Day in and day out, we – and our patients – feel rushed and stressed. Is it any wonder we’ve all distanced ourselves from the body’s signals of discomfort in an effort to get things done? Such messages and signals may manifest as a particular ache or in overall stiffness in the body.
As people sit, stand and walk throughout their day, shouldn’t we provide them with greater consciousness of their poor habits?
Faulty Repeated Movements
One of the first important concepts I try to educate patients on is that repeated movements (especially faulty movements) and prolonged postures result in changes in tissues and movement patterns. This results in a segment developing a susceptibility to move in a specific direction, and this may cause pain because of microtrauma from the stress on the tissues.
For example, consider failure of the stability muscle to hold the lower-limb segments in good posture during the stance phase of running or walking. If the gluteus medius, vastus medialis and tibialis posterior are not functioning optimally, there will be an increase in internal rotation of the femur and valgus positioning of the tibiofemoral joint from heel contact to mid-stance phase. The patella will track laterally, leading to an increase in activity of the tensor fascia latae and vastus lateralis, and the foot will excessively pronate. Such faulty mechanics can be the precursor for Achilles tendinopathy, medial tibial stress syndrome (MTSS) or iliotibial band syndrome.
In previous articles, I have written about normal postural alignment versus abnormal postural alignment, and how abnormal postural alignment can be detrimental to muscle function, is aesthetically unpleasing and might contribute to joint pain.
Since kyphosis is natural in the thoracic spine, we have to identify what excessive kyphosis is, which is typically the problem. Generally speaking, normal for a thoracic kyphotic curve measures 30-35.* Excessive kyphosis is greater than 35.* As doctors, we are used to looking at the static spine from the side to determine kyphosis. Using the Functional Movement Screen (FMS) or other movement analysis, we begin to see the interrelationships of muscle and fascial tissue attachments that may contribute to hyperkyphosis.
For treatment of hyperkyphosis, I often take the “bottom up” approach and teach patients how to lengthen the lateral column of the body, the peroneal group, iliotibial band, tensor fascia lata, lateral gluteal complex, quadratus lumborum, oblique complex, latissimus dorsi, and shoulder musculature to influence the kyphosis. When treating hyperkyphosis, always check the flexibility of the ankles, hips, adductors and anterior shoulder complex. The hip flexor tissue is fascially attached to the abdominal fascia, which connects to the external obliques, connecting to the pectorals, joining to the deltoids. As these structures become tight, they can influence thoracic kyphosis.
Patients often ask me, “What causes bad posture?” I often hear myself answering with something like, “How many hours do you spend at work each day?” The patient responds with, “On average, about eight to 10 hours,” to which I say: “During your work time, you probably sit unconsciously in a slumped posture and in improper body positions.
Some people just engage in repetitive movements. Either way, this can create muscle imbalances leading to poor posture.” For those patients who really “get it,” I might add, “I think that the mind and body communicate and that psychological distress from work, family, finances (or whatever else I have heard them share with me) shows up in our posture.”
Would you agree that poor self-esteem and depressive symptoms are displayed in our posture? Another cause of poor posture is a lack of a variety of movement in our activities of daily living and overall poor flexibility. In essential ways, our unique cultural, mechanical and spiritual histories are part of what affects overall posture and health.
Last year, I was given the opportunity to teach a thoracic spine rehab course. I had never been to a “thoracic spine seminar,” let alone put together eight hours of teaching material on the subject. The seminar could have been called, “The Thoracic Spine – The Forgotten Area Between the Lumbar Region and the Cervical Region.” I continue to learn the compelling interconnection between the thoracic spine and the cervical and lumbar regions.
Most of the time when we think of a winged scapula, we simply think of weak serratus anterior muscles. But the longer you are in practice, the more you notice posture and become a better “muscle whisperer.” And then you begin to realize so much more. Let’s explore the posture impairment of winged scapula as it relates to the serratus anterior, rhomboids, lower trapezius, and pectoralis muscles.
The biggest tip I can offer you to look for during static posture evaluation for scapular winging is this: If you can see the entire medial border of the shoulder blade, you should suspect serratus anterior dysfunction. If you see only a portion of the medial scapular border or the inferior angle (usually the lower half or third of the medial scapula border), then you should suspect excessive shortness of the pectoralis minor, and lower trapezius and serratus anterior muscle weakness dysfunction. Again, if you only see half or a third of the scapula border protruding away from the rib cage, this is known as “pseudo-winging” and implicates shortness of the pectoralis minor, along with lower trapezius and serratus anterior underactivity or weakness…
Let’s discuss normal shoulder resting posture so we can determine if there is a link between a postural deviation and pain. Static postural analysis is performed before range-of-motion examinations, orthopedic testing, movement pattern assessments and palpation analysis. When I perform a static posture evaluation, I focus on subtle asymmetries or deviations from normal patterns to aid my diagnostic decisions and treatment transition decisions (passive care to active therapy). I allow myself the time to pause and focus on what I see posturally before beginning other procedures. The changes I see in static posture and functional-movement assessments, visit to visit, help me navigate through the treatment process.
I ask the patient to stand with their shoes off, hands at their sides, in their normal, relaxed position. The evaluation is done with the person in a standing position, which accounts for the normal effect of gravity on the individual. I observe the patient from the front, side and posterior. I look to see the person’s chronic holding patterns.
