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Hello all.
I am starting to see more and more muscle strains- rec fem and medial head of gastroc. Although this may sound silly, but am struggling to fill out a half an hour session. especially injuries in the acute/ sub acute stage. I feel the patient comes for treatment, not just to be given a load of exercises. Apart from stretches, ultrasound and active release I am struggling to come up with anymore treatments.
Many thanks
In the acute stage there isn't a great deal you can do apart from ultrasound and gentle stretches and for them to ice at home. At this stage getting rid of any bruising is important.
If the patient has tenderness on palpation when sub-acute, when pain allowed I would start DTF's. As pain to palpation decreased I would start strength exercises starting at isometric if needed.
Ice is great in acute stage with rest at home. Gentle massage with active assisted or active free ROM without pain. You can start gentle stretch in sub-acute stage and upgrade to isometric exercises if there is no pain.
Why should we fill out a half an hour? Do what patient needs whatever it takes. It doesn't matter if it takes only 15 minutes.
hi
i agree with the others suggestions.you can even try soft tissue release in the subacute phase.
like others i suggest RICE in firs 3-7 days adding to immobilization but mobilization should be started after first 3- 7 days ( depends on case severity)
HI VERY NICE TO HEAR UR DIFFERENT APPROACH IN TREATMENT OF MUSCULAR STRAINS
.VARIOUS OTHER TREATMENT TECHNEQUIES APART FROM THE USUAL ONES ARE
1. MYO FASCIAL RELEASE - can start from the sub acute phase itself
2. POSITION RELEASE TECHNEQUIES
3.TRIGGER POINT RELEASE
4.P.N.F TECNEQUIES -can start even from acute phase
just try and see all these after having any idea of this surely u can show good difference in ur treatment when compared to the usual ones
BYE
PRATHAP
Perhaps consider "Why" they are injured. I could spend an hour easily on a torn calf looking at the why and strengthening/stabilizing/releasing any issues that might have contributed to their injury in the first place. So the simple answer is to look above and below the injury and consider prevention as part of acute treatment protocol as they might not still be with you if you wait until the tissue trauma has resolved. :)Quote:
Originally Posted by cleehaddock
Hi
Like a previous reply said, it is more important to look at the possible causes rather than trying 'speed up' recovery through localised treatments. I find a lot of injuries like this have another component to them. Commonly if it is a traumatic injury, eg a blow to the thigh/calf, then it may be local, although there could still be secondary changes in how the body responds. If it is a 'tear' or strain then it may mean the area of injury has been put under unnecessary stress through some other muscle malfunction. eg if the hip muscles are weak, this results in extra work being done by the quads and calf to compensate, as well as by the back muscles (common cause of LBP), thus this continuous overload can result in fascial tightening of the quads and calf sheathings and eventually a tear (most 'tears' are fascial not muscular...bleeding occurs with muscle tears). So always check hip strength and other muscle strengths above and below the injury to assess possible causes or responses in other muscles. Myofascial release is great for correcting these problems, as most weakness is as a result of myofascial tightness, NOT lack of exercise. It makes no sense to stress the body more by introducing exercise as a form of treatment when it is often exercise that caused it in the first place. Once normal base strength and full ROM is restored then exercise can be re-introduced.
