from the ground up…c.ymcdn.com/.../griffeth_from_the_ground_up_.pdf · · 2015-04-23from the...

FROM THE GROUND UP…©

Presented by Dr. Dar Griffeth

Multidisciplinary Practices

• MD/DC & PT relationships• Kinetic Chain Models• Integration Techniques

Multidisciplinary Practices

• Know your role:

– Common ground/scope of practice

– Having a plan

– Proper documentation/reporting

– Proper follow-up (re-eval)

– Knowing your limits

The postural patterns of the body and the

cascade of events that are created in an

attempt to adapt or compensate the

various bodily functions it takes to survive

in today’s stressful world depend heavily

on the congruent interconnectivity of the

human body as a whole.

Why is this important???

Is it enough to provide adjustments

only…versus adding stabilization

and rehab ???

• Normal vs. abnormal

• Neurological with Musculoskeletal

• Imbalances & Biomechanics

• Biochemistry and The Stress response

Postural pattern analysis

• It appears that, in a weight bearing model that

most postural patterning works from the base up.

As Dr. Greenawalt liked to say: “It all changes

when your foot hits the ground.”

Posture Patterns

American Academy of Orthopaedic

Surgeons (AAOS) -

“…a faulty relationship of the various parts

of the body which produces increased strain

on the supporting structures and in which there

is less efficient balance of the body over its

base of support.”

- Kendall FP. 1993

Definition =POSTURE

Webster’s -

1) a: the position or bearing of the

body whether characteristic or

assumed for a special purpose

<erect posture> b: the pose of a

model or artistic figure.

Dorland’s -

posture. the awareness of the

position of the body or its parts in

space, a combination of sense of

equilibrium and kinesthesia; called

also Position S.

Neurological -

The body’s attitude which facilitates

maximum efficiency of a specific

activity…without causing damage to

the body system.

Posture is the ability to:

• Conform to the supporting surface symmetrically and with weight distributed equally through the load-bearing surfaces

• Select and adopt the alignment of body segments appropriate to the efficient performance of a specific activity

• Balance and stabilize the selected body attitude relative to the supporting surface

Posture is the ability to:

• Adjust to changes within the body or support the body while maintaining balance and stability

• Free the parts of the body required for movement from their load- bearing role

• Secure a fixed point about which the muscles can act

Patterns

• Walking force projection = 2 ½ times your body weight

• Running force projection = 3 ½ times your body weight

Patterns

• 1980’s study done by NIKE™ ( Phys

Sports Med 1998) determined that:

• Walking created 5 N of force at heel strike

• Running created 7 N of force at heel strike

• … even after all the areas were absorbed 0.5 N of force still existed at the jaw

Harrison et al: 2000

“…it can be determined that there are 728

possible postures of each area (head,

thoracic cage, and pelvis) in 3 dimensions,

for a total of 7283 or 385,828,352 possible

upright human postures!!!”

“The possibilities are

staggering…”

4 Global Postural Distortions

Commonly Found Together

1. bilateral/asymmetrical foot pronation

2. pelvic tilt

3. ant. translation of pelvis

4. ant. translation of cervical spine

Pronation

Pronation (like Supination): is not a

visual assessment but a triplanar

mechanical effect at the sub-talar joint

of the foot; that manifests functional and

structural anomalies.

PELVIC TILT=PRONATION

….unilateral pronation or asymmetrical

bilateral pronation has the effect of

producing pelvic tilt, OR the unlevel pelvis

may cause the pronation.

Harrison D.,et al (1988)

Low Back Pain & Pelvic Tilt

• 25 hospital patients

• “Pronation was greatest on the side of

the longer leg, indicating that the

pronation was a functional adaptation to

reduce pelvic unleveling.”

- Langer S. (1976)

Developmental Distortions

• Ross laboratories, “What parents should know”

– Stages of development: Feet & Legs

• Birth to 2 years – Bow legs and toeing in

are common

• Age 3 to 5 – Knock knees and toeing out is

more common

• Age 6 to 7 – Knees and feet (arches)

should resemble adult positioning

Developmental Distortions

“Because (hyper-pronation) becomes

established by age six, functional foot

orthoses after that age may be invaluable

in maintaining a normal medial longitudinal

arch until the foot reaches skeletal

maturity during the early teens.”

Michaud TC. 1993

Plantar Vault

3 Facts About

the Feet

1. The most common subluxation pattern of the foot is: EXCESSIVE PRONATION

(Nearly all excessive pronation is BILATERAL but ASYMMETRICAL)

2. Most foot subluxations do NOT create foot symptomatology.

3. Whatever one arch in the foot does….so do the other two.

Arch Stability

“The highest relative contribution to arch stability was provided by the

plantar fascia, followed by the plantar ligaments and spring ligament.

