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Rehabilitation
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Rehabilitation
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Written by Stephen W. Boyles D.C,CKTI
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Thursday, 30 August 2012 00:32 |
W e all employ a variety of techniques with our patients, and even with people we may not originally have thought of as patients. In almost 20 years as an educator and practicing DC, I have often been asked to share in unexpected areas. Kinesio Taping, or Elastic Therapeutic Taping, has been a valuable tool for me since 1999, and I now have the pleasure of helping to spread its use in my role as a Certified Kinesio Taping® Instructor (CKTI).
 Several years ago I was practicing in the Houston area. My daughter attended a private school just north of Houston that had a nationally ranked basketball program. I was a pretty involved parent, and it doesn’t take long for the school to discover which parents have useful skills. I was happy to help whenever I could, to keep the school’s athletes in top form, but more importantly to help the young people get the most possible enjoyment from their high school years.
The head coach asked me to look at one of his best players who was having low back pain. The young man could only play half a game because his low back would tighten up and become painful by halftime. Even so, he was still scoring around 40 points a game, so it was natural for the coach to want him available for the entire game. And we all wanted the kid to feel better!
I adjusted him several times within a few days and applied tape to his low back to relax his muscles and relieve his low back pain. He had pretty classic lower lumber facet joint subluxation and sacroiliac inflammation. His range of motion was limited in flexion and extension.
I treated him with side posture adjustments to the lower back and sacroiliac (SI) joints and then applied tape in a space correction to the lumbosacral area along with an I-O application to the lumbar paraspinal muscles. The space correction helped reduce the edema in the lumbosacral and SI region, while the I-O lumbar muscle application reduced muscle tension and edema in the lumbar paraspinal musculature.
The next game he not only was able to play the whole game without pain, but he scored 102 points. I’m not going to try and take credit for the young man’s basketball skills, but apparently my treatment helped him get to a new level!
There are many individual considerations in developing a treatment and therapeutic taping program for each patient’s needs. The following is a basic elastic therapeutic taping strategy for the lumbar fascia:
With the patient standing in a neutral extension (with the closer arm raised) laterally flex the trunk to the opposite side. Apply the base of the tape “I” strip to the lateral 1/3 of the gluteal muscle bulk, approximately the posterior border of the gluteus medius.
Stabilize the base of the tape and apply downward pressure to increase the tissue tension. Apply the elastic therapeutic tape to the lateral border of the inferior angle of the scapula. Apply a second strip of tape to the other side in the same manner.
With the patient again in a neutral standing position, apply an “x” tape formation to the sacrum. Tear the paper backing away from the central portion of the tape, leaving the backing on the tails.
Holding the piece by the tails, direct the tape obliquely, pull the tape gently (mild tension) and apply the central portion of the tape to the center of the sacrum. Pull both ends of the tape with equal tension away from the central portion and apply the tape to the borders of the vertical pieces that you already applied.
As always, you will want to perform a thorough assessment before choosing your course of treatment for any situation, but elastic therapeutic taping is a great addition to the toolbox!
Dr. Stephen Boyles, DC, CKTI graduated from Parker College of Chiropractic in 1992. He was the team doctor for the Parker College of Chiropractic Olympic Team and worked there for 8 years as an associate professor in the student clinic. Since 2008 Steve has been with Southern Trace and Colony Chiropractic Center in central Florida. He is also certified as a Golf Fitness Professional by Titleist Performance Institute. http://www.southerntracechiropractic.com/ (352) 205-8500
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Rehabilitation
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Written by James C. Antos , D.C.
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Wednesday, 29 August 2012 22:00 |
A fter 34 years of private chiropractic practice, I have found that some fundamental keys to practice security, financial security, and peace of mind lie in these simple facts.
 First, as a chiropractor I must be able to get positive results for my patients concerning both their goals and mine. The patients must feel that I am there “for them” and that their goals are the most important in our relationship.
Second, I need accurate information in order to be able to work and perform efficiently. Accurate information allows me to achieve clinical results and to develop passion, enthusiasm, and satisfaction in excellent clinical performance. It has been my experience that one of the side effects of this is becoming financially successful and stable. For me this helps to achieve peace of mind in my “money” life and my chiropractic practice.
A number of years ago, especially after additional seminars in orthopedics, I began using lumbar braces and cervical collars. I also remember years ago using the at-home over-the-door cervical water bag traction devices. I would try anything reasonable to get better patient care outcomes. All of these things helped but there was very little financial profit in using them.