Cheers
Pete (see next reply for ideas on RICE)
Fllowing on from the previous reply. Some have mentioned RICE in the initial phases. I have a few things which might make you think about this differently. Although it is widely held that this is an acceptible approach to use for acute injuries, I feel we may be missing the point here. Theoretically ice reduces swelling, inflammation and pain, restricts blood flow to reduce bruising, however, this is theory, and yes these are the effects of applying ice to the body. But why would we want to starve an injured area of a natural blood flow for anything up to an hour. Inflammation, swelling, pain, bruising are all natural part of the injury process, BUT THEY ARE ALSO NATURAL PARTS OF THE HEALING PROCESS! Without these the brain will never know for sure the injury occured. So reducing these inputs can severely diminish the body's ability to repair itself. Where is the research to prove RICE helps the repair process or shortens the recovery period of an injury? I have not seen any, just as I have not seen any regarding ice baths! It is a SYMPTOMATIC APPROACH, not treatment approach. The ironic thing is that if injured and left to its own devices the body responds with vasodilatation in the injured area, NOT vasoconstriction, which goes against anything we have been told. So if the body itself increases the blood flow to the area, why are we shutting it down? For repair to begin the body needs platelets, red and white blood cells in the area, so it makes sense to increase the amount of blood in the area, but this takes place almost immediately, yet if we restrict blood flow, this cannot happen. Bruising will eventually stop as blood vessels repair quite quickly, so we should not worry about that and swelling is from damaged cells...they cannot get any more damaged and only have a certain amount of fluid in them.
In my opinion we should focus more on trying to influence more blood to the area, not away from it. This can be done by using small doses of ice (10 secs at a time, removed until the skin warms up again), below the injured area if possible to stimulate flow THROUGH the injured area, not around it which is what happens with orthodox icing.
My opinion: RICE...rest, yes. Ice, NO!
What do you think?
Pete
Hi
Pete I think you are missing a key point related to the use of ice and that is that vaso constriction is only a short lived phenomena it is followed by vaso dilation and finally vaso motion both within a relatively short period of time once ice is removed
Key phrase there being 'once ice is removed'. But what is happening while the ice is applied for 20 minutes or more at a time (I had a petient who was told to put ice on for an hour), if only once the ice is removed do these effects occur? So why leave the ice on for so long if the effect we should want is one of improved RATE of blood flow to flush injury byproducts away and allow fresh nutrients to get to the area? It boils down to maximising the rate of blood flow and encouraging the body to repair itself as soon as possible and for us to get the patient back on the road as soon as physiologically and physically possible. Our job is to remove obstacles to enhance healing not to install them surely?
Pete
there is no argument on the importance of ice in acute soft tissue lesions. It is standard practice and the evidence behind it is tremendous however based on protocol several are out there but in no way do I think icing anywhere for more than 20 minutes is therapeutic, let alone one hour.Icing in low doses, 10 seconds etc is also in my book not as effective. The reason is, the deep anatomy of the muscles being treated. The literature behind intramuscular temperature suggests that muscle does not start to cool until approximately 8 to ten minutes after icing(remember you have the fatty tissue insulation and countercurrent vascular exchange to deal with) . this is where your low dose theory will not work except u intend to stay there the whole year. moreover, intramuscular temperature decreases long after the skin temp has stabilized lasting several hours so therefore your best bet is too cool for the therapeutic time and leave alone for a few hours, authors suggest 2 hours and then recool but depending on the acute symptoms u may want to do it every hour but being practical two hours is enough. Vasodilation (lewis hunting reaction)that u claim occurs after vasoconstriction is questionable, current literature questions it however if it does occur it brings in deoxygenated blood low in hemoglobin which is not too beneficial to healing is it?so therefore stick to the current practice, people have researched it and the literature is consistent. If u are considering new management plans for your patient, then consider other forms of massage.gentle(and I repeat gentle) transverse frictions from a few short sweeps to probably numbness may be used but u need to judge from ur assessment and ur patients level of tolerance. stretching should be gentle in combination. The reasoning behind, this type of management is simple, transvers efriction ensures that the fibers heal without an abnormally formed scar and gentle stretching realigns, with adequate cooling your patient should be good to go in 3weeks or a little more because muscles are very vasculrized anyway. Change to heat after swelling and pain has subsided, that is standard practice. use your NSAID gels if necessary. you can become creative in the types of exercises(eccentric contractions,oneleg stance etc) you give but honestly the management cannot be better than that. if you decide to use US make sure it is pulsed mode u start with in the first few days and u can use phonophoresis of an NSAID if you want. but that is the practice and it is the practice because it works.
