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William Sy-Wei Hsu, D.C., DACBR, FCCR (C) Dr. Hsu is a 1992 graduate of CMCC. He completed his Radiology residency in 1995 and has since been a guest speaker at numerous Chiropractic College of Radiologist workshops. He was President of the College of Chiropractic Radiologists of Canada from 2003-2006. Dr. Hsu is a faculty Radiologist and Associated Clinical Professor at CMCC and Adjunct Faculty (Assistant Professor) at D’Youville College, Buffalo, New York, USA and past radiology instructor for Nichibei Chiropractic College in Osaka, Japan. He has authored and co-authored numerous papers in referred Journals including JCCA, JMPT and JNMS and a chapter in Haldeman’s textbook, The Principles and Practice of Chiropractic. Seminar topics Review of plain film findings of trauma related injuries of shoulder, elbow, wrist, pelvis, knee and ankle – from the obvious to the subtle injuries that may lead to chronic pain and failure to return to sport. Imaging of stress related injuries of lower extremities. Assess the advantages of imaging modalities such as bone scan, SPECT, CT and MRI in the evaluation of athletes with chronic lower extremity complaints. Systematic Approach to Plain Film Assessment of Hip 1. Signs of soft tissue swelling/joint effusion Capsular fat planes and obturator internus fat plane 2. Bony structures Femoral head/neck AIIS, ASIS, ischial tuberosity, greater and lesser trochanters Iliac crest apophysis Pubic tubercle 3. Alignments Kohler’s line Acetabular depth Cross-over sign Systematic Approach to Plain Film Assessment of Traumatized Knee 1. Signs of soft tissue swelling/joint effusion Anterior knee soft tissues – Hoffa’s fat pad, suprapatellar fat pad, prefemoral fat pad, suprapatellar recess, deep infrapatellar bursa, superficial infrapatellar bursa, prepatellar bursa, patellar tendon Medial joint line – medial collateral ligament Lateral joint line – Segond fracture Posterior knee soft tissues – non-specific 2. Bony structures Tibial eminences Medial femoral condyle vs lateral femoral condyle Patella Tibial tuberosity 3. Alignment Posterior Femorotibial alignment Systematic Approach to Plain Film Assessment of Ankle 1. Signs of soft tissue swelling/joint effusion Anterior and posterior joint capsule, Kager’s fat pad, Achilles tendon, soft tissue adjacent to medial and lateral malleoli 2. Bony structures Malleoli – medial, lateral and posterior Articular margins – tibial plafond and talar dome Distal fibula Anterior tibial tubercle and lateral clear space Talus – posterior process, lateral process, dorsum of talar neck Calcaneus – body, lateral border Navicular – dorsum, medial tubercle Styloid process of the 5th metatarsal Os peroneum, os tibiale externum, os trigonum 3. Alignment Medial clear space and lateral clear space Systematic Approach to Plain Film Assessment of Shoulder 1. Signs of soft tissue swelling/joint effusion FBI sign 2. Bony structures Humeral head, greater and lesser tuberosities Glenoid fossa rim Acromion Scapula – coracoid, spine, neck and body Clavicle 3. Alignment Glenohumeral joint Acromioclavicular joint Sternoclavicular joint Systematic Approach to Plain Film Assessment of Elbow 1. Signs of soft tissue swelling/joint effusion Anterior and posterior humeral fat pads Supinator fat plane 2. Bony structures Radial head/neck Capitellum Olecranon Medial and lateral epicondyles Coronoid process 3. Alignment Anterior humeral line Radiocapitellar line http://www.radiologyassistant.nl/en/4214416a75d87 Systematic Approach to Plain Film Assessment of Wrist 1. Signs of soft tissue swelling/joint effusion Navicular fat plane Pronator quadratus fat plane 2. Bony structures Distal radius – metaphysis, epiphysis, styloid process Ulna – styloid process Scaphoid – proximal pole, waist, distal tubercle Lunate Triquetrum 1st metacarpal – base Hamate – hook 3. Alignment Carpal arcs Scapholunate angle Volar tilt of radius Ulnar variant – positive, negative and neutral Gregory Doerr, DC, CCSP, ART, CKTP Dr. Gregory H. Doerr is a graduate of the New York Chiropractic College, in Seneca Falls, NY. He completed a certification in Chiropractic Sports Medicine in 1998 (CCSP). Dr. Doerr lectures for Graston Technique and The Council on Chiropractic and Extremity Procedures (CCEP). He has lectured at the US Olympic Training Center and internationally at the College