But today net income from such equipment is very good. Also, at this time the financial as well as the clinical improvement in Medicare, especially in providing DME supplies, such as back braces or at home traction devices, is excellent.
For years I have been providing DME supplies with great patient results and satisfaction. After sharing what I was doing with some close associates and friends, they started enjoying the benefits. Once they found out the “secrets” of this undiscovered opportunity that is “naturally right” in delivering chiropractic care, their practices became better.
The most common question I get from chiropractors is, “How does Durable Medical Equipment (DME) fit into the clinical picture for a chiropractor? Why should I even consider DME in my practice?”
My answer is always the same. Consider this: As a chiropractor who is certified as a supplier of Durable Medical Equipment (DME) under Medicare, you are certified to be able to be paid by Medicare at a strong net financial gain. The reimbursement levels are very good at this time. How would an additional $5,000 in your pocket or more affect your lifestyle? Did you know that your patients are receiving these supplies from other sources already? Medical doctors, physical therapists, and supply stores have been in this side of the health care business for a long time. You are letting business that is sitting on the table in front of you just go to other sources.
Now consider that durable medical equipment includes strong clinical items that greatly help your patients live healthier lives. Consider that you may be insufficiently treating your patients if you do not incorporate, when appropriate, durable medical supplies in your treatment plans.
Utilizing durable medical equipment helps a chiropractor achieve two very important goals. First, we achieve results in patient care and second, we capture a sound financial compensation stream for the practice. Let’s be honest; without both why are we practicing chiropractic care anyway?
The next question I hear all the time is, “What are some durable medical items that I, as a chiropractor, could consider as useful in my chiropractic practice for my chiropractic patients?”
The most common durable medical items used by chiropractors and other physicians are lumbar braces, cervical traction devices, and tens units. Besides these, there are many other categories and items that are considered DME supplies. The key is to use durable medical equipment that is approved and certified by the proper Medicare agency. You must use approved items for approved uses.
The next most common question is, “How do I get certified as a DME Provider/supplier?” First, anyone can contact the DME department of Medicare and try to do all the forms by themselves. This may prove to be a difficult thing to do as the forms can be very confusing. Submitted improperly, the difficulties can be overwhelming. Consultants, such as me, can be very helpful at this point.
The next strategy is to hire a consultant to help with the process. Be sure to use reliable people or companies and make sure that your needs are met so you can accomplish your goals with the best integrity possible.
Every day I have chiropractors asking for help with their DME situations. Many got their DME Medicare certification by themselves or from other companies. Now they are confused over some issue and need help with something their previous consultant did not resolve.
For example, the chiropractor may not know how to bill, or how to document, or how to protect themselves when there is an audit from Medicare or when another agency investigates, and they may not know how to solve the many little problems that show up along the way. Again, a consultant who has experience in this area can make the difference between success and failure as a DME provider.
Being a DME provider/supplier is a wonderful addition to any chiropractic practice in this day of diminishing returns and increasing government regulations. I do not know of any other addition to a chiropractic practice in this day and age that has the benefits and safety that being a DME provider/supplier has to offer. Be not afraid! Help yourself and your patients. Become a DME provider.
James C. Antos D.C., DABCO, Dr. Antos has been in private chiropractic practice for 34 years. He is a a lecturer for Florida State License renewal on behalf of the Florida Chiropractic Association in the years of 2011 and 2012, teaching the the topic"DME and Lumbar Bracing". He can be reached by phone at 386-212-0007, or visit his website at www.antosdmebrace.com
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Rehabilitation
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Written by Dr. Dennis Woggon & Dr. Josh Woggon
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Tuesday, 01 May 2012 17:20 |
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What Scoliois Can Teach Us about Postural Rehab
M anifestation of any health problem is not a spontaneous event; before the clinical onset, precluding factors exist. Although these factors are unique in each patient, understanding how they contributed to the malady is the first step in reversing it. Regardless of the specific disorder, the crux of the issue is mal-adaptation: the body is adapting to demands placed upon it. When the ability of the body to adapt is exceeded, the result is overt symptomatology, often classified into a medically-recognized disorder.
 Posture is a classic example of a condition which lacks a medical label to apply to it, but nonetheless has a dramatic effect upon health. Due to the fact that “poor posture” is not recognized as a medical condition, very little standardized research can be performed upon it, and this makes it difficult to understand its etiopathogenesis and the ideal methods to combat it. However, there are few diseases which have as strong an association with posture as scoliosis, and ongoing research on scoliosis may shed some light on the best strategies for patients suffering from imbalanced posture.
