and Diaphragm. We also need to reflect on the shortening of the Biceps Brachii, triceps and connections down to the wrist; if muscles distally to the shoulder are imbalanced they can alter the elbow’s neutral position and therefore affect the GH joint.

MET for Pec major fibres


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Patient supine and hand on breast, therapist place your hand over theirs to support and depress the breast tissue to expose the Pec fibres. Abduct and elevate the shoulder till the Pec muscle becomes taut and then release to point of bind. Instruct the patient to adduct, diagonally return to the midline against resistance at 30, 40 50% and hold for 10 seconds followed by comfortable stretches between isometric contractions. Variations include sternal and clavicular fibres.

Latissimus Dorsi assisted stretch


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Variation to this stretch is therapist stands directly behind the patient and stabilises the elbow with the hand behind their head. The patient is then asked to return the elbow to beside the body whilst the therapist resists the move. The patient then laterally flexes and rotates her trunk to increase the stretch of the lumbo-sacral fascia of the pelvis. Repeat x 3 and each hold 10 sec, each stretch 30 seconds.

Variation 2 – both hands behind the head and the therapist holds the elbows drawing into shoulder extension so bind is felt both in the lats and the Pecs. The client is then instructed to try to pull the elbows together with the isometric contraction. Repetitions are as above.

MET Teres Minor and Infraspinatus

Stabilize the shoulder and wrist of the patient set at 900 shoulder and elbow flexion, take the forearm into internal rotation until point of bind and instruct the patient to externally rotate at 30% effort x 3 hold for 10 sec each time and move into new bind after each stretch.

Teres Major V Rhomboid reversal of antagonists

Feel for myofascial trigger points in the Teres to confirm the need to activate the rhomboid. Isometric contraction of the medial scapular stabilizers to reciprocally release the rotator cuff muscles (specifically the Teres). This


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is a take home exercise for the patient. The clinic treatment in prone and small movements used instead of isometrics.

CRAC Biceps

The therapist instructs the client to bend at the end of the table or find a bench top suitable for them to hyperextend the arms at the shoulder joint so they can elicit a stretch in the bicep. They are then to supinate the forearms so that the dorsum of the hand is fixed on the surface. This will take the long head of the bicep into greatest length. In this position they can contract the bicep without flexing the elbow – 15 seconds followed by contracting the triceps group for 15 seconds to further induce biceps muscle to relax.

Pelvic rotations and torsions

The pelvis transmits load from the vertebral column to the limbs and vice versa. The lines of force circle the pelvic brim, and due to its suspensory ligaments, the sacrum is held or wedged more firmly the heavier the load, making it a self locking system. The pubic symphysis allows some ilial rotation through the transverse plane and is compressed by the forces of the pelvic brims.

As these joints of the pelvis rely upon one another for stability as a whole, dysfunction of any leads to impairment of the pelvic resistance to load. In walking, ilial rotation on the sacrum occurs in the SIJ at a point that corresponds


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to the inferior sacral axis. This ilial rotation during walking occurs with pubic rotation and forward torsioning of the sacrum on its diagonal axes. Sacroiliac flexion and extension within the ilia occurs with respiration and with flexion and extension of the spinal column. Inhalation flattens all the spinal curves therefore extending the sacrum and exhalation therefore flexing the sacrum.

The axes of the sacrum are attached via the bodies’ musculature, the piriformis anchors the lower corner of the sacrum, the Lx extensors, lateral flexors and their association fascia loosely anchor the top corner. When any of these muscles or ligaments are altered in their normal resting length then symptoms of SIJ will occur. These include unilateral lower back pain with possible radiation into the buttock, posterior thigh/leg, groin, anterolateral thigh and occasionally the labia or scrotum.

Common symptoms include pain on asymmetrical weight bearing, rolling in bed, sitting to standing and walking up or down stairs. The Ilia will be imbalanced, the ASIS and/or PSIS uneven and the leg length affected, also pain and decreased lumbar flexion, paravertebral difference and Hypolordosis or hyperlordosis.

Common defects are: Ilial Rotations – anterior and posterior Ilial upslips, inflares and outflares Sacral torsions

Common muscles and soft tissue affected: Short tight - Lx ES, Psoas, Rectus Femorus, Vastus Lateralis and

ITB/TFL Weak (stretch or tight weakness) – lower abdominals, Gluteals, Vastus

Medialis and VMO Short and strong or short and weak – Hamstrings and Gastrocnemius With Sciatic symptoms – piriformis and deep external rotators Posterior pelvic tilt – obliques Sacral torsion – lumbo-sacral fascia, ilio-lumbar and sacro-tuberous

ligaments

Anterior Ilial Rotation


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Variation - MET requires the therapist to fixate the pelvis and the client to press the leg into the therapist at 300, 400 and 500 x hold for 10 seconds and between each MET for the therapist to re-define bind.

