An Essay for Physical Therapists: Let's Move Forward

Sharing to you a noteworthy blog from Forward Thinking PT.

This is the way that we should go. Our profession has to continuously adapt, evolve and give justice to our true worth in society.

"He who treats the site of pain is often lost." - Karel Lewit

 Sharing with you...No,  ECHOING to you what needs to be heard.  See the big picture.  Take a holistic approach in your management strategies.

Wagner T, et al. Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings. J Orthop Sports Phys Ther. 2010 Feb;40(2):112-9.

LOOK AT THE BIG PICTURE!!!: A Holistic Approach to Therapy

Credit and thanks to erikdalton.com.  I just found this picture in Google images. This picture thus conveys a thousand words.

Now the picture above might be similar to your leg and foot.  Obviously it is a 'COMMON' postural imbalance.  Most people who have this present with back pain and back pain is all they get treated for!

Back pain in this scenario is only a symptom; a manifestation of the imbalance in the kinematic chain.  As you can see from the picture above, this is not a regional problem.

So why does conventional treatment focus on a regional approach?  Such treatment is symptomatic and gives immediate but not a lasting solution.

An accurate diagnosis of postural and movement dysfunctions cannot be made through interviews and history-taking.  

We have to assess posture.

We have to assess gait.

We need to look at the entire body.

We have to see the bigger picture.

WE HAVE TO PALPATE.

Assess. Intervene. Re-test.

FIND THE ROOT OF THE PROBLEM.

Fix the primary somatic dysfunction.

Find it. Fix it. Leave it alone.

A building with a poor foundation becomes unstable and eventually topples over.  Can you guess the similarity between the picture of the building and the picture of the leg above?

If you do, you probably know how to start fixing the problem for both.  Initially, that is.  Initially.

Happy Feet

The ankle and foot complex is just that, complex.  This intricate structure serves as the base of the entire body.  Both logic and wisdom would dictate the status of the base has a bearing on the integrity of the entire structure.  The Tensegrity Principle and the Anatomy Trains Concept would both attest to that.

Tensegrity simply means that mechanical stresses placed on or across any given structure can transmit to adjacent structures with an intensity that diminishes as the distance from the original point of stress increases.

Anatomy trains refers to the myofascial or connective tissue connections that run within the body.  The deep back line below illustrates how the bottom of the foot is structurally and functionally connected by fascia to the head and neck extending as far as the forehead.

This illustration can help us understand the concept that a problem in one part of the "train" can affect the other structures along the line.  Now this is only one of the many anatomy trains across the body and their functions are interdependent of each other.  Hence, problems of the ankle and foot complex can have far greater consequences on the body than we previously thought!  My patient-clients from Canada and the US who have had experience with other soft tissue workers and bodywork experts appreciate this inter-connectedness of the body and understand what I mean when I say that the work I do on their feet and lower leg would have an effect up their back and spine.

Observe your feet.  Are your medial arches of equal height? Is one higher than the other?

Wipe the bottom of your feet with a wet towel, ensuring that the entire palms of the feet are wet but not dripping.  Then, stand on a piece of paper wide enough to accommodate both feet and make sure you put equal weight on both of them.  Now step off and observe the mark that your feet made on the piece of paper.  For most of us, there would be a difference in the inner middle part( the middle third) of the feet  (much like how the first picture above looks like).

The state of the arches may have implications on the pelvis and, ultimately, the entire spine because the pelvis is the base of the  spine.  A supinated foot (or a collapsed, flat medial arch) may be indicative of an anteriorly rotated pelvis on the same side while a pronated foot (a high medial arch) may be indicative of a posteriorly rotated pelvis. Both rotatory preferences have their own effects on the posture, stability and movement of their respective sides and if you have one foot supinated while the other is pronated, that may have a different presentation as well.  Foot pronation and supination have other implications on the biomechanics of the foot and the body but it is too diverse and lengthy to discuss here but basically, a supinated foot may represent a short leg while a pronated foot is the longer leg.  If that is your presentation, you have to get work done on your feet.

The recent advent of minimalist shoes, of which Vibram is the forerunner, has given us a new and much needed adjunct to treatment.  Though it is not for everyone to run in because of variability among individuals, five finger shoes can be used by almost everyone for walking.  What I like most about it is that it facilitates flexion and extension of the toes and weight bearing amongst them during the walking cycle.  This is one of the normal mechanisms of movement of the feet that have been lost in a lot of individuals (even athletes).  This may have been brought about by reliance on footwear that alter the normal movement of the ankle and foot complex or is too 'rigid' to allow such motions.  In athletes I have worked with, it seems to also be caused by years of reliance on ankle and foot taping.  You see, external measures such as these take away from the normal function that the structures of the feet are supposed to be performing thereby weakening those structures and making them insufficient.  Minimalist footwear like the five finger shoes aim to restore the natural motion of the feet and ankle and strengthen them in the process.

The benefits of minimalist footwear are indeed substantial and significant but it takes commitment.  You cannot achieve these benefits overnight.  Working with a  knowledgeable professional can increase the probability of  successfully running in them later on and correcting any muscular imbalances arising from faulty movement mechanics and posture.

The feet are so integral to our movement  that problems with them or arising from them will definitely affect our functions of daily living and recreation, even our posture.  Physical fitness is affected adversely.  In fact, according to an article, the American Podiatric Medical Association states that (in reference to problems of the feet):

"Unfortunately, once the feet go, so does physical activity, and guess what's right behind (or about to be on your behind)? Weight gain."

 

 Take care of your feet, take care of your body.

 Keep those feet happy!!!