There can be numerous causes of poor posture – some directly identifiable, others less so. While pathological conditions (such as a congenital malformations) or external forces (unlevel shoes, for instance) can be a cause, most postural deficits can be traced to repetitive micro-traumas. Almost all healthy children around the age of 5, before beginning schooling, have no readily-identifiable postural abnormalities; at the end, almost all of them do.1 Similarly, scoliosis seldom has a direct cause, but in some populations is so prevalent as to be considered practically a normal phenomenon.2 Understanding both scoliosis and poor posture as mal-adaptations to imposed demands leads us to search for similarities between the two, and may provide helpful clues for postural rehab.
Axial loading of the spine: it’s all in your head!
One of the main drivers of adaptation is the innate desire of our nervous system to expend as little resources as possible on tasks such as balance, posture, and co-ordination; in essence, to operate in a “minimum-energy state.” Understanding how to use this natural tendency towards energy conservation to your advantage is a key factor in postural rehab.
Spinal imbalances frequently arise as a consequence of the body’s attempt to integrate the primary righting reflex - our vision – with the proprioceptive feedback from the rest of the body and maintain erect bipedalism. The unique mechanics of the fully upright human spine play a decisive role in the pathogenesis of scoliosis.3 While scoliosis can be induced in an animal model artificially, humans are the only species on Earth that spontaneously develop idiopathic, structural scoliosis. Human bipedalism induces forces into the spine which predispose the spine to rotate in a certain fashion; in non-scoliotic spines, there is a pre-existent pattern of rotation, similar to what is observed in idiopathic scoliosis, which is lessened when a quadrupedal-like (on hands-and-knees) position is adopted.4
Compressively loading the spine exacerbates spinal curvature.5 Renee Cailliet, MD stated that for every inch of forward head translation, ten pounds of compressive loading are applied to the spine.6 Positive sagittal imbalance predicts health-related quality of life in adult scoliosis patients,7 and forward head posture (FHP) is a common clinical finding in adolescent scoliosis patients that can lead to a flexion or “librarian”-type posture.8
The typical scoliosis patient exhibits right head tilt; when the visual righting reflex establishes its dominance, a right high shoulder manifests. This chain reaction continues in the form of a left low hip and left weight-bearing foot behind the right one. Whether the righting reflex is a cause or effect of the scoliosis, the end result is that it reinforces the spinal deformity. To correct postural abnormalities, begin by examining how the righting reflex of the eyes affects them.
Self-correction of posture versus Innate Correction
 Without proper instruction, many strategies employed by people to correct their posture actually have a detrimental effect. Research suggests verbal commands to “stand up straight!” are insufficient to retrain children’s postural habits, and may cause a worsening of the thoracic kyphosis, with little to no effect on the lumbar lordosis.9 This information is especially poignant to the parents of children with scoliosis; thoracic lordosis is a predominant component of the deformity,10,11 and this research suggests that this is aggravated when the parents instruct their children to ‘straighten up.’
This phenomenon is not isolated to the sagittal plane, either; the “pathological pattern of incorrect posture” involved in scoliosis leads to alterations in body weight distribution (e.g., bilateral weight scales).12 When patients were instructed to equalize their weight distribution, the deformity worsened in subjects with scoliosis, and non-scoliosis patients developed spinal asymmetries. An active attempt on the part of the untrained patient to “self-correct” their posture appears to lead to further sagittal and coronal imbalances.
The patient’s posture may be changed passively through a brace; however, the obvious detriment is that any corrective benefit is lost after a sustained period outside of the brace. This is exemplified in scoliosis, where this loss of correction has prompted many researchers to suggest an exercising during weaning to prevent this.13 For non-scoliotic patients, there are numerous braces on the market which claim to improve posture; however, very few published studies exist regarding their effectiveness, and while they may show improvement in-brace, there is no evidence that this correction is maintained out of the brace.
With immobilization, muscular atrophy and disc degeneration is accelerated.14,15 There are concerns that bracing could encourage a mild, postural scoliosis to develop into a rigid and permanent spinal deformity. Bracing is an effective short-term solution for sprains, strains, and sports injuries; however, there is insufficient evidence that bracing creates long-term postural changes, and increasing evidence that long-term immobilization has dramatic negative effects.