of Chiropractic and Sports Sciences and Central American Sports Medicine Congress on treatment and rehabilitation of the endurance athlete. Doctor Doerr has had the pleasure of working with athletes from the AVP Volleyball Tour in 2007, the Gold Cup in 2007, Central American Games in July of 2006, with Washington Redskins in March of 2004 and the University of Colorado in 2004. He currently is the doctor for 2 club soccer teams and a club volleyball team. Doctor Doerr has a growing reputation with marathon runners treating athletes from running clubs in NJ and Manhattan. He has served on the medical staff of two 19K foot climbs including Mt. Kilimanjaro in Africa and El Misti in Peru. FAKTR-PM was developed to help speed recovery from acute and chronic musculskeletal pain syndromes. Chronic pain results from dysfunction of the sensorimotor system, which is manifested in soft tissue and fascia. This new treatment approach to soft tissue dysfunction combines instrument-assisted soft tissue mobilization with proprioceptive techniques to reduce pain and return function. Combining manual treatment of soft tissue with propriceptive exercises produces faster results than conventional treatment methods. Tom Hyde, DC, DACBSP [email protected] Greg Doerr, DC, CCSP [email protected] with contributions from MANY DC’s and PT’s Warren Hammer, DC, MS, DABCO www.faktr.com www.faktr-pm.com • What is FAKTR(PM)? – Functional : treat during function; not just static – Kinetic: assess & use entire kinetic chain – Treatment: variety of soft-tissue techniques – Rehab: incorporate resistance & proprioceptive ex – Provocation: reproduce pain and treat – Motion: treat with motion if more painful 2 Introduction • Brief History – Developed by Tom Hyde DC and Greg Doerr DC – Contributed to by PTs and DCs – Originated from Graston® Technique – Directly addresses patient complaints of pain and incorporates movement into treatment 3 Introduction • 3 Key Components – Soft Tissue Mobilization – Movement – Proprioception 4 Introduction • 1. Soft Tissue Mobilization – Purposes • Mechanical effects: collagen remodeling • Neural effects: touch, afferent stimulation • Vascular effects: tissue viscosity – Types: • IASTM (Graston, ASTYM, Gua Sha) • STM, Cross Friction massage • Cyriax, ART 5 Introduction • 2. Movement – Purposes: • • • • glide fascia & soft tissue Incorporate kinetic chains Initiate proper collagen alignment Increases afferent stimulation – Types: • Active • Resisted (concentric / eccentric) • Functional patterns 6 Introduction • 3. Proprioception – Purposes: • Increase afferent input • Restore motor programs – Types: • Skin proprioception • Joint proprioception 7 Introduction • Algorithm – Test – Treat – Re-Test / Re-Treat – Train (Exercises / Adjuncts) 8 Introduction • 1. Test – Determine provocative position; rate pain 1-10 – Add active movement (note change in pain) – Add resistive movement (note change in pain) – Add functional movement (note change in pain) – Add proprioception (note change in pain) 9 Introduction • 2. Treat – Treat soft tissue in painful position (with or without motion, resistance or proprioception) – May also treat areas of reduced ROM or function – 30 seconds to 2 minutes 10 Introduction • 3. Re-test / Re-treat – Reassess provocative position/activity; rate pain 110 – Re-treat up to 3 times – Continue to move up or down kinetic chain – Progressively add more complex testing positions with improvement 11 Introduction • 4. Train – Restore muscle balance – Train movement patterns – Apply adjuncts (Kinesiotaping, etc) 12 Introduction • Indications – Tendinopathies • • • • Tennis elbow Rotator cuff tendinopathy Achilles tendinopathy Patella tendinopathy – Fascial Syndromes • ITB Syndrome • Trigger Finger • Indications – Entrapment Syndromes • Carpal Tunnel Syndrome • Thoracic Outlet Syndrome – Ligament Pain • MCL Sprain • Ankle Sprain • AC Ligament Sprain – Scar Tissue / Adhesions – Edema 13 Introduction • Clinical Decision Making – – – – Use in both assessment and treatment Perform comprehensive clinical examination Integrate in treatment ; no protocols or boundaries If patient improves, then symptoms return, do not treat more than twice without further assessment, 2nd opinion, etc. • Indicates FAKTR may not be appropriate treatment 14 Soft Tissue Techniques • There are many soft tissue techniques employed by chiropractors, osteopaths, physical