Plantar fascia was a major factor in maintenance of the medial

longitudinal arch.”

Huang et al. 1993

Muscles in the Foot

• “The first line of defense of the arches is ligamentous…

• …muscles did not come into play until a force greater than 400 pounds was exerted.”

Basmajian JV et al. 1963

PLASTIC DEFORMATION

• Low intensity forces for prolonged

periods of time create PERMANENT

plastic changes

Weight bearing vs. Non-

Weight bearing

• “If subtalar joint motion….. is measured in a non-

weight-bearing rather than full weight-bearing

(casting), then 37% of the available ROM may be

overlooked.”

Lattanza L. et al. 1993

Rigid Orthotics

1. Do not permit adequate

biomechanical motion

2. Create hypomobile and

hypermobile joints

Weight-bearing diagnostics can

help determine

• Extent of plastic deformation

• Specific corrections needed

• Better fit and function

Accommodating vs. Functional

Stabilization

• Accommodating:

– Molded to the

deformity (non-

weight bearing)

– To provide

comfort???

• Functional:

– Molded to the foot

(weight bearing)

– Designed at the

lowest end of normal

– Blocks excessive

motion

– Allows normal

motion

Balanced-Symmetrical

50-50 Weight

Distribution

Crescent

Shape

Transverse

Arch

Medial

Arch Line

Lateral

Arch

Minimal

Pressure

Calcaneus

Centered

Optimal, Mild,

Moderate or Severe?

Optimal

V7+ Key Features

• Pronation/Stability index- Calculated

measurement that reveals individually the

severity of pronation for each patient.

Pronation/Stability Index

Pronated or Supinated?

Supinated

• Line from great

toe falls medial to

the midline of the

calcaneus

• Indicates rigid –

angular foot

• Deep curvature of

medial arch

present

Pronated

• Line from great toe

falls lateral to the

midline of

calcaneus

• Medial arch (MLL)

migrates medially

• Typically more

flexible

Body Assesment

Demonstrates

patterns of spinal

misalignment

Pelvic AssesmentPosterior view of pelvic unleveling

Indicators of

Excessive Pronation– Foot flare/toe out

– Dropped navicular/ falling arches

– Posterior lateral heel wear

– Achilles tendon bowing (inward)

– Patellar approximation/ internal tibial rotation

– Superior lateral tracking of the patella

– Decreased muscle tone of hip abductors

– Plantar surface callus formations at the 2, 3, 4 met

heads

Excessive Pronation Subluxation Pattern

BONES SUBLUXATION DIRECTION

Navicular Inferior & Medial

Cuboid *Superior & Lateral

(or Inferior & Lateral)

Cuneiforms Inferior

Metatarsal Heads 2-3-4 Inferior

Metatarsal Heads 1 & 5 Superior and Lateral/Medial

Talus Mostly Anterior & Slightly Lateral

Calcaneus Everted & Plantar Flexed

Fibular Head Posterior & Lateral

Excessive

Pronation

Subluxation

Pattern

Navicular(inferior and medial subluxation)

Cuboid(superior and lateral subluxation)

Cuneiforms(inferior subluxation)

Met Heads 2-3-4(inferior subluxation)

Talus (anterior and lateral subluxation)

Calcaneus (plantar flexed – everted)

Fibular Head (posterior – lateral)

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=36EpnGEjI8e12M&tbnid=7AnmbLON0qNqSM:&ved=0CAUQjRw&url=http%3A%2F%2Fblog.opedix.com%2F&ei=5UVEUsXAHKHY2wWy0IHYBA&psig=AFQjCNHn6YxTY_E7KXrfl2LPMxjue6BjqA&ust=1380291294573865

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=36EpnGEjI8e12M&tbnid=7AnmbLON0qNqSM:&ved=0CAUQjRw&url=http%3A%2F%2Fblog.opedix.com%2F&ei=5UVEUsXAHKHY2wWy0IHYBA&psig=AFQjCNHn6YxTY_E7KXrfl2LPMxjue6BjqA&ust=1380291294573865

Gait System Analysis

• 3 Primary Components– Kinematics = Analysis of movement without

calculation of forces

– Kinetics = Analysis of Forces and Movements

acting on the body segments

– Neuromuscular Activation and Proprioceptive

Coordination

Gait Cycle

• Typical gait/running systems

–#1 Heel Strikers (80%)

–#2 Mid-Foot Runners (<10%)

–#3 Toe Runners (<5%)

• Optimal stride is 2.8-3 steps per second = 180

steps per minute or 90 strides (for a running gait)

Gait Cycle

• Stride length – The average distance

between heel strikes (The longer the stride

the greater the impact)

• Stride Rate – The number of heel strikes

per second (The lower the rate the greater

the impact forces)