Isa 52:7

How beautiful on the mountains
    are the feet of those who bring good news,
who proclaim peace,
    who bring good tidings,
    who proclaim salvation,
who say to Zion,
    “Your God reigns!”

The nervous system is a continuous structure that runs throughout the body, like the extensive roots of a tree. It includes the brain, spinal cord and the nerves that connect almost every structure of the body to the spinal cord. It is a key information transmitting organ; transmitting instructions from the control centers or sensations from body structures towards the interpretative and integrative higher centers. It is commonly injured by compression, tension and friction or irritation as it is subjected to contact stresses outside or inside the body.

                                 

 As everything is all connected, tension or impingement on one part of the nerve affects everything else along its course.  Take for example the pictures shown below.

It is not uncommon for symptoms of nerve pain presenting at distal areas of the body such as the elbow or wrist and hand to have its primary from the neck, considering that as the nerves exit, they can be compressed by muscles of the neck.  What this means is that we should look at the whole body structure and not focus on the regional complaint.  Oftentimes, releasing the restrictions on the neck would have significant effects on the symptoms experienced down the arm.  That is usually my first course of treatment.

It is also possible for nerve structures to develop adhesions along their course and for that, they might need to be mobilized.  I prefer not to do the limb tension techniques as I prefer not to stretch and provoke an already irritable and painful nerve.  Also, according to the book Manual Therapy for Peripheral Nerves by Barral and Croibier:

"A nerve tension can prematurely stop intraneural circulation.  When this happens, nutrition is compromised, particularly if the nerve sheaths are broken open.  This decrease in nutrition occurs intraneurally as well as to the accompanying nerve vessels. Normally, the spiral or winding regional vessels can adjust very well to the changing

position of the nerves without becoming cracked or overstretched.  However, as soon as their adaptability thresholds are exceeded, their lumen narrows.  This causes the blood flow to slow or even cease.  Studies on living tissue shows that the first microcirculation changes occur at a length increase of 8%.  With a stretch of about 15%, the blood flow is interrupted but normalizes again after the release of the traction force.  Manual therapy can help to decrease the mechanical forces acting on the nerves to improve the microcirculation."

If and when I have to, I prefer instead to use the principles of Clinical Neurodynamics as they use neural sliders initially and progress to neural tensioners only when the patient's body has shown a capability to tolerate it.  Tensioners though are end stage progression of treatment and are not always necessary.

The sequence of movements applied in neurodynamics are very specific so the nerve slides along its course and are mobilized only where the therapist wants them to be moved and the entire course of the nerve is not subjected to traction force or stretch.

Exodus 31:2-4

New Century Version (NCV)

² "See, I have chosen Bezalel son of Uri from the tribe of Judah. (Uri was the son of Hur.)³ I have filled Bezalel with the Spirit of God and have given him the skill, ability, and knowledge to do all kinds of work.⁴ He is able to design pieces to be made from gold, silver, and bronze,

Skill, ability and knowledge come from the Lord!

Video Interview of my DNS Instructor

DYNAMIC NEUROMUSCULAR STABILIZATION

Dynamic Neuromuscular Stabilization  or DNS is a system of assessment, treatment and exercise that is integrative and holistic in its approach to address pain syndromes and movement dysfunctions.  Developed by Dr. Pavel Kolar from the Prague School of Rehabilitation and Manual Medicine, it is truly a groundbreaking neurodevelopmental approach and quite revolutionary in its use of reflexes inherent to the body.

I was blessed to have taken Course A of the DNS program back in 2010.  Two DNS certified instructors held a four-day seminar-workshop at the Gleneagles Hospital in Kuala Lumpur, Malaysia.  It was a convention of physical therapists, osteopaths and chiropractors brought together by a common desire to acquire an entirely new learning experience.  I was eventually able to pass the exam and become Course A certified.

The culturally and professsionally diverse class

Breathing is the single, most fundamental movement of the human body.  There is no movement pattern of the human body that does not involve breathing.  Can you persist in any functional activity without breathing? No.  This puts the diaphragm in the limelight as an essential muscular component of any movement pattern.

The DNS paradigm recognizes this and is actually the first school of thought that emphasized it and delved into it in such detail.  It goes so far as to say that no successful movement rehabilitation can be achieved if the proper breathing pattern is not reinforced.  To formulate a summation: breathing is the key to proper movement, core stabilization, and joint alignment.

Stomach in, chest out? That's wrong!!!

The DNS paradigm introduces exercises based on a neurodevelopmental approach.  That means they want you to learn movement and strengthen your muscles in the same manner and sequence that you learned them growing up from infancy.  This effectively engages the core muscles while integrating proper breathing techniques as you exercise.  Core stability is one of the goals of the DNS program.

Notice the similarities.

The most fascinating aspect of DNS though is their use of reflex zones located within the body that elicits an involuntary reflex movement pattern embedded within our central nervous system.  These patterns are normally evoked in infants as they go through a sequence of motor development as they growing up and learn to move.  Stimulating these points is like giving the body and the nervous system a review of proper movement coordination and modulation.  The result of this intervention is truly astounding!

Note: the movements of the patient in the are involuntary and are elicited by proper positioning and stimulation of the reflex zones.

The true beauty that I see in the DNS paradigm is that we are basically "restoring" the body's systems to what it should have been.  And no matter how astounding and revolutionary the methods may seem, we are just finding out and using what God had already put in place.

Psalm 139:13-15

New International Version 1984 (NIV1984)

¹³ For you created my inmost being;
    you knit me together in my mother’s womb.
¹⁴ I praise you because I am fearfully and wonderfully made;
    your works are wonderful,
    I know that full well.
¹⁵ My frame was not hidden from you
    when I was made in the secret place.
When I was woven together in the depths of the earth,