therapists, medical practitioners, massage therapists, occupational therapists and others around the world. All are designed to assist in the treatment of disorders related to soft tissue lesions. Various Soft Tissue Techniques • • Cross Friction • Trigger Point • • Myofascial Release • (MFR) • Active Release • Technique (ART) • Strain-Counterstrain • • Post isometric relaxation (PIR) • • Barnes • Post facilitation stretch (PFS) Nimmo Proprioception Neuromuscular Facilitation (PNF) Graston Technique (GT) Instrument Assisted Soft Tissue Mobilization (IASTM) Active Isolated Stretch (AIS) This represents a partial list The Kinetic Chain: • Barker and Briggs • Thomas Myers Anatomy Trains • Tensegrity SUPERFICIAL POSTEROR SPINAL FASCIAL LAMINA Barker PJ, Briggs CA. Attachments of the Posterior Layer of Lumbar Fascia. Spine 24 (17):1757-64. Deep Posterior Spinal Lamina FUSION OF SUPERFICIAL & DEEP LAMINAE Barker PJ, Briggs CA. Attachments of the Posterior Layer of Lumbar Fascia. Spine 24 (17):1757-64. SERRATUS POSTERIOR INFERIOR GLUTEUS MEDIUS SACROTUBEROUS LIGAMENT Anatomy Trains Myofascial Chains Muscular system intimately linked with fascial system Muscle and fascia influence each other throughout body Skeletal keystones link muscles via fascia Chain Reactions • Anatomy Trains (Superficial Back Line) Plantar Fascia Scalp 21 Chain Reactions • Anatomy Trains (Upper Extremity) Trapezius Fingers 22 Anatomy Trains Upper Part • Serape Effect • Santana Lower Part • Sling mechanism • Peronei and tibialis anterior Tensegrity • This refers to structures that maintain their integrity due primarily to a balance of continuous tensile forces through the structure as opposed to leaning on continuous compressive forces. • Thomas Myers – Anatomy Trains Tensegrity • Tensegrity structures offer a maximum amount of strength for a given amount of material. • Thomas Myers – Anatomy Trains Tensegrity • Tensegrity structures are characterized by continuous tension and local compression. They naturally transmit themselves over the shortest distance between 2 points, so the members of tensegrity structures are precisely positioned to best withstand stress. • Thomas Myers – Anatomy Trains Tensegrity in the Human Body REHABILITATION TOOLS 29 Rehab Tools • Resistance Tools • Balance & Proprioception Tools • Vibration & Oscillation Tools 30 Rehab Tools • Resistance – Isotonic (dumbbells, pulleys, cuff weights, soft weights) – Elastic (Thera-Band, loops, tubing, FlexBars) – Isometric (manual resistance) – Body Weight 31 Rehab Tools • Resistance – Thera-Band Different Thera-Band colors indicate progressive resistance with increasing thicknesses of material 32 Rehab Tools Thera-Band® Force-Elongation in Pounds 25% 50% 75% 100% 125% 150% 175% 200% 225% 250% Yellow Red Green Blue Black Silver Gold 1.1 1.5 2 2.8 3.6 5 7.9 1.8 2.6 3.2 4.6 6.3 8.5 13.9 2.4 3.3 4.2 5.9 8.1 11.1 18.1 2.9 3.9 5 7.1 9.7 13.2 21.6 3.4 4.4 5.7 8.1 11 15.2 24.6 3.9 4.9 6.5 9.1 12.3 17.1 27.5 4.3 5.4 7.2 10.1 13.5 18.9 30.3 4.8 5.9 7.9 11.1 14.8 21 33.4 5.3 6.4 8.8 12.1 16.2 23 36.6 5.8 7 9.6 13.3 17.6 25.3 40.1 Page, et al. JOSPT 30(1):A47. 2000. Rehab Tools • Resistance – Thera-Band Eccentrics • Inherent elastic recoil in elastics make ideal for slow and controlled eccentric contractions • Eccentrics are very effective at treating tendinopathies • Metabolically more efficient than concentric contractions • Eccentrics are functional for phasic / gravity-resistance muscles that are typically weak 34 Rehab Tools • Eccentric FlexBar for Tennis Elbow http://info.thera-bandacademy.com/FlexbarElbow 35 Rehab Tools • Balance & Proprioception – Sensorimotor System • • • • Joint stabilization Balance Postural Stability Core Stabilization Controlled by Sensorimotor System 36 Rehab Tools • Balance & Proprioception – Sensorimotor System • Sensory System : Afferent proprioceptive input – Joint Mechanoreceptors – Muscular Receptors – Exteroceptors • Motor System: Efferent motor output – Muscle Facilitation – Muscle Inhibition 37 Rehab Tools – Balance & Proprioception • Labile surfaces ↑ afferent input,↑ speed of contraction, ↑ motor output • • • • • Stability Trainer Balance Board Exercise Ball Minitrampoline Balance Sandals • • • • • • • • • • • • • • • • Arokski et al. 1999 Balogun et al. 1992 Beard et al. 1994 Blackburn et al. 2002 Bullock-Saxton et al. 1993 Clark et al. 2005 Eils et al. 2001 Heitkamp