Gait Cycle

• Vertical Oscillation – The height the body

elevates during walking/running (high VO

= greater impact force)

• Swing – leg flexion/extensions between

heel strikes

• Foot flare – the angle of internal/external

tibial rotation at heel strike

Gait Cycle

• Knee flexion – (self explanatory) as the leg

gets straighter the greater the force at

impact on the knee

Biomechanical

Response of

Connective Tissue

from the ground up

Adhesions

Muscle Imbalances & Joint

Dysfunction

Altered Neuromuscular

Control

Cumulative Sheer & Repetitive Stress

Kinetic Chain Defects

Inflammation

Muscle Spasms &

Trigger Points

Cumulative Injury Cycle:Chronic Inflammation

WHAT IS NORMAL???

Haas et al – describes a series of

“Biological processes…plausibility's…”that appear to demonstrate the situations

that would allow cervical kyphosis and

other anomalies as normal variants that:

“have no effect on physiology…” or long

term postural defects.

WHAT IS NORMAL???

Harrison and Toyanovich – state that:

“although spinal anomalies occur in the

human body there are processes by which

the body remodels…and abnormal spinal

loads over time DO cause pathologies.”

According to Yochum And Rowe’s – ‘Essentials of Skeletal radiology’ 2nd edition:

•Cervical Lordosis = approx. 40 - 45º

•Thoracic Kyphosis (depending on age and

gender) = approx. 20 - 50º

•Lumbar Lordosis = approx. 50 - 60º

Ranges of motion

• Cervical Spine:• Flexion = 30º - 45º

• Extension = 40º - 55º

• Rotation = 70º - 80º

• Lateral Flexion = 40º - 45º

Ranges of motion

• Thoracolumbar Spine:• Flexion = 90º

• Extension = 30º - 35º

• Rotation = 30º - 35º

• Lateral Flexion = 30º - 40º

How is it Normal???

• Neurologically there are several factors to consider:

• Spinal mechanoreception/Proprioception

• Left brain/right brain controls

• Cerebellar controls

• The vestibular system

• The righting reflex

…just to name a few

The Concept of

NOCICEPTIVE or

PROPRIOCEPTIVE

NOISETM

MECHANORECEPTORS

• Provide continuous feedback about where the body is in space

• Position sensitive

• Motion sensitive

• Vibration sensitive

• Pressure sensitive

• Thermo sensitive

• Chemo sensitive

• Inhibit perception of pain

Types 1, 2, and 3 mechanoreceptors

_______

Type 4 mechanoreceptors(aka Nociceptors)

_____________

NOCICEPTORS

“a continuous tridimensional plexus of

un-myelinated nerve fibers…and weaves

(like chicken-wire ) in all directions .”

-Neurological Aspects of Pain Therapy. 1980

NOCICEPTOR LOCATION

• Skin

• Subcutaneous tissue

• Adipose

• Joint capsules

• All spinal segments

• Blood vessels

• Cancellous bone

• Periosteum

• Muscles

• Tendons

• Fascia

• Aponeurosis

• Dura mater

• Epidural tissue

-Grieve G. Common Vertebral Joint Problems

What are the nociceptors in

your wrist/foot doing right now

that they weren't doing when

your wrist was in a more

neutral position?

______________________________

What is the final destination of

the nociceptive impulses,

created in your wrist/foot, if

they are not inhibited ?

_____________________________

If the nociceptive impulses from your

wrist/foot were not inhibited and the

impulses elicited an action potential

in the sensory cortex, what is the

conscious sensation that one would

feel called ?

__________________________

2 Things Nociceptors Do

1. _____________

2. _____________

“Restricted joint motion causes an

increase firing in nociceptive

axons…. and a decrease firing of

large diameter mechanoreceptor

axons.”

-Hooshmand H. 1993. p.33-35

What inhibits nociceptive

impulses ?

__________________________

Where does the inhibition of

nociceptors by types 1, 2, and

3 mechanoreceptors occur ?

_____________________________

How many impulses reach the

sensory cortex every second ?

________________________________

How many of the sensory impulses

that bombard the sensory cortex

every second are conscious

impulses ? Pain is a conscious

sensation.

________________________

Furman and Gallo, 2000

“A clear indication that using

conscious perception of pain

to determine the need for care

is hugely inadequate and

inaccurate.”

Chestnut, James L. 2001

Nociceptor activity reflexively

activates the sympathetic

nervous system…

Kabell J. Sympathetically maintained pain.1992

“…..nociceptive input ….can cause

symptoms such as sweating, palor,

nausea, vomiting, abdominal pain,

sinus congestions, dyspnea,

cardiac palpitations, and chest

pain…”

Nansel D. Szlazak M. 1995:118:379-97.