Posterior Ilial Rotation

Variation – MET requires the therapist to fixate the pelvis and the therapist to resist the leg from hip flexion by the client at 300, 400 and 500 x hold for 10 seconds and between each MET for the therapist to re-define bind.


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Sacral torsion correction

Client supine with both knees bent, therapist guides both legs to the right to assess mobility and to the left for balance. Which ever side has the least amount of range indicates contralateral soft tissue tension. MET is applied from the restricted side to the side of ease at 300, 400 and 500 x hold for 10 seconds and between each MET for the therapist to re-define bind. Wait for 10 – 15 seconds between each contraction for maximum benefit.

PNF Quadratus Lumborum

Adductor V lumbo-sacral fascia CRAC


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The Therapist kneels behind the client to support their back and torso and to ensure that the trunk doesn’t twist. The client has BOTH legs fully abducted to a level that they can manage and then are instructed to reach over to touch their hand to the calf, ankle or foot. The pull they will feel should be in the tight lateral and/or lumbo-sacral fascia; they are then encouraged to contract the lateral abdominals on the short side to produce a reciprocal release of the taut

contralateral abdominal groups. This is applied for a minimum of 20 seconds each side and then they will position themselves as the second picture and the therapist will add over pressure to the lumbar spine whilst the client contracts their anterior abdominals. This is repeated 3 times with 20 second minimum holds.

Combined hip & Knee joint PNF


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All ranges are assessed for muscle length of hip flexors, quads, abductors and adductors. The therapist then makes sure the client is supported in the supine position and the lower back is not over arched. The most hypertonic muscle or muscle groups will be targeted by using the PNF appropriate for the increase in ROM and to reduce muscle tension with that/those groups.Hip flexors – hip flexionRectus Femoris – Knee extensionAbductors – hip abductionAdductors – hip adduction

Oscillation of Sacrotuberous and Ileolumbar ligaments

Though recognised as a mobilisation technique it still utilizes the flexibility of the ligaments of the sacrum and look at balancing length and tension between the superior and inferior poles of the sacrum.The therapist places thumb over thumb on each of the ligaments in turn and press posterior to anterior in a bouncing motion to feel for the end of range of the soft tissue tension. Applying these cardiac-like compressions for 20 seconds each

group x 3 or until greatly reduced pain is felt, balanced discomfort is noted or all poles have a sense of even tension. The mobility of the ilia and sacrum is paramount for pelvic and lower back function.

Chronic hamstring strain/tendinopathy

Injuries to the hamstring muscles primarily occur proximally and laterally, and they usually involve the Biceps Femoris. The injury almost always occurs at the proximal myotendinous junction. In the biceps Femoris, this junction extends over most of its entire length and the injury usually does not occur within the tendon itself unless there is pre-existing pathology. The Chronic condition of Tendonitis and Tendinopathy is causes by overuse of the muscles most commonly by


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runners in mid and long distance usage and can be due to an imbalance in the anterior and posterior leg muscles.

Treatment includes Cold therapy and NSAID (non steroidal anti inflammatory drugs) to reduce

pain and inflammation along with Ultrasound Apply deep tissue sports massage techniques once the acute stage has

passed. This is thought to be the most effective form of treatment for this condition.

Hamstrings

Using the Mattes method (Active Isolated Stretching) utilizes the neuromuscular system rather than just the musculoskeletal system. The action of contraction of the antagonist muscle group (Quadriceps) in

opposition to the short target muscles (Hamstrings) via active normal hip flexion followed by gentle, brief (2-3 sec) stretches of 8 – 10 repetitions by either the therapist manually or by the client via the use of a rope or band. By providing the brief contraction of the quadriceps it elicits a neural inhibitory response of the hamstrings relaxing them further. By changing the angle of the foot/ankle the medial and lateral groups can be separated for more effective stretching.Avoids disadvantages with static stretches of blood flow reduction, neural compression and unwanted stretch reflexes

Deep Hip Rotators PNF/MET pain dependant

Stretching of the Deep Hip Rotators should be


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incorporated in any chronic hamstring condition. The level of pressure applied is dependant upon the loss of range being associated with pain or strains/tears within the Gluteals or Rotators. The patient is supine with both legs straight and the therapist manually takes the hip into flexion and external rotation to till bind is felt on the Gluteals. Then the knee is guided towards the opposite axilla to induce a strong stretch in the Hip rotators and held for 20 seconds. The patient is instructed to contract and recruit the muscles in the leg to activate all those involved in reversal of the stretch. Hold for 10 seconds and repeat x 3 between further stretches.