Work with what u see and create along the lines of what u see.I know that a gastroc tear will affect gait and step phase because of stretching, so I may want to strap the strap the gastroc or provide crutches in the interim get it?but the practice still remains the the same for soft tissue lesions.Holla back if you disagree or have new info, its always good to hear opinions.
Hi Dr Damien
Thanks for the input, always good to see different ideas.
I understand your points and do not agree with the proven effectiveness, but i only have one question and this is probably the main reason I wrote about RICE. Is the application of ice seen to be effective because it gives symptomatic relief, or is it actually proven to shorten the repair time of an acute injury?
My argument is that all the research into the effectiveness of RICE seems to be based on treatment of symptoms, which fair enough, is sometimes called for, but I would like to see some proof of whether RICE is more effective in the entire recovery, compared to another approach, for example acupuncture, myofascial release and normalising sympathetic control of blood flow rate to the injured area. I have used this approach, eg on a sprained ankle (lateral ligs),and had the dancer performing (although slightly abbreviated performance) the next night after the injury. I used no ice no elevation, only ensured that the leg was well supported by the hip and upper leg and that the calf muscles were functioning to support the ankle. This eas done with acupuncture and myofascial release massage, freeing the space for muscles and ensuring correct natural biomechanical stability. Added to this I ensured the sympathetic nervous system was controlling blood flow rate. I saw him once more and he was back to full time dancing. The point is, would he have improved as well if he had iced his injury immediately after the injury? I would like to see this type of research, not research which tells us how the body responds to cold...we already know that.
Sometimes I think we might have been baffled by evidence of symptom relief, and because it is so widely used, we accept it as gospel. I am not saying it is not effective, just is it effective for symptoms or for the bigger picture of full repair. Personally I feel our job is not to treat the damaged tissues but to support the body in it time of repair. If we can remove any obstacles getting in the way of the body repairing itself, eg poor blood flow rate, tight fascial tissues (not necessarily scar tissues...normal in repair), weak supporting muscles, and if necessary pain (acceptable in certain cases), then I think we are well on the way to guiding the body into full repair.
What we must remember is that every injury is new for the body, and as much as it is designed to repair damaged tissues, a knee injury is different to an elbow injury , and it is our job to guide the body, educate it, and show it how to repair each area of the body, so it does a good job first time. Eg, it makes no sense using weight bearing exercise for the elbow when it is a hing joint in an essentially non-weight bearing arm.
Personally I am not sure about cross frictions as scar tissue is natural and I feel it has been given a bad name by my profession's teaching as if it ALWAYS sticks, which makes the use of x-frictions sound feasable. I all my years of practice, I have rarely seen poor scarring in an acute muscle/ligament injury, and believe it should be left alone to repair without any outside interference. It makes the body sound like it is completely inept at fixing itself, which is crazy. Tissues will heal, we must ensure the environment of the repair is satisfactory.
By the way, not sure if you heard, but I have been led to believe, about 8 years ago US was proven in research not to work. For this reason and for the reason that deep heating can slow the rate of blood flow by deep vasodilatation, thus decreased O2, etc. I have not and will not use US in practice at may not be evidence based. Once again, just because we know what it does to the body does not prove it is actually effective.
Please also see other thread on RICE in forum...I think in Sports or general discussion.
Thanks for your input again, I think it is important to question treatment regimens sometimes, even though the approach might be seemingly solid. As we learn more about the body so things should change.
regards
Pete
Well like I said before lateral thinking is fine, there is absolutely nothing wrong with it.But to make a really arguable case, then something should be wrong that one has seen or experienced over and over again. first of all, the question I have is what was the grade of the ankle sprain, how long did you have to treat for?since we all know that ligament sprains do not always carry the same extent of injury what was the situation with the patient you treated. I can not say what the situation would be if I gave u 30 patients to treat with the same protocol with differing scenerios.see what I mean?