“Adjustments to decrease

nociceptor input to the spinal

cord seem to be an effective

way to decrease

“the hyperexcitable central

state.”

Patterson M. 1993:9(3)2-11

Brain Balancing

“Depolarization of mechanoreceptors

initiates cortical activity to down regulate

Sympathetic N.S. controls that are

responsible for postural alterations as the

environment dictates.”

Principles of Neuroscience (3rd ed.) Kendal, Schwartz, Jessel, 1991:597

Brain Balancing

• Cortex and the Mid-Brain

– Periaqueductal gray = analgesic

– Nucleus Raphe Magnus = serotonin

– Reticulospinal Pathways (Dorsal Horn)

• Produce endorphins and enkephalins

• Inhibits nociceptive afferents

Guyton A., Textbook of Medical Physiology (8th ed.) 1991

Left Brain vs. Right Brain

• uses logic

• detail oriented

• ruled by facts

• words and language

• math and science

• comprehension

• knowing/acknowledgement

• names of objects

• reality based

• practical

• safe

• forms strategies

• order/pattern perception

• uses feelings

• ‘big picture’ oriented

• ruled by imagination

• symbols and images

• Philosophy and religion

• believes/faith

• get’s the meaning of things

• knows object function

• fantasy based

• impetuous

• risk taker

• presents possibilities

• spatial perception

Ways to determine Hemispheric

Control

• Ipsilateral to Weak Cortex –– Dilation of pupil

– Claudication ( ‘hands up’ squeeze test)

– Internal hand pronation (‘hand turned in’ appearance

– Foot flare (turned out)

– Palatal Paresis (also related to sleep apnea)

Ways to determine Hemispheric

Control

• Head Tilt away from weak cortex

• Cerebellum:– Sway towards weakened side (eyes closed

– Standing resistance test (eyes open) - patient will fall

when pushed on the weakened side

Brain Balancing

• Typical Presentation – Decreased Left Cortex

– Decreased Right Cerebellum

• Atypical Presentation– Same side decreased Cortex and Cerebellum

– Need the most help

– Must balance cerebellum and stimulate cortical

weakness/ adjust opposite side ONLY

• More connections b/w (R) Brain and Sympathetic

N.S. and (L) Brain with Parasympathetic N.S.

Brain Balancing

• More connections b/w (R) Brain and

Sympathetic N.S. controls and (L)

Brain with Parasympathetic N.S.

controls.

Brain Balancing

• Parasympathetic N.S.

– Largest stimulator» Neuronal tract – Tractus Soletarius (taste)

» CN 7, 9 & 10

• Loss of appetite control

» Propagated by stress response

» Increase eating cycles to try to balance cravings

Brain Balancing

• Parasympathetic N.S.

– Increase Left Brain controls

• CN 3 – cardinal fields of gaze = reading

• CN 7 – crying, eating

• CN 9/10 – eating

• CN 10 – breathing exercises, Yoga/deep breathing

Males• Action without consequence

• testosterone driven

• Heart rhythm (AV node of the heart)

• stubborn

• Psychology = ID

• = Schizophrenia

• = Depression

Females

• Anxiety, worry, consequence

• estrogen/tryptophan/serotonin

• Heart rate (SA node of the heart)

• Accommodating (Agape)

• Psychology = Super EGO

• = Anxiety attacks/Sympathetic N.S.

• = Depression


• B Vitamins breakdown = lactic acid in muscles (creating active or latent trigger points)

Tryptophan Serotonin Melatonin (insomnia)

B Vitamin B Vitamin

Serotonin availability L Brain fxn depression


• There are less serotonin receptors on the

left side…so if serotonin control of the right

side decreases the left side will go first

then you have depression in either case of

decreased function creating a “Stress

response”

“Stress Response”

• “Stress” = uses cortisol pathway – Building block for cortisol is CHOLESTEROL

• “Relaxation” = uses Estrogen, Progesterone, Testosterone for fertility and

tissue repair

– Building block is also CHOLESTEROL

Physiology of Dis-ease

• STRESS RESPONSE

(Left Brain Weakness)

– Tachycardia

– Loss of sphincter tone

• GERD

• Duodenal Ulcers

• Diarrhea Constipation IBS Toxic

Colon


– Shunted blood to extremities = Indigestion

– Cholesterol shunted into cortisol and away

from anabolic hormones (testosterone,

progesterone, estrogen) = Amenorrhea,

Infertility, ED


• Stress response

– Increased Sympathetic stimulus

• Decreased B Vit.