Look for postural deviations, including forward head, forward shoulders (scapular protraction), humeral internal rotation, and increased thoracic kyphosis. All of these deviations have been implicated in the development of shoulder pain.1-4
Posted by DrTucker in Articles by Dr. Tucker, Blog, Daily Exercises, Fitness & Exercise, Rehab Exercises on 06 16th, 2013 | no responses
I like using the following ‘exercise template’ when educating patients on what a long-term exercise program includes:
1) Perform self-myofascial release using foam rolls, sticks, and “knot-outs” as the beginning of an exercise session. These are tools to break up hypertonicity and tension in muscles.
2) Perform stretching (static and dynamic) on the overactive muscles. I teach my clients techniques using the ‘Stretch straps’, yoga straps, and bands.
3) Perform movements or isometric exercises that re-awaken and/or strengthen the core and underactive muscles. These are usually bodyweight or thera-band exercises targeted at isolated weak stabilizers muscles.
4) Perform whole body integrated exercises that will add lean muscle and decrease fat.
5) Next, if the client has more time and wants to perform cardio work, this is where I place it.
After talking with patients and hearing what they do or don’t do physically, my suggestions begin first with ‘remove the negatives’. I discuss proper posture, breathing, hydration, diet, supplements, attitude, and sleep. I want to make sure patients are doing the right thing and not the wrong (negative) thing in each of these categories. In addition some patients need to “add in” cardio, strength, or flexibility training depending on there goals. The ‘fatty-bomba-lattes’ who do absolutely no physical activity need to start a walking program; the long distance runner, swimmer or cyclist might need a flexibility program; the Country Western dancer’s and the ‘dance-with-the stars’ people might need some strength training; the yoga dominant person might need some free weight training; the weight lifter might need some cardio and flexibility added on. Depending on the patient’s goals (fat loss, finish a marathon, flexibility, etc), I often find the program they designed isn’t “enough” on its own.
To read the whole article click on link….
Posted by DrTucker in Arthritis, Articles by Dr. Tucker, Chronic Pain on 05 21st, 2013 | no responses
The Functional Movement Screen (FMS) has popularized our awareness of checking for asymmetries in the body during movement. Muscle strains and joint dysfunctions caused by asymmetrical movements over time can generally be reduced by treatment using the Deep Muscle Stimulator (DMS).
The DMS is a hand held device that delivers strong vibration, oscillation and percussion. Use of the DMS appears to reduce stiffness by signaling inhibition of the sympathetic nervous system. Palpate tight or stiff fascial tissue or a taut and tender muscle fiber, and then apply the Deep Muscle Stimulator (DMS) device for approximately two to three minutes, the post treatment/application will leave the skin red, warm and it will palpate as “softer.” This probably has to do with local changes in the arterioles and capilliaries and the mixing up of tissue viscosity.
To really appreciate the DMS, we need to review some neurology. Golgi receptors are located in dense connective tissues such as ligaments, joint capsules (Golgi end organs) and around myotendinous junctions (Golgi tendon organs).1 Golgi receptors are stimulated by slow active stretching or strong local pressure resulting in a lowered firing rate of associated alpha motor neurons via the spinal cord, this leads to decreased active muscle tone in related muscle fibers. Read more: http://www.dcpracticeinsights.com/mpacms/dc/pi/article.php?id=56505&aoid=dcpinu_20130521_ulan
This article by Dr. Tucker appears in the March 15, 2013 issue of Dynamic Chiropractic.
his is part 2 of a three-part series on creating a healthy aging practice to better serve the aging baby boomer population, which likely will comprise an increasing percentage of your patient base in the coming years. Part 1 appeared in the March 1 issue.
Teaching postgraduate seminars has given me the opportunity to travel around the country and see what is happening in our field. It’s great seeing what the chiropractic profession is up to nationwide. I am seeing students shift away from making X-ray markings to learning advanced exercises for whole-body movement. Some of the key differences I see in young doctors today is that they use modern technology and keep evolving. Patients want to have a much more active role, a more consistent relationship with good, caring doctors. That’s why I believe there’s a need for much greater action by chiropractors today in the healthy aging specialty. Read more: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56408&aoid=dcnu_20130312_chirotouch
Assessments are undeniably important to reduce compensatory movement patterns that can increase the risk of injury when engaging in remedial exercise or athletic activities. I have many different techniques for assessing my patients.
I begin at the feet and look for any eversion of the foot in relation to the tibia. I also look for ankle pronation or supination, as well as excessive ankle dorsiflexion or plantarflexion.
At the knees, I look for valgus or varus stress, tibial torsion in relationship to the femur, internal or external femur rotation, and any excessive knee flexion or hyperextension. At the hips, I look for any abnormal elevation, anterior or posterior pelvic tilt, pelvic rotation or lateral flexion. When assessing the upper body, I look for any thoracic offset, rotation or flexion. I also check the shoulders for rounding or unusual elevation discrepancy. When assessing the head position, I check to see if the ear is in line with the shoulder, noting if there is a forward head posture.1-2 In addition, I will check to see if the load-bearing joints appear forward of the lateral malleolus or if the person appears to have a side lean.