et al. 2001 Ihara & Nakayama 1996 Lanza et al. 2003 Linford et al. 2006 Myers et al 2003 Osborne et al. 2001 Rodd et al. 2002 Vera Garcia et al. 2000 Wise et al. 2001 Rehab Tools • Balance & Proprioception – Balance Balls • Exercise ball bridge position curl-up compared to stable surface • Significantly more (4x) external oblique activity • Significantly ↑ lower abs activity Vera-Garcia et al. 2000 39 Rehab Tools • Balance & Proprioception – Stability Trainers • 4 levels of progressive challenge – Foam: Green, Blue – Air: Black, Silver – Foam surfaces ↑ EMG 41-57% in lower leg (Lanza et al. 2003) © 2008. The Hygenic Corporation 40 Rehab Tools • Balance & Proprioception – BOSU Ball 41 Rehab Tools • Balance & Proprioception – FlowIn 42 Rehab Tools • Balance & Proprioception – Perfect Push-Up 43 Rehab Tools • Balance & Proprioception – Balance Boards • Neutral stance in different axes of board while maintaining short foot • Small movement of board simulates walking on uneven ground, stimulating automatic postural reactions © 2008. The Hygenic Corporation 44 Rehab Tools • Balance & Proprioception Research: – Trunk stabilizers are best activated on unstable surfaces or with unilateral resistance exercises – However, unstable surfaces reduce force output (up to 70%) which might not be sufficient stimulus to overload muscle • Practice: – Use unstable surfaces for trunk stabilization, NOT extremity training – Use light to moderate instability and reduce © 2008. The Hygenic Corporation extremity resistance Behm & Anderson, 2006 Rehab Tools • Vibration & Oscillation – Vibration facilitates a vibratory reflex, which stimulates muscle spindle (Roll et al. 1989; Hagbarth et al. 1998) – Popular methods of treatment with mostly anecdotal evidence 46 Rehab Tools • Vibration & Oscillation – I-Joy Board 47 I Joy Board I Joy Board 49 I Joy Board 50 I Joy Board 51 Rehab Tools • Vibration & Oscillation – FlexBar • 4 progressive levels – YELLOW – RED – GREEN – BLUE © 2008. The Hygenic Corporation 52 Rehab Tools Thera-Band® FlexBar Oscillation (Green) Page et al. 2004 • Rehab Station Rehab Tools Multi-Planar Wall Unit with Coordinates Pro Series™ Exercise Balls Fixed Length Tubing 4 Instructional Posters Accessories Stability Trainers Floor Unit FAKTR: Bringing Soft Tissue and Exercise Rehabilitation together • Rehab / proprioceptive techniques • Functional movement patterns utilizing the kinetic chain • Movements and/or positions of provocative to recreate symptoms, referral patterns, imbalances, instabilities, weaknesses, functional loss or injuries. • Performed with many different soft tissue techniques Why Dynamic activities during soft tissue treatments? Structural/Physiological • Soft tissue treatments increases fibroblastic proliferation • Active motions, functional positioning, and exercise rehabilitation during the soft tissue treatment initiate proper alignment of collagen synthesis and soft tissue remodeling through fibroblastic activity Why Dynamic activities during soft tissue treatments? • Dynamic activities force fascial planes to move against each other • If there is an adhesion preventing proper fascial, muscle, ligament, soft tissue function why would we ever treat statically • We can use dynamic activities to assist us in separating adhesions with our soft tissue treatment and promote proper fascial glide Why Dynamic activities during soft tissue treatments? Neurological • Increased afferent input from joints, muscles, skin, ligaments • Sensory gating mechanisms associated with pain Why Dynamic activities during soft tissue treatments? Vascular/Microcirculatory • Improves viscosity of tissue/extracellular matrix • Assists in the pumping of edema and metabolites from injured/sore areas • Improves blood flow to an area: hyperemia on Ligaments INSTRUMENT-ASSISTED CROSS FIBER MASSAGE ACCELERATES KNEE LIGAMENT HEALING: Dept of anatomy and cell biology, Indiana University. Loghmani, MT et al., 2006 • Controlled study: 20 rats underwent surgical bilateral transection of the MCL. • 7 days postoperatively GT was used on the left MCL for one minute 3x per week for 3 weeks. • Results: “Ligaments treated with IACFM were found to be 31% stronger and 34% stiffer than untreated ligaments.” • Article will appear in JOSPT. Effect of GT on Ligamentous Healing 20R 506004 4wk untreated 20R PH2 Before Treatment: Irregularly oriented and diminished amount