New research, new possibilities
If telling the patient to “stand up straight” won’t work, and bracing is not an ideal long-term solution, the question remains, what is the best method of correcting posture? Firstly, by recognizing that balance, posture, and co-ordination are regulated primarily by the cerebellum as involuntary and automatic responses. Altering posture through active muscle contraction can actually have the opposite of the intended effect. The improvements documented in a case series of 19 scoliosis patients has implications for non-scoliotic patients.16 Rather than focusing on active, patient-initiated exercises, or passive, external methods, there is a third option: re-active therapy. Have you ever observed someone carrying a heavy bag at an airport? Too much weight pulls them over, but with the right amount, they react and counter-balance for the uneven load, thereby affecting their spine and posture.
There exists a motor-sensory feedback loop between the postural regulation systems of the cerebellum and the intrinsic spinal musculature; improper processing of vestibular signals by the CNS may lead to spinal deformity, which in turn prompts the development of new neuromuscular motor control strategies.17 In scoliosis, whether it is a defect of the CNS or a purely mechanical issue that initiates the process, once the curvature is present, both biomechanical and neuromuscular forces become involved in its progression.18 This creates a “Vicious Cycle” of scoliosis progression leading to imbalanced forces, which then encourage further progression. Arresting this cyclical pathology demands recognition of all of the biomechanical, soft tissue, and neuromuscular adaptations involved - this does not apply only to the scoliotic population, but to all individuals with postural problems.
Basic principles of re-active therapy
It is imperative in re-active therapy that the patient is standing on an unstable surface, such as a foam pad or inflated disc. By first destabilizing the patient, we increase the communication that is required between the brain and the body to maintain overall balance; perturbation initiates the process of consolidation in balance-control strategies.19 Next, a patient-specific system of weights, cantilevers, and therapy glasses are combined to achieve ideal posture, or even an over-correction. The idea is primarily to work with the body’s natural righting reflexes; if the patient has a right head tilt, and through re- active therapy we can induce a left head tilt, as the eyes balance out to the horizon, we achieve a complete reversal of the physical stance of the body. This form of dynamic rehabilitation is not active therapy, as it does not require the patient to perform any form of conscious, self-directed motion.
Rather they are re-acting to the imposed demands without conscious thought. Posture should be rehabilitated in the same manner that it began to deteriorate – without conscious thought.One quick note: it is surprisingly easy to measure posture in a quantifiable manner, with the aid of inexpensive and readily available software programs. Furthermore, the accuracy of these methods has been established in the peer-reviewed literature.20 Assigning a numerical value to postural deviations greatly enhances the perceived value of care; it is one thing to tell a patient that their posture has improved, but quite another to be able to tell them that their right shoulder, which was 1.13 inches higher than their left, is now only 0.34 inches higher. These objective measurements reinforce the patient’s confidence in the effectiveness of chiropractic. As Galileo famously stated, “Measure what is measurable, and make measurable what is not so.”
Chiropractors play a vital role in public health by promoting awareness of the importance of good posture. As the general public begins to recognize the numerous correlations between posture and health – including headaches,21 spinal pain,22 depression,23 impaired respiratory function,24 and increased vulnerability to injury,25,26 to name a few – it is imperative that the chiropractic profession employs effective, validated methods of measuring and improving posture objectively. The ideal method of postural rehabilitation works with the natural reflexes of the body and simultaneously addresses all of the involved aspects – including spinal biomechanics, soft tissue deformations, and neuromuscular adaptation strategies.
Research & References
- Widhe T: Spine: posture, mobility and pain. A longitudinal study from childhood to adolescence. Eur Spine J. 2001 Apr;10(2):118-23.
- Avikainen VJ, Vaherto H: A high incidence of spinal curvature: a study of 100 young female students. Acta Orthop Scand. 1983;54:267-73.
- Kouwenhoven JW, Castelein RM: The pathogenesis of adolescent idiopathic scoliosis: review of the literature. Spine 2008 Dec 15;33(26):2898-908.
- Janssen MM, Vincken KL, Kemp B, Obradov M, de Kleuver M, Viergever MA, Castelein RM, Bartels LW: Pre-existent vertebral rotation in the human spine is influenced by body position. Eur Spine J. 2010 Oct;19(10):1728-34.
- Little JP, Izatt MT, Labrom RD, Askin GN, Adam CJ: Investigating the change in three dimensional deformity for idiopathic scoliosis using axially loaded MRI. Clin Biomech 2012 Jan 4 [Epub ahead of print]
- Caillet R: Soft Tissue Pain and Disability. Philadelphia: FA Davis Co., 1977, p. 214.