• Release of Nor-Epi…dopamine (L brain)

• Increases blood glucose levels for Cortisol

pathway


• Cortisol Release

– High Blood Sugar (flight /fight response)

• Uses up all B-Vitamins

–Anaerobic glycolysis Lactic acid build up diffuse pain = Fibromyalgia – Chronic Myofascial Pain Syndrome

–Anaerobic glycolysis Inefficient ATP production tired all the time = Chronic Fatigue




• Uses up all B-Vitamins

–No B-Vitamin to convert Tryptophan to

Serotonin = Depression

–No B-Vitamin to convert Serotonin to

Melatonin = Insomnia




• Cells starve for glucose = Sugar cravings

• Glucose pathway altered enters adipose

tissues = Obesity

• High Osmotic pressure endothelial damage =

CVD + Small Vessel Disease (Eye + Peripheral

Neuropathies + ED)




• Eventual exhaustion of pancreas =

Type II Diabetes

• Depresses the immune system =

Infections + Cancers

• Increased clotting factors = Stroke


• Increased LDL to carry more Vit A, Vit E, CoQ10, & Cholesterol (to make more cortisol)


• Long term stress

– Hyperadrenia Hypothyroid Hypoadrenia

Hyperthyroid

– Parasympathetic shut down = dry eyes + dry mouth

(combo with autoimmune = Sjogren’s

– Sympathetic ramped up = Allergies + Raynaud’s +

RSD

– Decreased Growth Hormone & cell repair no

regeneration of intestinal cells = Leaky Gut

Autoimmune diseases


• Flexor (& Adductor) Dominance

– Global MS System effects ( inhibition of

SNS)

• Hypertonicity of Anterior muscles above

T6

• Hypertonicity of Posterior muscles below

T6



– AWB head carriage (sedentary lifestyle)

• Hypertonic scalenes 1st rib elevation

compression of brachial artery & brachial

plexus (esp. C8 &T1 NR)

TOS + Peripheral Neuropathies &

Raynaud’s



– AWB head carriage (sedentary lifestyle)

• Decreased rib expansion Hypoxia = TIA +

Alzheimer’s + Parkinson’s (men) + ADD (men)

+ depression (women)

– Increased acidity inc. cancers + inc.

infections + inc. degenerations + inc.

osteoporosis

– Decreased afferent drive into brainstem

HBP



– Tethering of the spinal cord Ischemia to

the cord = Myelopathy

– Stretched & Weakened erector spinae

Hypertonic Multifidus vertebral wedging

Disc Herniations

Physiology of Dis-ease• Flexor (& Adductor) Dominance

– Global MS System effects ( inhibition of SNS)

–Anterior rolling of the shoulders stretched extensors (supraspinatus) Bone Spurs Rotator cuff tears

–Elbow Flexion stretching the ulnar nerve = neuritis

–Hypertonic pronator teres Pronator Teres Syndrome

–Wrist Flexion Carpal Tunnel




» Psoas flexion Sciatica & Piriformis

Syndrome

» Erector Spinae Contract AS Ilium on

the same side of weak cortex (usually the

left side) Stronger tighter Psoas

opposite the weaker cortex = PI Ilium

(usually the right side)




» Internal rotation of femur/tibia (opp. weak

cortex)

» Internal rotation pronation + heel spurs

+ plantar fasciitis + bunions

» Gastroc & soleus flexion Achilles

Tendonitis

Left Brain Exercises

• Logic and Calculations

• Attention to details

• Comprehension

• Order/Pattern perception

• Sex (esp. foreplay)

• Prayer/Meditation


• Office Setting =»Adjust opp. weak cortex

»Cold laser cortex/cerebellum

»Isolated exercises opp. weak cortex

»crossword puzzles, logic brainteasers and mathematical word problems


• Home =»TALK - aloud

»MATH - 15-20 min. a day (3 digit numbers)

»READING - w/o pictures

»ESSENTIAL OILS – Left nostril ONLY (lavender, eucalyptus)

Right Brain Exercises

• Office Setting =

»Laser right cortex (neural

stimulation)

»Isolated Left-sided exercises

»Pictures

Right Brain Exercises

• Home =

» PICTURES

» ESSENTIAL OILS – Right nostril ONLY (rose, cinnamon)

» CLASSICAL MUSIC (Mozart, Beethoven, etc…)

***left ear ONLY to isolate right brain stimulus***

• Research on Music and Autism: Implications for Music Educators. Darrow, Alice-Ann; Armstrong, Tammy, Applications of Research in Music Education, v18 n1 p15-20 Fall-Win 1999

Cerebellar Control• The cerebellum and its connections

are responsible for the coordination of

skilled voluntary movement, posture

and gait.

Cerebellar Control• The three lobes receive information from

the muscles and tendons of the peripheral

limbs and communicates back and forth

from the cerebral cortex to stimulate tone

and regulate alpha/gamma neurons in the

spinal cord.

Cerebellar Control

• Any interference of these pathways can affect the initiation, stopping and controlling of movement.