of fibroblasts 20L 506004 4wk treated 20L PH2 4wk treated The treated appears to have increased cellularity and more regularly oriented, elongated fibroblasts. Graston Technique Instrument-Assisted Soft Tissue Mobilization (GISTM) Moderate Heavy GISTM GISTM pressure pressure Increased pressure increased the amount of fibroblasts. Light GISTM pressure Gehlsen, G. M., Ganion L. R., et al. (1999). Fibroblast responses to variation in soft tissue mobilization pressure." Medicine & Science in Sports & Exercise, 31(4): 531-5. on Tendons Achilles Tendinosis Langberg H, et al Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 2007;17:61-66. Training Schedule for Chronic Achilles Tendinosis • Two times daily for 12 weeks, 3 sets of 15 heel raises (eccentric) • Wear a backpack containing 20% of body weight. • Increase weight as soon as no pain immediately after training or the next morning. • Expect pain to increase during first 3-4 weeks. Continue even if pain persists. • Continue with sport if pain does not increase. Langberg H. et al. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 17;2007:61-66. Eccentric Loading for Achilles Tendinosis Knee straight Knee bent Alfredson H. Chronic midportion achilles tendinopathy: an update on research and treatment. Clin sports Med 22:4;2003:727-741. Eccentric Contraction without Concentric Contraction PAINFUL ECCENTRIC WRIST FLEXION 2 sets of 15 reps two times per day Rehab Tools • Eccentric FlexBar for Tennis Elbow http://info.therabandacademy.com/FlexbarElbow 79 on Fascia F.A.K.T.R. ON FASCIA • Muscle bundles will only elongate to the extent that their fascial sheath will permit • Fascial contracture restricts muscular elongation and joint ROM • Each muscle spindle is enclosed within fascia that limits elongation and is thus involved in neuromuscular function. Calliet R. ;Hand Pain and Impairment. 4th edition. Philadelphia, PA: FA Davis Co.; 1994:74. F.A.K.T.R. ON FASCIA When a relaxed muscle is physically stretched, it’s the connective tissue and sheathing within & around the muscle that offers resistance.1,2. 1. Casell C. Tensile force in total striated muscle, isolated fibre and sarcolemma. Acta Physiol Scand 1950;21:380-401. 2. Ramsey R, Street S. The isometric length-tension diagram of isolated skeletal muscle fibers of the frog. J Cell Comp Physiol 1940;15:11-34. MUSCLE fascicle fascia muscle fiber epimysium perimysium endomysium myofibril Thoracolumbar Fascia Load Transfer: Superficial & deep TLF transmits tension from the biceps femoris, sacrotuberous ligament, and gluteus maximus across the sacroiliac joint to the contralateral latissimus dorsi. - a pathway is thus provided for an uninterrupted mechanical transmission between the pelvis and trunk. Barker PJ, Briggs CA. Attachments of the posterior layer of lumbar fascia. Spine:17571764:1999. Langevin’s research on the effect of acupuncture on soft tissue relates directly to the effects of Graston Technique®. • Creates a deformation of the extracellular matrix • Changes were shown to occur within 1 minute in the fibroblasts when the needle was rotated [1]Langevin HM, Churchill DL, Wu J, Badger GJ et al. Evidence of connective tissue involvement in acupuncture. The FASEB Journal ezpress article 10.1096/fj.01-0925fje. Published online April 10, 2002. [2] Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. The FASEB Journal 15; 2001:2281. Fibrosis • “Increased connective tissue stiffness due to fibrosis is an important link in the pathogenic mechanism leading to chronicity of pain.” • Loose connective tissue is the interstitial tissue fascia that allows normal motion between muscles, tendons and ligaments. • Ex: gluteal hip rotator muscles to sacrum and TLF. Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical Hypotheses 68 (1),2007:74-84. Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical Hypotheses (2006), article in press. • Langevin and Sherman write that not enough attention has been paid in the research world to connective tissue in relation to low back pain, especially the loose connective tissue and fascia compared with specialized connective tissues such as cartilage. • Authors give many examples showing how LOW BACK PAIN relates to FIBROSIS i.e. repetitive strain, immobilization, inflammation, altered biomechanics, hypoxia, cytokines, etc • Authors state that ability to change fibrotic lesion is major reason techniques exerting mechanical load are successful. Connective Tissue Healing in 3-D Matrix Grinnell F “Fibroblast Mechanics in 3-D Collagen Matrices” • As Fibroblasts Migrate they pull the disrupted Extracellular Matrix • This is the Theoretical Model for Wound Healing Connective Tissue Healing in 3-D Matrix Grinnell F “Fibroblast Mechanics in 3-D Collagen Matrices” • Actual Remodeling following 1 hour of migration • In a high tension state, the cell body size of the fibroblast enlarges and becomes metabolically active producing collagen and ECM • In a low tension state, fibroblasts cell body is smaller and it is in a dendritic state with many interconnections Nerve Fibers in Fascia Siegfried Mense, MD • Dense Network of Nerve Fibers • In close association with vascular tissue Innervation by layers of TLF Siegfried Mense, MD • 90% of all nerve fibers were located in the superfical layer of TLF • Middle layer composed of dense collagen bundles with few fibers • Inner layer was likewise few nerve fibers Types of Fibers found in the TLF Siegfried Mense, MD • Substance P and CGRP Free nerve endings were discovered in abundance in superficial layers • No substance P ending in the middle layer Distribution of Nerve Fibers in TLF Siegfried Mense, MD • Greater than 90% in Superfical Layer • Over 40% of nerve fibers were Sympathetic EFFERENT endings • Effectively leading to a possible pathway for CNS mediated event leading to vasoconstriction and a change in viscosity of the TLF Are Humans Rats? Siegfried Mense, MD • On cross sectional analysis of Human TLF the findings of Nerve Endings in Rat TLF was found to be of equal proportions to that of Human TLF • Rat = Human Neurologic Hypothesis • Johannson: Gamma/Alpha Loop • Schleip: Mechanoreceptor stimulation – Vascular – Neurologic – Endocrine – Fascial smooth muscle cells • Johansson etal have proposed it is the gamma motor neurons that chiefly influence the alpha system, through extensive interconnections in the spinal cord. • The sensory afferents from the skin, ligaments, muscles and tendons have extensive interconnections on the gamma motor neurons in the cord....not the alpha motor neurons. • These soft tissues are constantly relaying messages to the gamma motor neurons, which feedback onto the intrafusal fibers of the muscle spindles and therefore set the reaction time of the muscle. • We stimulate the skin, fascia and ligaments over a joint and start to introduce normal motion (FAKTR) • Creating a barrage of proprioceptive input that alters muscle reaction time and "resets" normal tone in the muscles. • End Result of FAKTR may not be the break down of adhesions as much as proprioceptive reflex on the gamma-alpha loop Fascia; “interstitial myofascial receptors” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. • A neuro and vascular cascade of events occur from soft tissue manipulation – changes in muscle tone via stimulation of the gamma motor system. – Ruffini endings lowers sympathetic tone…affecting vasodilation – Type III/IV receptors may stimulate extrusion of blood plasma from blood vessels into the interstitial fluid matrix…resulting in a change of extracellular matrix viscosity. www.worldofwallpapers.nuche.org Fascia; “intrafascial circulatory loop” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. Fascia; “interstitial myofascial receptors” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. • It is thought that the interstitial receptors may affect the hypothalamus resulting in a “deep and healthy” change of the global; – neuromuscular system – emotional state and – cortical and endocrine function • The “Hypothalamus Loop” Fascia; “the hypothalamus loop” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. Fascia; “the ACTIVE adaptive organ” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. • Yahia etal, 1993 & Chaitow & Delany 2000 describe a “ligament contraction” – lumbodorsal fascia was discovered to stiffen (increase its resistance) when held on length isometrically…similarly to visceral muscle (Price, 1981) • Electron microscopy by Staubesand and Li 1996 found smooth muscle cells in fascia. – this work also confirmed findings of an elaborate network of vascular tissue, autonomic and sensory endings Fascia; “fascial contraction loop” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. Fascia; “rationale of short-term plasticity; summary” Robert Schleip, Journal