- Mac-Thiong JM, Transfeldt EE, Mehbod AA, Perra JH, Denis F, Garvey TA, Lonstein JE, Wu C, Dorman CW, Winter RB: Can c7 plumb line and gravity line predict health-related quality of life in adult scoliosis? Spine 2009 Jul 1;34(15):E519-27.
- Culbert T, Olness K: Integrative Pediatrics. Oxford University Press, 2010, p. 164.
- Stolinski L, Kotiwcki T: Self-correction of posture: assessment of the quality of the movement accomplished by non-instructed school children. Scoliosis 2012 Jan 27;7 Suppl 1:O66. [Epub ahead of print]
- Dickson RA, Lawton JO, Archer IA, Butt WP: The pathogenesis of idiopathic scoliosis. Biplanar spinal asymmetry. J Bone Joint Surg. 1984 Jan;66(1):8-15.
- Millner PA, Dickson RA: Idiopathic scoliosis: biomechanics and biology. Eur Spine J. 1996;5(6):362-73.
- Nowotny J, Brzek A, Nowotny-Czupryna O, Czupryna K, Plaszewski M: Some possibilities of correction and compensation in body posture regulation among children and youth with low degree scoliosis. Scoliosis 2012, 7(Suppl 1):O64.
- Zaina F, Negrini S, Atanasio S, Fusco C, Romano M, Negrini A: Specific exercises performed in the period of brace weaning can avoid loss of correction in adolescent idiopathic scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper. Scoliosis 2009 Apr 7;4:8.
- Eisinger DB, Kumar R, Woodrow R: Effect of lumbar orthotics on trunk muscle strength. Am J Phys Med Rehabil. 1996;75:194-197.
- Stokes IA, McBride C, Aronsson DD, Roughley PJ: Intervertebral disc changes with angulation, compression, and reduced mobility simulating altered mechanical environment in scoliosis. Eur Spine J. 2011 Oct;20(10):1735-44.
- Morningstar MW, Woggon DA, Lawrence G: Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskeletal Disorders 2004 Sept 14;5:32.
- Burwell RG, Dangerfield PH, Freeman BJ: Etiologic theories of idiopathic scoliosis. Somatic nervous system and the NOTOM escalator concept as one component in the pathogenesis of adolescent idiopathic scoliosis. Stud Health Tech Inform. 2008;140:208-17.
- Veldhuizen AG, Wever DJ, Webb PJ: The aetiology of idiopathic scoliosis: biomechanical and neuromuscular factors. Eur Spine J 2000 Jun;9(3):178-84.
- Tjernstrom F, Fransson PA, Hafstrom A, Magnusson M: Adaptation of postural control to perturbations - a process that initiates long-term motor memory. Gait Posture 2002, 15:75-82.
- Brink Y, Louw Q, Grimmer-Somers K: The quality of evidence of psychometric properties of three-dimensional spinal posture-measuring instruments. BMC Musculoskeletal Disorders 2011, 12:93.
- Lennon J, Shealy N, Cady RK, Matta W, Cox R, Simpson WF: Postural and respiratory modulation of autonomic function, pain, and health. Am J Pain Manag. 1994;4:36-39.
- Mieke D, Barbara C, Pascal C, Guy V, Greet C, Roseline D, Lieven D: Sagittal standing posture and its association with spinal pain: a school-based epidemiological study of 1196 Flemish adolescents before age at peak height velocity. Spine 2011 Nov 19. [Epub ahead of print]
- Canales JZ, Cordas TA, Fiquer JT, Cavalcante AF, Moreno RA: Posture and body image in individuals with major depressive disorder: a controlled study. Rev Bras Psiquiatr. 2010 Dec;32(4):375-80.
- Huggare JA, Laine-Alava MT. Nasorespiratory function and head posture. Am J Orthod Dentofacial Orthop. 1997;112(5):507-11.
- Stemper BD, Yoganandan N, Pintar FA: Effects of abnormal posture on capsular ligament elongations in a computational model subjected to whiplash loading. J Biomech. 2005 Jun; 38(6) 1313-23.
- Oktenoğlu T, Ozer AF, Ferrara LA, Andalkar N, Sarioğlu AC, Benzel EC: Effects of cervical spine posture on axial load bearing ability: a biomechanical study. J Neurosurg. 2001 Jan;94 (1 Suppl) 108-14.