Spinal Mechanoreception /

Proprioception

• The spine houses the base line defense

for many afferent action potentials that

can be interpreted as pain.

“Proprioceptive noise”

• Mechanoreceptors are found in all the

joints of the body

Spinal Mechanoreception /

Proprioception

• There are IV types, and only Types I-III can

adapt over time and returned to normal without

other stimulus; Type IV’s don’t adapt and are

often the primary initiators of pain.

• Type IV’s can be decreased by the firing of

Types I-III: more commonly through motion in

the joints of the body or to a lesser extent

mobilization of tissues.

The Vestibular System

• Balance is maintained by three sensory systems: the vestibular, visual and somatosensory system (Mohapatra, Krishnan & Aruin, 2011). The stimulation of either of these systems evokes a deviation in balance and increases body sway.


• Maintains balance through the proper

input from the inner ear apparatus

called the labyrinth.


• The three canals respond to rotational and

linear acceleration…including gravity;

which works hand in hand…or rather eye

and eye with “The righting reflex.”

The Righting Reflex

• The primary function of the involuntary

motor output of the human body…

___________________________________

The Righting Reflex• Coordinates the process by which we are

able to ambulate and not fall over after

every step.

Agonist vs. Antagonist

• Agonist = The muscle that is primarily

responsible for a specific joint motion

(directly engaged in contraction).

• Antagonist muscle = the muscle that

opposes the agonist during an exercise.

• Normal stress creates a certain amount of functional changes that the body will naturally adapt to over time. (muscular development with exercise)

• The same is true for Abnormal stress and long term changes that occur from Micro- and Macro- events. (postural routines at work sitting at a computer and MVA’s)

Balancing Act

“When a good musculoskeletal

system goes wrong…”

• Restriction/ hypomobility occurs when normal

body mechanics are altered (moves less than

normal ranges of motion)

– In adults… joints & cartilage are nourished

only by motion

– When an area decreases it’s normal function

due to stress then a cascade of events takes

place that slowly accelerates the

degeneration of that area

“Restricted joint motion causes an

increase firing in nociceptive

axons…. and a decrease firing of

large diameter mechanoreceptor

axons.”

Hooshmand H. 1993. p.33-35

Restriction Degeneration

• The tissues most involved in these

processes are:» Muscles

» Tendons

» Ligaments

» Cartilage

» Nerves

» Vasculature

» Bones


• Stress(load) comes in 4 types:»Normal stress – force perpendicular

to the surface on which it acts

»Shear stress – parallel to the cross section

»Tensile – 2 forces that oppose each other

»Compressive – 2 forces towards each other


• Deformation comes when there is a change in shape due to stress.

• Elastic deformation - ex. Muscles and tendons

• Plastic deformation - ex. ligaments

PLASTIC DEFORMATION

• Low intensity forces for prolonged

periods of time create

PERMANENT plastic changes


• Muscles–are the first to weaken and fastest to

heal

– It takes 6 hours for atrophy to begin

–You lose 1.5% muscle mass per day of non-use


• Tendons–Breakdown based on the load usually at

the insertion to the bone

–Subject to Davis’ Law


• Ligaments–Loss of muscle tone decreases

joint tension and increases the load to the ligaments

–Have similar viscoelasticity like IVD’s and change according to the load applied


• Cartilage–Where the most severe damage

can occur

–Heals the slowest and the least

**Nutrition is critical for repair**


• Disc dynamics-

• Law of compressed fluids

• Rotational torque is 25% less in

degenerated discs


• Nerve

–(lower threshold)

–Nerve pathways defacilitate with restriction

–The body part affected becomes weak and clumsy

–The longer the nerve isn’t functioning the more likely the effects are PERMANENT (after 2 years)


• Vasculature–Aerobics (motion)

–Facilitation

–Hypoxia of certain tissues occurs


• Bone–ADHESIONS

–Boney degeneration over time

–Wolfe’s Law

“Abnormal stress to the bone creating boney abnormalities.”

Patterns

• Postural patterns are developed

– Factors that affect the patterns we

develop

»Stress

»Time

»Load

Patterns

• Postural distortions can be linked to patient symptomatology

Patterns

• Factors that alter structure

• STRESS – 2 types

–Static

–Dynamic

Patterns


• Trauma (which technically is also a Stress)

–Micro

Patterns


• Trauma

–Macro

Patterns

• Factors that alter structure• Malformation (genetic)

Trauma

Structural injury results in asymmetric movement of

one or more vertebrae with respect to the sub-

adjacent vertebrae

Since each vertebrae surrounding the injured disc

articulates with the vertebrae both above and below,

four vertebrae or three FSU’s are affected

Plaugher, 1993

Trauma

The disturbed Kinematics of the FSU will lead to unequal

movements of the right and left facet joints

Unequal load sharing

High load on one facet

Cartilage degeneration, facet atrophy, narrowing of the IVF

• Structural anomalies

–SBO

–Sacralization/ Lumbarization

–Cervical ribs

–Congenital Fusions

–Spondylolisthesis (congenital)