Many of these techniques you mention are also lacking in evidence base so why pick out a technique that has consistently shown to be effective?I dont know if I am making sense? the evidence base of acupuncture is poor even though new papers turn out every other day.
Cryotherapy involves several techniques and my point is understanding why you do whatever you do.
Cryotherapy is not a symptomatic treatment alone, if anything at all acupuncture is because it addressed only pain in the most part just like Tens would.Myofascial release techniques work just like any soft tissue mobilization so where is the justification for thinking ice is problematic?
You sound like you have a great of experience doing what you do but I tell you if cryotherapy was not working effectively I would support your argument a 100% but it is and we have the literature to prove it.
I like the way you think and it is good, perhaps you should work more in research rather than in the clinic.this is where you and I are different, I will give weight bearing exercise to the upperlimb if I see reason to, for instance in a neuro case were weight bearing experience is important not because the patient will walk on his hands but because it helps joint memory.
I agree with you that you need to make the area satisfactory for healing but I tell you one thing about scars and inflammation, they can get excessive depending on personal body responses. So I would not go treating every patient like I treated the last, I would rather judge from what I see and act accordingly, if inflammation is not excessive then I may not consider ice. this brings me back to my initial question what was the state of ur patient?
if the body is so good at handling its own problems then why do we have diseases?why do we die?why can a simple infection turn fatal, why do we even need to guide healing? Maybe if we had never introduced the concept of medicine before then we may have evolved into superhuman beings but that is not the case.
I had a cut in my wrist some few years backthat was pretty deep but not deep enough to cause too much damage. I got it stitched and always tried to move it so it did not get stiff. yeah, if i did not have the pain to guide me then I may have moved it too much and caused more damage. Then again if I did not have the inflammation controlled with drugs who knows what the scars may have been like. this is eight years since and I still have a scar to show for it although its clearing up. Imagine having an excess scar tissue that is one ugly to look at disorganised in collagen laid down and quite frankly was a keloid.
So scar tissue are what they are temporary bridges between injured sites, they are not the main tissue but a replica and they need to be moved to ensure they organise properly. That is what frictions and mobilizations do.
Concerning the treatment of US being non effective, you need to be clear where the literature says US is not effective and its mostly in degenerative conditions and the reason is simple.Its degeneration, not too much inflammation going on, modalities designed to address that are likely to be ineffective.
I'm sure you know some physios who still believe US is ok and they have every right to believe so because they have used it and it worked.
trust me if you left a tendon, muscle or ligament to heal on its own.If you are lucky nothing will happen, if you are unlucky and with a muscle you get tethering or calcifications and you suddenly try exercises and you get myositis ossificans then you will appreciate the value of some of these doctrines.
Manual based physios are not strong advocates of therapeutic modalities anyway. I am a manual physio and I dont use any of them not because I do not want to but because I think I can do something with my hands;its a training thing for me.
If you must criticize anything at all, start by criticizing some of these techniques you use that lack evidence base.
I for one am not against anything that is being done, I am fully evidence based but I am also very practical, if the evidence is strongv and consistent within all parameters, sample size, blinding, randomized,methodology is good , equipments used are reliable and results are consistent then its most likely good.
when you think of changing the practice prove that something is wrong somewhere causing abnormal results, its that simple not imagining that things should work according to how you are used to doing them.Then everyone might as well claim that their practice is the best.see what I mean?
I respect ur opinion because it takes a fantastic mind to think like you do but I will be honest with you after sampling every single evidence out there and you have criticized them properly, then you can make an informed statement. For someone who is pro-acupuncturev and Myofascial release ,i am surprised that you want to pit against ice when these ones are even more on shaky grounds evidence based wise.
if the thought still bothers you and you cant seem to find the evidence to answer your question, then carry out a study and get it published but you must realise nothing that comes out from your study says anything, its only going to be an added piece to the jigsaw puzzle because after critical appraisal for methodological issues, no one's study is considered to be above anyone elses. they all add to knowledge somehow.
thanks for your reply, holla me if you feel the need to discuss anything, we could always clarify each other out.
by theway, you do not see abnormal scar tissue or excessive adhesions because the sites are deep and are not fully immobilized. so consider what is happening to your patient during your management as well, what are they doing or not doing.