Neural tethering of the sciatic nerve

Serves to remove/reduce any fascially bound peripheral nerves from the deep fascia between the Medial and Lateral Hamstrings. The therapist takes the patients leg into SLR till point of bind and then applies multiple (15 – 20), rapid (1 second) stretches of the entire neural tract of the sciatic nerve. The patient is requested to plantarflex the foot at maximum strength

isometrically briefly and then completely relax until the therapist completes the dorsiflexion of the ankle. The therapist will dorsiflex 2 – 3 times until the new end-feel is found and then the patient repeats the procedure. When a softening if felt at the ankle joint, the therapist should continue to elevate the leg till the new bind for the sciatic nerve is felt. NB* at no time is there an aggressive over-pressure to the neural system.

ITB Friction Syndrome

Is the result of the ITB rubbing across the lateral epicondyle of the femur; the friction or impingement occurs during foot strike between the posterior edge of the iliotibial band and the underling lateral femoral epicondyle. Most common in runners due to the stride length creating a decrease in the normal knee flexion ranges thereby aggravating the area and causing friction i.e. less than 300 flexion. Downhill running appears to exacerbate the condition due to the reduced knee flexion angle on heel strike. MRI studies have shown that the tendon seems to remain intact so no tendinopathy occurs, though there are significant findings of swelling on the bursa which needs to be dealt with also. Inappropriate training


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and abnormal biomechanics seem to be the main causes of the condition which need to be addressed by the therapist.

Studies have shown that stretching or myofascial work directly to the ITB is ineffective so other means need to be applied to decrease the friction at the epicondyle. Included in this is to stabilize the lateral stabilizers of the hip/leg region, correcting firing sequences are the most effective first step and although not a stretching technique it is a agonist/antagonist based treatment option.

Tom Myers Functional Back Line

The Bony stations and Myofascial Tracts of this line attachThe Bony stations and Myofascial Tracts of this line attach at the shaft of the humerus, tract along the Latissimus at the shaft of the humerus, tract along the Latissimus Dorsi and Lumbodorsal Fascia and Sacral fascia to attach Dorsi and Lumbodorsal Fascia and Sacral fascia to attach at the Sacrum, then travel via the Gluteus Maximus at the Sacrum, then travel via the Gluteus Maximus attaching on the proximal portion of the Femoral Shaft attaching on the proximal portion of the Femoral Shaft through the Vastus Lateralis and to the Patella to re-through the Vastus Lateralis and to the Patella to re-connect at the sub-patella to end at the Tibial Tuberosityconnect at the sub-patella to end at the Tibial Tuberosity

This line can be useful to treat in order to release any biomechanical imbalances found which may be causative in the ITB Friction Syndrome. Activation of the Latissimus Dorsi will stimulate increased muscle length of the Vastus Lateralis and should be applied if Ober’s or modified Ober’s is positive. There is often evidence of posterior pelvis and shorter leg length with pain at the Tibialis Posterior inferior portion due to Tibial torsion.

The therapist directs the client to stand at a desk or table with the affected side’s hand resting in line with the body. The shoulder at neutral and the elbow flexed as shown. The client is then asked to gently press into the bench with their hand whilst keeping the shoulder motionless x 20. Relaxing completely between contractions will allow for complete rest of neural activity in the upper portion of the functional back line.


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Quadriceps around the Patella

The patient lies supine with the leg relaxed whilst the therapist palpates the patella and distracts it caudally to fixate it at the Tibia. The patient is then asked to flex the quadriceps (creating an isometric contraction of the group), hold for 10 seconds and repeat x 3. The patella is then distracted inferiorly and medially to a new point and the procedure is repeated.

Bibliography

Text BooksBiel, A. Trail Guide to the Body 3rd Ed Books of Discovery 2005

Brukner and Khan. Clinical Sports Medicine 2nd Ed McGraw Hill 2001

Chaitow, L. Muscle Energy Techniques 2nd Edition Churchill Livingstone 2001

Kisner & Colby. Therapeutic Exercise - Foundations and Techniques 4th Ed F.A. Davis Company 1996


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Fritz, S. Fundamental of Therapeutic Massage 3rd Ed Mosby 2007

Myers, Tom W. Anatomy Trains Myofascial Meridians for Manual and Movement Therapists 1st Ed Churchill Livingstone 2001

Course NotesArbuthnot, H. Structural Balancing for remedial Therapists 1998Nutting P, Before the Core Fascial Trains and Muscle firing Disruption 2009Powdrell, J. Myofascial Assessment & Treatment Techniques 2001

ArticlesDepartment of Physical Therapy, School of Physical Therapy, the University of Texas Branch

Physiotherapy article 4428: Advanced Therapeutic Exercise and Muscle Testing Spring 1999

The Journal of the American Osteopathic Association Cervicogenic Headache: A Review of Diagnostic and Treatment StrategiesAuthor: David M. Biondi, DO

Headache Pain Author: R. Michael Gallagher, DO

Shoulder Impingement Syndrome: Treatment & MedicationAuthor: Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, University of Connecticut Health Centre

Musculoskeletal Spine Fellow, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Centre Coauthor: Wing Chang, MD.

Photos by permission of Sonya Klease 2007 and various Google images


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