Malformations

• Developmental malformations

–Scoliosis

–Anatomical short leg deficiencies

–Pronation

–Spondylolisthesis (degenerative)

–Varus/ Valgus knee deformities

(Bowlegged & Knock Knee)

Malformations

Structural vs. Functional

•Size or length •Alignment

• Ex. Leg length

Measurements from the ground to the femurs

Mechanical differences

Affects on the surrounding tissues

Structural/ Anatomical Short Legs

• 65% of patients with a leg length inequality

(LLI) greater than 10mm had:» Anterior Translated Pelvis

» Sacral unleveling

» Lumbar curvatures (mean range of 9°)

Fickberg, O. “Clinical Biomechanics” 1987


• Leg Length Discrepancies greater than 9mm caused:

» Asymmetrical Vertebral body height

» Asymmetrical disc thinning of the long leg

side

» Traction spurs on the short leg side

» Adapted a “Pole Vaulting Gait”

Giles LGF, “Spine” 1981


• Low Back Pain and associated anatomical short leg Length discrepancies:

»653 patients with chronic LBP

»359 patients with measured short leg deficiencies but NO back related symptoms

Fickberg, O., “Spine” 1983


• Low Back Pain and associated anatomical short leg Length discrepancies:

– Findings = 228 patients with sciatica (78.5% on long leg side)

338 patients with hip pain (88.9% on long leg side)

As LLI increased the incidence of low back issues INCREASED!!!

Fickberg, O., “Spine” 1983

TO lift or NOT to lift???

Anatomical vs. Functional Short Legs

Anatomically

Changes in size or length creates:

• meniscus injuries

• Foot pad defects (abnormal callus formations,

malformations of the foot)

• Bowing of the femur on the long leg side

• Lateral convexities of the Lumbar Spine

TO lift or NOT to lift???

Anatomical vs. Functional Short Legs

Functionally

Changes in the alignment of structures creates:

• Varus/ Valgus knee deformities

• Foot Pronation/ Supination patterns

• Unilateral muscle weakness

• Accelerated degeneration of the Lumbar Spine

Robert Kuhn DC, DACBR from Logan CC submitted 3 papers to the

ACC on the effects properly fitted custom orthoses have on

balancing the pelvis.

Custom Fitted Orthotics

Common Stress Patterns of the spine

» Right upper cervical/left mid-cervical areas

» Lower cervical/upper thoracic transitional area

» Mid-Dorsals

» Lower thoracic/upper lumbar transitional area

» Lower Lumbar and pelvic relationships

» Upper extremity patterns

» Lower extremity patterns

From the ground up…

• Bilateral asymmetrical foot pronation

– Foot flare/toe out

– Dropped navicular/ falling arches

– Posterior lateral heel wear

– Achilles tendon bowing (inward)

– Patellar approximation/ internal tibial rotation

– Superior lateral tracking of the patella

– Decreased muscle tone of hip abductors

Excessive Pronation Subluxation

PatternBONES SUBLUXATION DIRECTION

Navicular Inferior & Medial

Cuboid *Superior & Lateral

(or Inferior & Lateral)

Cuneiforms Inferior

Metatarsal Heads 2-3-4 Inferior

Metatarsal Heads 1 & 5 Superior and Lateral/Medial

Talus Mostly Anterior & Slightly Lateral

Calcaneus Everted & Plantar Flexed

Fibular Head Posterior & Lateral


• Tibial rotation

– Patellar approximation

– Progressive weakness of vastus medialis

The Unhappy Triad

• Anterior Crutiate Ligament

• Medial Collateral Ligament

• Medial Meniscus

ACL Injuries

Prolonged pronation of the foot and ankle

complex produces excessive internal

tibial rotation, and thus may produce a

preloading effect on the Anterior

Crutiate Ligament.

Incidence of Hyperpronation in the ACL Injured Knee: A Clinical Perspective. 1992

Chondromalacia Patella

• The excessively pronated foot is

accompanied by a compensatory

internal rotation of the tibia. This

increased amount of rotation triggers

stress throughout the peripatellar

tissues of the knee.

Harries, M. et al: Oxford Textbook of Sports Medicine. Oxford University Press, 1994.

Foot Type and Lower

Extremity Injury

• “Athletes with pronated and supinated

feet had significantly more knee pain

than the normal group.”

J Ortho Sports Phys Ther 1991; 14(2): 70-4.

Research @

Logan CC by

Robert Kuhn

D.C., DACBR

demonstrates

orthotics

improve

q-angle and

patellar

tracking.