I cannot say if ice shortens the repair time of any injury because it depends on the injury and the persons personal acute response level. some people may get injuries and heal quickly, others may get it and react excessively...do you understand the point? anyone one who gives ice for mere symptomatic alone is not conversant with the literature on ice.
I agree with previous posts but you also try trigger point releases with dry needling in the acute stage which can make a huge difference in reducing recovery time.eccentric loading early in the repair stage is essential in conjunction with good biomechanical assessment and appropriate correction.
cheers
Don't know what all the fuss is about, but this is why Physio Therapists are in the business of Problem Solving. Research into any of the modalities mentioned is pretty weak, but that shouldn't get in the way of efforts into solving the problem. It could be related to repetitive stress, poor posture, muscle imbalance, poor proprioception, sensation, inactivity in muscles, poor neuromuscular recruitment, fascial problems. Who knows. Well we should at least try.
physiomitch -
You site the lack of research as to why you don't use ice in the acute phase (I use it very little myself) and as to why you don't use ultrasound (I haven't turned an US machine on in around a year, probably). But, you then go ahead and state you use myofascial release to treat an acute ankle sprain, which has absolutely no data that supports its efficacy, and a lot of scietific data that calls into question the theory behind it. Additionally, you state that you additionally treated the sprain by.Quote:
normalising sympathetic control of blood flow rate to the injured area
How exactly does one do this? And, if it is indeed possible, is there research to support that it reduces recovery/healing time?
I'm afraid that you can't question a treatment because you feel there isn't enough evidence and then support another group of techniques wich have no evidence either. Or, I guess you can. but it doesn't make for a very convincing argument.
Quote:
Originally Posted by jesspt
I don't use ice either.
Ice is for inflamation. Most muscular problems are not inflamitory in nature.
The single most useful tool that I have found is direct pressure into the muscular body at 90 degrees or perpendicular to the muscle fiber. This causes a specific distress to the muscle which helps to "recalibrate" the muscle spindle and golgi tendon organ. Further, it provides a specific feedback into the neuromuscular system of control and the prorioceptive sense.
This is true even for strained msucles, although pressure has to be greatly reduced.
This is not to be confused with trigger point treatment. Although Janett Travell did us a great work in mapping the trigger points, her manual does not differentiate between cause and effect. I find the active trigger point is an effect, but the latent trigger point is the cause. Or the trigger point in the complaining muscle under a stretch is the effect and the non complaining muscle in a shortened state causing a distortion, the cause.
Hope you find this helpful.
Best regards,
Neuromuscular
The problem with trigger point therapy is that which is the cause and which is the effect.Quote:
Originally Posted by timrobinson
J Travell did not state this, but just mapped the trigger points.
Postural deviation is helpful in determining the cause /effect.
The latent trigger point is more commonly the problem and not the active trigger point.
Hope you find this helpful.
Best regards,
Neuromuscular
See previous entry.
Hi 'neuromuscular'
Thanks for the reply, glad to see we are not all duped by non-evidence based approaches...
I agree with your comments re: evidence for use of myofascial release in treating ankle strains. I think I should quantify this by saying it is not the myofascial release that corrects the ankle strain but the effect of releasing fascial restrictions which cause muscle weakness and stiffness around the ankle. It has been shown that fascia reacts by tightening up when stressed, a natural protective response to injury. We also now that tight fascial sheaths around muscles cause muscles to become weak. This is due to restricting the muscles blood flow and its biodynamics (lack of full range motion).