Dr. A. Joshua Woggon, a 2010 Graduate of Parker College, is the Associate Director of the CLEAR Scoliosis Treatment and Research Clinic in Dallas, Texas. He can be contacted at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
, www.clear-institute.org.
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Rehabilitation
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Written by Joseph Ventura D.C.
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Tuesday, 01 May 2012 17:15 |
 Consider the conclusions from two recent studies:
“A significant linear trend for increasing sagittal plane postural translations of the head, thorax, pelvis, and knee was found in children age from 4 years to 12 years.”1
“Poor posture was diagnosed in 38.3% children, more frequently in boys. A significantly different occurrence of poor posture was found between 7-year-old and 11-year-old children (33.0% and 40.8%, respectively). The most frequently detected defects were as follows: protruding scapulae (50% of all children), increased lumbar lordosis (32%), and round back (31%). Children with poor posture reported headache and pain in the cervical and lumbar spine more frequently.”2
Study after study is validating what chiropractors have been seeing for the past decade or more: Children at a younger and younger age are seeking relief from adult type pain and discomfort. What could be the cause of this increased frequency of young patients seeking care? The author believes it is the result of sociological and technological pressures that have only developed within the past generation, the Tweet Generation.
It began in the early 90s when schools eliminated lockers and required children to carry their lockers in backpacks. A couple of years later that child began playing handheld video games. Next came the cell phone for kids with affordable family plans. But the child didn’t use the phone to make and receive calls. They used them for texting. Massive amounts of texting. The author’s 11-year-old daughter sent out 11,000 text messages in one month.
Next we go back to a change made at the school level. As the Internet expanded so did the reliance of schools on the Internet as a method of delivering content. So, as a result, time in front of a computer at school and at home was required.
The connection between all these activities is clear: Since the early 90s children from the age of nine up through young adulthood, their musculoskeletal formative years, have engaged in activities that create a Forward Head Posture environment. These activities have literally molded their bodies into an abnormal posture profile. Re-read the conclusions of the studies cited at the beginning of this article. For those readers not yet alarmed at those conclusions, consider these other studies.
- “All measures of health status showed significantly poorer scores as C7 plumb line deviation in creased.”3
- “Older men and women with hyperkyphotic posture have higher mortality rates.”4
- “Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.”5
What is being done to raise adult awareness of this growing trend in children? Not much. Every State requires a school scoliosis exam. During a school scoliosis exam a child is also examined from the side, but only to observe evidence of gross kyphosis. And in most States that part of the exam is not mandatory. Studies have shown that 4.2% of the children screened for scoliosis trigger a referral for radiographs. And of those 4% only a small fraction will require advanced treatment. It appears that nobody is educating parents and schools about the 30% of children in that same age group that are experiencing Forward Head Posture and its effects.
Forward Head Posture Epidemic
 While developing a new posture grid for school posture exams, the author placed a typical middle school youth in front of the grid and asked the youth to send out a text. It was discovered that the head was placed in a position 4.5” in front of the shoulders and placed the shoulder joints in internal rotation. The typical youth can text up to 30 hours per month.
Combined with other technology and social stressors, today’s youth is at a greater risk for “molded” forward head posture than any past generation.
Considering the important immediate and future health ramifications of poor posture, accurate posture exams and counseling with parents, children and schools should be a part of every wellness practice.
The author recently examined over 1,000 posture exams from a single office. Using sophisticated posture analysis software, deviations from normal were calculated and charted.
"16 years ago I estimated that 80% of the population had FHP. I was surprised and concerned to learn that in such a large population the number was 96.5%"
The additional mechanical loads from FHP stress and eventually break down the spine, disks, muscles, etc. In other words, FHP could be the CAUSE of patient complaints.
There are several methods of identifying FHP and systems available for correction. For additional information about these options contact the author.
References:
- Postural development in school children: a cross-sectional study. Chiropr Osteopat. 2007; 15:1 (ISSN: 1746-1340)
- Prevalence and risk factors of poor posture in school children in the Czech Republic. J Sch Health. 2007; 77(3):131-7 (ISSN: 0022-4391)
- SPINE, 2005
- Journal of the American Geriatrics Society, 2004
- American Journal of Pain Management, 1994
- Archives of Internal Medicine 2007
Joseph Ventura D.C. is owner of PostureSoftware.com, a 32-year-old company that develops software and marketing strategies for the chiropractic profession. Dr. Ventura can be reached at (888) 713-2093 or at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
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Rehabilitation
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Written by Jeffrey Tucker, D.C.