of Body Work and Movement Therapies. Apr 2003. Cervical Spine Disorders FAKTR-PM Cervical Spine – Posterior Cervical Group • GT • Active Isolated Stretch – Anterior Cervical Group • GT • Active Isolated Stretch – Upper Trap/ Levator • GT • Myofascial Release – TMJ FAKTR-PM Treatment • • Treat in Position of provocation – Single plane – Coupled • Treat in Motion of provocation – Single plane • – Coupled motions • Treat with Resistance – Static – Motion – Iso/Concentric/Eccentric Treat with Functional positions – Chin tucks, Heading ball, etc – With or without resistance Treat with any of the above with added proprioception – Oscillation/Vibration – Unstable surfaces FAKTR-PM Upper Trap/Levator Scap CS with Active Isolated Stretch CS with Active Isolated Stretch CS with Rotation FAKTR-PM Occiput Occiput, Posterior Cranial Muscles Suboccipital Muscles Suboccipital Cervical Spine GT Cervical GT for Traction FAKTR-PM Cervical Flexion/Extension FAKTR-PM Cervical Spine FAKTR-PM Cervical Spine FAKTR-PM Cervical Spine FAKTR-PM Cervical Spine FAKTR-PM Thoracic Spine FAKTR-PM Cervicothoracic FAKTR-PM CS with Rotation FAKTR-PM Chin Tuck FAKTR-PM Algorithm for the Cervical Spine • Determine provocative position for the CS if one: treat in this position • Add active movement if necessary: treat in motion pattern (note change in pain) • Add resistive movement if necessary: treat under load (note change in pain) • Add functional movement: treat in sport specific or functional activity (note change in pain) • Add proprioception: create unstable environment and treat (note change in pain) LUMBAR SPINE Examination: • Functional Movements – Trunk • Bend • Twist • Stabilize 133 Training • Functional Movement for Spine Stabilize Twist © 2008. The Hygenic Corporation Bend FAKTR-PM Lumbar Spine • Quadratus Lumborum – GT – Nimmo • Erector Spinae – GT – Pin and Stretch • Gluteals/Piriformis – GT – Nimmo • Cross Crawl • Psoas – GT – Cross Friction/ Nimmo FAKTR-PM Treatment • Treat in Position of provocation • Treat with Functional positions – Single plane – Any kinetic chain activity – Coupled – With or without • Treat in Motion of provocation resistance – Single plane • Treat with any of the above – Coupled with added proprioception • Treat with Resistance – Oscillation/Vibration – Static – Unstable surfaces – Motion – Concentric/Eccentric FAKTR-PM Lumbar Spine FAKTR-PM Lumbar Spine GT Lumbar Spine GT with Crossed Extension GT with Ball Extensions FAKTR-PM LS Standing FAKTR-PM LS Standing LS Standing with Resistance LS Standing with Resistance FAKTR-PM Seated LS LS Standing Ball with Alternating Knee Flexion LS GT with Ball GT Lumbar Spine FAKTR-PM Abdominals FAKTR-PM Abdominals FAKTR-PM Abdominals FAKTR-PM Abdominals FAKTR-PM Abdominals FAKTR-PM Psoas FAKTR-PM Psoas FAKTR-PM Lumbar Spine FAKTR-PM Algorithm for the Lumbar Spine • Determine provocative position for the LS if one: treat in this position • Add active movement if necessary: treat in motion pattern (note change in pain) • Add resistive movement if necessary: treat under load (note change in pain) • Add functional movement: treat in sport specific or functional activity (note change in pain) • Add proprioception: create unstable environment and treat (note change in pain) Rotator Cuff Injury Rotator Cuff Anatomy • • • • • Shoulder Girdle Supraspinatus Infraspinatus Teres Minor Subscapularis Shoulder Girdle • Bones – – – – – Clavicle Acromion Coracoid Process Glenoid Humeral Head • Ligaments/Cartilage – – – – – Coracoclavicular Lig Coracoacromial Lig Acromioclavicular Lig Labrum Articular Cartilage Supraspinatus • Attachment Sites – Supraspinous Fossa – Greater Tuberosity • Nerve Supply – Surpascapular Nerve – C4,5,6 • Action – Shoulder Abduction – Dynamic stabilizer of the humeral head in the glenoid Supraspinatus Infraspinatus • Attachment Sites – Infraspinatus Fossa – Greater Tuberosity • Nerve Supply – Suprascapular Nerve – C4,5,6 • Action – External Rotator of Humerus – Dynamic stabilizer of the humeral head in the glenoid Infraspinatus Teres Minor • Attachment Sites – Upper 2/3 of lateral border of scapula – Greater Tuberosity • Nerve Supply – Axillary Nerve – C4,5,6 • Action – Adductor and External Rotator of humerus – Dynamic stabilizer of the humeral head in the glenoid Teres Minor Subscapularis • • • Attachment Sites – Medial 2/3 of anterior surface of scapula – Lesser Tuberosity, shoulder