So the approach to treating an ankle strain is to focus less on the actual injury site (ligaments) and focus on removing any obstacles that can prevent the body repairing the ligaments, ie muscle weakness (including the hip) and fascial tightness of the fascia in the calf/foot.
As for ice, I know we have evidence as to what it does and that is proven, but my quesion has always been has research shown it to speed up recovery from time of injury to full return to activity? That to me is what we should be aiming at, not so much restricting natural reactions to injury, such as inflammation, swelling and pain. Does RICE actually make the body work quicker to repair the damage or does it slow it down? I am not adverse to using ice, usually in 10 second doses, but I feel we need to investigate this further and not be ruled by effects of a treatment, but rather what it does to assist the body to repair itself.
Regarding your ideas on trigger points, this fits perfectly into the fascial module. In my experience, I find that most pain from 'trigger points' is actually in the area which is compensating for a tightness or weakness somewhere else. The general rule of the body is that where there is tightness in fascia there will be weakness in the opposite muscles and vice versa. Example, tight low back fascia = weak abdominals (reciprocol inhibition). So strengthening abdominals is useless without first releasing the lumbar fascia, which will often result in increased abdominal tone anyway. As you know trigger points have been seen to be fascia related not muscle, which is why myofascial release techniques work so well, compared to ischaemic compression and stretch. Muscles do not have a sensory nerve supply. Personally I use a muscle spindle stretch at the end of my treatment to 'stimulate tome', almost like a quick 'kick start' for the muscles as spindles can become too relaxed if the opposite group of muscles' fascia has become too tight.
Thanks for the input again.
Cheers
Physiomitch
I agree that the fascia is a problem in long term pain.
However, I have found that the weak muscle theory is very weak.
Most muscles have been activated by a guarding response which inhibits others and makes them appear weak. I call this a recalbration of the muscle spindle and the golgi tendon organ, although most do not.
For example, in the Trendelenberg test, it is presumed that the gluteals are weak in a positive. However, try this: instead of "strengthening" the supposed weak gluteals try treating the adductor magnus with direct pressure into the muscle fibers at 90 degrees to the muscle fiber. You will see that the gluteals are suddenly very "strong" in the next Trendelenberg test. The hypertonic adductor magnus in a guarding response was inhibiting the gluteals. When one gives exercise to strenghten the supposed weak gluteals, they are giving an exercise that stretchs the adductor magnus. So, even thought they have success in the treatment it is not from the supposed "cure" to strengthen the gluteals.
Muscle problems vs fascia problems is like the difference of what you would prefer to hit in a auto accident. If you had the choice would you rather hit a train, a bus or a micro mini car? Muscles are like hitting a train: fascia is like hitting a car.
In therapy, I have found that if you get the muscular part first, the person returns to anatomical neutral faster or immediately and that pain is reduced the most first. Long term pain is from fascia.
Best regards,
Neuromuscular
Hi
It seems we are both in agreement as to the mechanical imbalance, in that where there is weakness there is often opposite muscle weakness (abduction vs adduction), however we are looking at it from 2 different approaches. In your example of the Trendellenberg type weakness, I work with the fascia around the gluts and TFL/ITB, which are often tight, and this restores abduction strength. At the same time I expect to see a release of tension in the adductors as they do not have to over-compensate anymore.
If I look at trigger point therapy from a fascial point of view, I do see correlations, as pressure vertically into a muscle will be affecting the fascial sheath, thus a form of myofascial release is affected. This can have the effect of stimulating reflex loops to opposite muscle groups, thus restoring strength and balance. However, if fascial shortening has taken place in the gluts or the adductors, release is necessary to restore normal ROM and thus strength.