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Tuesday, 23 August 2011 23:05 |
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F ascial therapy has become a very popular technique over the past several years. Fascia is the term applied to all of the connective tissues fibers and glue of the human body. Many tools to perform fascial therapy have gained popularity amongst Chiropractors, physiotherapists, personal trainers, and massage therapists. In addition to our hands (ART, myofascial release), key instruments used for fascial therapy are Sound Assisted Soft Tissue Mobilization (SASTM) tools, Graston tools and the Deep Muscle Stimulator (DMS).
This essay aims to present the results of 30 patients performing the overhead deep squat assessment and discuss how the Deep Muscle Stimulator can be applied as the therapy to fascial dysfunction to improve the quality of the overhead deep squat assessment. The average numerical pain score (0-10, 10 being the worst pain) improved by 2-3 points with one 15 minute DMS treatment
Tom Myers, Luigi Stecco, Mike Clark, and many others have made significant contributions to our understanding of fascia, fascial connections, and fascial therapy. Though the diagnosis and treatment of fascial syndromes is varied and unfolding, one of the main focuses of treatment is on the concept that the endofascial fibers and interfascial planes need to glide along each other, stay hydrated, and not get stretched faster than they can allow. Myer’s work has been identifying the fascial interconnections that he calls anatomy trains. Recently there has been a wealth of research demonstrating evidence for fascial injury, remodeling, and evidence for effects of intervention. Poor fascial gliding could cause adverse tension, and given that many mechanoreceptors are embedded within fascia, altered proprioceptive afferents could then result in non-physiologic movements at joints.
Though the diagnosis and treatment of fascial syndromes is varied and unfolding, one of the main focuses of treatment is on the concept that the endofascial fibers and interfascial planes need to glide along each other, stay hydrated, and not get stretched faster than they can allow.
Over the last 11 years Dr. Jake Pivaroff has developed a comprehensive assessment and treatment approach using a hand held device called the Deep Muscle Stimulator or ‘DMS’ that delivers vibration and percussion to the muscles and fascia. The DMS is made of stainless steel and titanium. The 2 inch round vibrating head moves at 2200 RPMs. Application of the DMS provides a vibratory sensation of 2-4 inches from the point of contact on the body. Hyperemia caused by the vibration could modify the extracellular matrix and restore gliding of mechanically stuck fascia. Dr. Pivaroff based the design and treatment of the DMS on original ideas, clinical experience and expertise.
I have used the overhead squat assessment and analysis on hundreds of individuals and provided fascial therapy using the DMS to improve movement and stability dysfunction. The overhead squat assessment as described by Clark & Lucett in their book NASM Essentials of Corrective Exercise Training assesses dynamic flexibility, core strength, balance, and overall neuromuscular control. The overhead squat test is performed with the individual standing with the feet shoulder-width apart and pointed straight ahead. The foot and ankle complex should be in a neutral position with shoes off. The client raises the arms overhead, with the elbows fully extended. The upper arm should bisect the torso. The client is instructed to “Sit back as if you are sitting in a chair” and return to the starting position. This is repeated 5 times. The assessment is similar to the overhead deep squat based on the Functional Movement Screen by Cook and Burton.
The key features of my client evaluation and treatment includes a static posture analysis, functional movement screen using the overhead deep squat assessment, and palpation of soft tissues and joints. Treatment includes inhibitory techniques (myofascial release using the DMS), then teaching clients stretching or lengthening techniques of overactive muscles, teaching clients how to perform activation techniques (isolated local and global muscle control stability retraining), and teaching clients whole body integrated dynamic movements. This is the corrective exercise continuum as taught by the National Academy of Sports Medicine (NASM).
One of the key principles in the DMS vibration is that it improves blood flow which can speed up recovery by increasing the availability of important nutrients as well as removing damaged tissue.
Using the DMS principles is a huge advantage to therapists retraining movement faults in patients with mobility disorders.
Two practitioners each observed 15 different patients with neck-shoulder pain using the overhead squat assessment to identify overactive muscles and fascial structures. The overhead squat assessment reveals common patterns of overactive myofascial structures. The most common compensation patterns observed are: one or both feet turn out, one or both knees move inward, the torso leans forward, the arms fall forward, and the head forward - chin poke posture occurs. In the literature these muscles have been shown to be dominant and overactive: gastrocnemius, soleus, adductors, hamstrings complex, psoas, TFL, rectus femoris, piriformis, quadratus lumborum, erector spinae, pectoralis major/minor, latissimus dorsi, teres major, upper trapezius, levator scapulae, SCM, scalenes.