joint capsule, humeral shaft, transverse humeral ligament Nerve Supply – Subscapular nerve – C5,6,7 Action – Adductor and Internal Rotator – Dynamic stabilizer of the humeral head in the glenoid Subscapularis Rotator Cuff Insertions Clark J et al. Tendons, ligaments, capsule of the rotator cuff. J Bone Jt. Surg.1992;74A:713-25. Mechanism of Injury • • • • • • Tensile Failure of rotator cuff fibers Poor Scapular Mechanics Rotator Cuff Imbalance Anterior Capsular Laxity Posterior Capsular contracture Supraspinatus outlet narrowing Examination: • Standing – – – – – AROM MMT: Supra, Biceps, IR & ER, Ortho: Lift Off Scapular Mechanics Shoulder Girdle Testing • Seated: – Ortho: Hawkin’s, Impingement, AC Add, O’Brien’s, Ant Shift – Labral Tests • Supine: – PROM – Labral Tests – Relocation • Functional: Push, Pull, Reach, Press Down Examination: • Functional Movements – Upper Body • • • • Push Pull Reach Press Down 169 Training: • Functional Movements for Upper Body Pull Press Push © 2008. The Hygenic Corporation Lift FAKTR-PM Treatment using individual muscles SEATED • Deltoid – – • Supraspinatus – – • • • – – – – – Prone • Lat GT NIMMO • GT NIMMO Pin and Stretch GT Myofascial Release (Axilla) Serratus Anterior GT Cross Friction (tendon) Myofascial Release (Axilla) Scapular Stabilizers GT Myofascial Release Subscapularis – – – – Infraspinatus/Teres Minor – – • • GT Pin and Stretch Subscapularis/Axillary Fascia – – – – – GT Cross Friction Biceps – – • GT NIMMO SUPINE • Pectoralis Major GT Myofascial Release GT Myofascial Release Triceps – – GT Cross Friction FAKTR-PM Treatment • Treat in Position of provocation – Single plane – Coupled • Treat in Motion of provocation – Painful arch • Treat with Resistance – Static – Motion – Iso/Concentric/Eccentric • Treat with Functional positions – Throwing position – With or without resistance • Treat with any of the above with added proprioception – Oscillation/Vibration – Unstable surfaces FAKTR-PM Deltoid Isometric Supraspinatus Subacromial Space FAKTR-PM Biceps FAKTR-PM Biceps FAKTR-PM Posterior Rotator Cuff FAKTR-PM Subscap FAKTR-PM Serratus FAKTR-PM Scapular Stabilizers FAKTR-PM Scapular Stabilizers FAKTR-PM Scapular Stabilizers FAKTR-PM Scapular Stabilizers Scapular Mobilization Scapular Mobilization FAKTR-PM Lat FAKTR-PM Pec FAKTR-PM Shoulder Rehab Tools Thera-Band® FlexBar Oscillation (Green) Page et al. 2004 FAKTR-PM Algorithm for Shoulder • Determine provocative position for the shoulder if one: treat in this position • Add active movement if necessary: treat in motion pattern (note change in pain) • Add resistive movement if necessary: treat under load (note change in pain) • Add functional movement: treat in sport specific or functional activity (note change in pain) • Add proprioception: create unstable environment and treat (note change in pain) 191 Knee Disorders Examination: • Functional Movements – Lower Body • • • • Step Lunge Squat Press 193 Training • Functional Movement for Lower Body Lunge © 2008. The Hygenic Corporation Squat FAKTR-PM Treatment • Quadriceps • • • • • • • • • • Hamstrings Pes Anserine Coronary Ligaments Infra/Supra Patella Ligaments MCL/LCL ITB Meniscus Patella Plicae Gastrocsoleus FAKTR-PM Treatment • Treat in Position of provocation – Single plane – Coupled • Treat in Motion of provocation – Flex/Extension – Open chain/Closed chain • Treat with Resistance – Static open/closed chain – Motion open/closed chain – Concentric/Eccentric • Treat with Functional positions – Squating, bike, lunge, kicking – With or without resistance • Treat with any of the above with added proprioception – Oscillation/Vibration – Unstable surfaces Quadriceps FAKTR-PM Quad FAKTR-PM Quad, Patellar Tendon, ITB, ADDuctors, Hamstring FAKTR-PM Patellar Tendonopathy FAKTR-PM Quad FAKTR-PM ITB Hamstring Insertion Hamstring Insertion Gastrocsoleus w/wo Resistance FAKTR-PM Gastroc FAKTR-PM Gastroc FAKTR-PM Hamstrings FAKTR-PM Hamstring FAKTR-PM Hamstring FAKTR-PM Algorithm for the Knee • Determine provocative position for the knee if one: treat in this position • Add active movement if necessary: treat in motion pattern (note change in pain) • Add resistive movement if necessary: treat under load (note change in pain) • Add functional movement: treat in sport specific or functional activity (note change in pain) • Add proprioception: create unstable environment and treat (note change in pain)