So I have to disagree on one thing, and that is muscles being the 'more important' to treat first, as they depend on fascial integrity for their strength. If the problem is acute and no fascial shortening has occured then your approach will be successful, no doubt, but if fascial sheaths become tight around a muscle, naturally pulling from end to end, the golgi tendon organs will be stretched, hence reciprocol inhibition, but the spindles will be relaxed, thus reducing tone in the short muscle, and this can manifest as weakness on a resistance test, not to mention the blood flow being deminished. In this case release of fasia is vital to restore muscle function.
Similar approach, slightly different roads...nice though to hear someone else thinking functionally, not anatomically.
Dear physiomitch:Quote:
Originally Posted by physiomitch
I do agree that fascia is a factor that requires therapy. However, in hip pain and low back pain, I have seen no return to anatomical neutral of the innominate bones in the ASIS to ASIS, PSIS to PSIS, ASIS to PSIS (R&L) with hip abduction directly lateral in the coronal plane. After fascia only tretments, the pelvic imbalance remains. Have you tried a four sided assessment with hip abduction pre and post therapy?
I find numerous methods desensitize the area without creating a postural change. What are your findings?
Treating the muscular imbalances always creates a change in the anatomical position of the innominate bones and relief of the pain. Treating fascia after creates a longer term pain reduction.
Hope that this is helpful
My best to you,
Neuromuscular
Truth is my approach is a bit more complex than just fascial release. I have found an underlying common denominator in most musculo-skeletal dysfunction and pain and that is the sympathetic nerve cell dysfunction. This dysfunction seems to be a starting point of the body's adaptation to overload or stress, and if this system fails it loses control of the blood flow rate to certain areas of the body resulting in fascial shrinkage, muscle weakness and pain. I usually treat this first to see the effects of restoring function to teh sympathetics, and in most cases (>95%) this restores muscle strength immediately. I then use myofascial release to restore the flexibility, thus giving muscles the 2 main things they need apart from an intact nerve supply, namely good blood flow rate and space in which to operate.
I find this restores muscle balance, pelvic balance and general function in the musculoskeletal system, and because of this pain is relieved. I find there are 2 main types of pain, that from fascial stress due to musculoskeletal dysfunction, and that from poor blood flow control (commonly pain at or after rest, or after too much activity). Pain with movement is more mechanical, thus related more to the myofascial component.
Before I started using myofascial release 16 yrs ago I used to do manual pelvic adjustments which showed similar changes in muscle strength, however it did not last very long, but myofascial release gives a more permanent change in the strength and posture.
In my view if we restore good blood flow rate and fascial integrity, there is very little reason why there should be any pain from a musculoskeletal origin.
Dear Physiomitch:Quote:
Originally Posted by physiomitch
Thank you for your reply.
I have never used the manipulative approach as it would appear to me to create a feedback much like a strain or sprain where the area is at first inhibited and then the prprioceptive sense is fooled to accept an abnormal as normal.
The affect is temporary at best as you menrtion.
I am result driven. I do not use methods taht flatter me as the great healer. If I do not see a change I do not feel that a change has been made.
I have mentioed the assessment that I use as the four sided pelvic bone assessment with hip abduction. Pretherapy the angles are off the normal plane.
Post treatment the angles are in the anatomiclal neutral position. That is my criteria for success. in low back treatment. The other areas such as the ankle are harder to quantify by postural assessment.
I use postural asssessment first and foremost as it is the most objective. If i fool the proprioceptive sense, the muscle strength may appear to be normal until the patient returns to normal activity and then the muscle "strength" may not be so "normal".
I would be most interested in how your therapy corresponds to the comparison using the assessment of the four sided pelvic assessment pre therapy and posttherapy.
The OGI test in Nebraska USA is finding very positive affects of using the assessment. Patients who previously did not respond to any treatment by any discipline are responding to this assessment and the changed therapy resulting.
Thamks again.
My best to you,
Neuromuscular,:)
Hi again
I have never come across the 4 sided pelvic assessment, but I can understand the approach especially in this day and age and the need for objective measures. Personally I trust the muscles themselves for giving me an idea of where things are at physically/posturally. I too do not use manipulation, my treatment for the sympathetics is based on specific application of cold, not as we are taught, based on Frederick Erdman's approach.