For the purposes of this study the DMS was used over the gastrocsoleus, biceps femoris, TFL/ITB, latissimus dorsi, and levator scapulae. By treating these muscles with the DMS, changes in posture and alignment during movement were improved, as well as pain scores.
The DMS can help identify the most likely site of the source of pathology and symptoms which is often at a distance from the actual site of pain. The DMS technique involves vibration over the overactive muscles (to the deep muscular fascia) and is always applied at a distance from the actual site of pain. In this way, the method can be applied safely even during the acute phase of a cervical dysfunction. For example it is well known that excess lumbo-pelvic extension is associated with back pain and this can be caused by overactive hamstrings. Uncontrolled scapula forward tilt caused by overactive pectoralis and levator scapulae and underactive mid/lower trapzius muscles is associated with shoulder ‘impingement’ type symptoms; Yarwood et al did a study in 2011 that showed DMS exposure shows increases in ROM in those participants who have low and decreased flexibility for shoulder flexion and shoulder external rotation.
Within the myofascial and joint system uncontrolled movement needs to be controlled eg uncontrolled scapula forward tilt, uncontrolled lumbar flexion, uncontrolled lumbo-pelvic rotation. This is usually treated with stabilization exercises. However it’s important for treatment and rehab to identify the lack of give within the myofascial and joint systems. I find using the DMS reveals the taut and tender sites within the myofascial system. By moving the DMS device in multi-directional movements (side to side, up and down, criss-cross) I can differentiate muscle fibers and lack of fascia glide. Locating tissues that do not glide or are overactive will guide the treatment process.
Merging DMS into my practice has provided a useful tool for skin and surface tissue stimulation to enhance fascial proprioception. Kinser et al report positive results of flexibility following a stretching with vibration protocol. Tom Hydes has been doing a combination of motion with the Graston tools for many years. Direction of movement using the DMS is important in clinical terms.
Because each participant improved their neck-shoulder pain score, I think this shows the possible relationship between lower extremity involvement, possible previous injury (muscle, bone, etc) and residual and/or distant fascial adhesions. Fascial adherences and muscle overactivity may limit the patient’s ability to adapt to new strains and or posture patterns (that is, sitting at a computer for prolonged periods). I find that treatment of these distance sites of myofascial tightness can relieve pain, and produce an immediate change in neck-shoulder symptoms. There may be a release of tension along an entire myofascial connection from the feet, knees, hips, or lumbopelvic region that helps the neck.
Effective myofascial release may improve the release of tension, decrease activity of overactive neuromyofascial tissues, improve local stability muscle (to control translation) recruitment, and improve functional movements such as the squat. There is general agreement that lack of stability in the myofascial system will result in uncontrolled translation at a motion segment. If muscle length is altered resulting in ineffective active stability mechanisms, then tension development will be reduced and the muscle system (to control through range movements) will be unable to generate proper force for efficient movement. There is an optimum length tension relationship that the DMS can help restore. Any dysfunction in this system will result in faulty range at one or more motion segments.
In the clinical environment the overhead squat assessment can be used to assess for dynamic flexibility, core strength, and overall neuromuscular control. Any movement pattern dysfunction should be matched with symptoms and disabilities.
Using the DMS as an assessment tool to provide local therapy to a suspected overactive muscle and then repeating the overhead squat assessment and noting improvement or lack of change, can help the practitioner make prioritizing decisions about the choice of location and which myofascial structures to target therapy. In other words, if a change was made that improved the squat, then the specific muscle treated would also need to be stretched at home on there own. Teaching patients which muscles need strengthening is also an important component to treatment.
I use DMS treatments to focus on fascial release.
Using the DMS principles is a huge advantage to therapists retraining movement faults in patients with mobility disorders. A specific assessment is needed to identify the individual’s dysfunction and once established DMS therapy can be used to retrain the movement faults.
Dr. Jeffrey Tucker is a certified instructor for the Functional Movement Screen (FMS) workshops, the National Academy of Sports Medicine (NASM) workshops, and is a post-graduate instructor for the entire Diplomate program offered by the American Chiropractic Rehabilitation Board.
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