I am of the belief that if the muscles are strong, the ROM is normal and equal side to side, and this is backed up by good circulation control, then the body should function pain-free. The great thing about using muscles as a test either through Kinesiology or basic strength tests is the patient is immediately involved and when strength returns or a Kinesiology indicator muscles changes from weak to strong, they can feel something is happening, even though there may not be any change in symptoms initially. I judge improvement by increased strength and flexibility, not symptoms, these will follow basic functional stability.
In essence, as an Acupuncturist/Kinesiology practitionar as well, I am able to improve strength in many ways, including one needle in Pericardium 9 for hip abduction (as an example only..usually 5 elements approach used here), or by stimulating neurovascular or neurolymphatic points for a minute or so. All these can show an improvement in strength, but need to be backed up by blood flow control and soft tissue flexibility. If the pull of muscles is balanced then pelvic posture will be restored, thus I am positive all the angles will be normal, otherwise strength and symptoms will not be restored. Posture follows fascial changes like a shadow, and as fascia is an adaptable tissue and able to shrink, it is the primary suspect in postural changes and thus bony positions.
Out of curiosity, how do you measure the angles of the pelvis?
Regards
Dear physiomitch:
You are not alone in trying to find information on a four sided pelvic bone position test. There is little on this type of testing. The OGI is doing a research project on it and a paper should be forthcoming soon.
I use a landmark test with the following comparison referenees: ASIS to ASIS. PSIS to PSIS, ASIS to PSIS (R&L) with hip abduction directly lateral in the coronal plane from closed foot stance to the maximum obtainable by the patient using 30 cm increments..
Any deviations should be significant. Normal is all landmarks level or even in the horizontal plane.
You can use a goniometer or eye sight. The differences will be greater than 1 cm in the ASIS comparisons and less in the PSIS comparison. ASIS differences are often in the order of 2 cm plus. PSIS usually are less .5 cm or sligthly greater.
Do not look for mm differences. The differecnes must be significant.
See if your results pre therapy and posttherapy are significantly different.
Hope that this is helpful.
Best regards,
Neuromuscular.
I take it this is done in supported standing? Do you do actual manual muscle strength tests as well in your assessment?
Dear physiomitch,Quote:
Originally Posted by physiomitch
The test must be in full support against gravity. The patient must be free standing and have complete control at each progression. The idea is to see how the posture muscles hold against gravity. Each stance must be complete and with the patient in control to his ability.
Most patients will deviate much from anatomical neutral as the foot width stance progresses. Some will appear to come closer to anatomical neutral. However, each will tell you why the patient cannot hold close to anatomical neutral throughout the progression. It will take some time before it falls into place for the practitioner as this is a new direction for them, but it will make sense as it is used.
Unlike the Kendall manual on muscle testing, I have not found muscle testing to be objective. The role of reverse inhibition has not been explored. Although, I have taken seminars on "better" positioning to get the most objective results, I have not found that I can depend on these as an absolute test.
The postural test that I use gives me the most objective information on the patient.
We cannot say that the synergist, antagonist, joint, fascia, etc is not inhibiting the muscle in muscle testing no matter the position or care given. Using an instrument to measure the responses only rules out the practitioner's input, but does not rule out other factors such as reverse inhibition or eccentric contration problems interfering with the muscle testing.
I also do a supine and prone assessment to see if there is a difference in the gravity to non gravity action of the muscles. There often is.
The supine test is of ASIS to ASIS for superior or inferior placement and distance of ASIS to the bench or table or plinth.
The prone test is of the PSIS to PSIS for superior to inferior placement and the distance of the buttocks from the table left compared to right
Hope that this is of benefit to you.
Try these test against your therapy to assess your success in return to anatomical neutral.
My best to you,
Neuromuscular Ed