Custom Fitted Stabilizers

From the ground up

• The Hip


• Internal femoral rotation

– Overworked ITB/Quads trying to stabilize the knee and hip

– Early hip arthroses


• Anterior translation of the pelvis

– Affects the hamstrings and the quads abnormally


• Common pelvic orientations

• AS

– Hip flexion, decreased SBA with sacral

extension, decreased lumbar lordosis, normal

ext. ROM, decreased flexion

• PI

– Hip extension, increased SBA with sacral

flexion, increased lumbar lordosis, normal

flexion ROM, decreased extension

Custom Fitted Stabilizers

Custom fitted


• Common Pelvic orientations

– AS Ilium = opposite side subluxation at L4

– PI Ilium = same side L5 subluxation

Note: These are empirical observations but highly reproducible.


Remember -

Anterior Translation is not

necessarily related to AS, PI, EX, IN listing

systems.


• Sacral involvement

– Often associated with same side pelvic orientations


• Sacral involvement

– X-rays are a good way to help rule in or out major/minor sacral involvement

–No Ilium involvement = adjust sacrum

–AS, In dominant listings = adjust sacrum

–PI, Ex dominant listings = adjust ilium


• Thoraco-lumbar transitional area

– T12/L1 can be a huge relief when thoracic and lumbar segments are counter-torqueing each other


• Thoracic involvement

– Increased kyphosis

– Tends to affect other regions as well

» Decreased cervical lateral flexion

– Look at mid-dorsals (T4-8) palpation is the key


• Shoulders (ant. occ. inferior humeral head)– Anteriorly drawn and internally rotated

– Multiple areas of weakened muscles

– Trigger points

– Poor lymphatic drainage

– Decreased AROM


• Elbows (excessive pronation)

– Weakened annular ligament around radial head

– Lateral/Medial epicondylitis


• Wrists (decreasing carpal arch)


• Cervical/ Thoracic junction

– Tends to be one of rotation/counter-rotation of

either C7/T1 or T1/T2

• Mid-Cervicals

– dominantly right upper and left lower cervical

patterns


• Cervicals

– check the atlanto-occipital junction

– When you find C2 involvement look at the

opposite side C5/6 region for compensatory

subluxations

Upper/Lower extremities

• Dr. Mark Charrette’s upper/lower extremity

protocols ®

Treatments and Rehab

• Treatments– “All techniques work”

– “Three points of tension”

– Ease of adjustment and easily reproducible

– Mixing and matching is ok!!

Treatments and Rehab

• Biological Effects of these patterns

– Right brain dominance effect

– Biochemical effects

– Biomechanical effects

– Lifestyle changes

Treatment and Rehab

• Rehab http://blip.tv/file/3118863

http://blip.tv/file/3118863

Treatment and Rehab

Movement, the book

Movement: Functional Movement Systems—

Screening, Assessment, Corrective Strategies

Gray Cook, MSPT, OCS, CSCS

with

Dr. Lee Burton, Dr. Kyle Kiesel, Dr. Greg Rose &

Milo F. Bryant

RehabMike Boyle’s

STRENGTHTRAINING.COM

Sports specific training for any level

Office Procedures for Rehab

• Determine the most important exercises (based

on postural deficiencies and ADL)

• Demo exercise, watch and correct patient

• Dispense home equipment with instructions

• Re-check in 1 week, have patient demo

• Document separately identifiable procedures

Supplementation

• Multi-Vitamins

• Fish Oils

• Joint Supports (Glucosamine, Chondroitin)

• CoQ10

• Detox Protocols

• Colloidal Silver (natural antibiotic)

• Etc………….

Supplementation

• DNA synthesis from supplements

– 20% protein synthesis

– 80% cellular function - communication

Supplementation

• Joint Supports

– Glucosamine Sulfate vs. HCL

– MSM

– Collagen

• Fish Oils – Omega 3, 6, 9

– Cod Liver vs. Flaxseed

– Inflammatory pathways

Supplementation

• Bio-Availability vs. Absorbability

• Potency (pharmaceutical grade and ‘Walmart’ brands)

• Cost

• Function

– www.vitamins-nutrition.org

– Merck Manual

– Mosby’s Handbook on Herb’s and Supplements

http://www.vitamins-nutrition.org/

Supplementation

Supplementation

AMCoQ10 120mg

Body Balance 4 oz

(or equivalent multivitamin)

Udo’s Oil 2 tablespoons

(or equivalent omega complex roughly 5-6gm)

B-complex 200mg

B-12 1000ug

Joint Complex 1-2 tablets

Supplementation

PM CoQ10 120mg

Vitamin A 25,000 I.U.

Vitamin D 2,000 I.U.

Zinc 100mg

Vitamin E 400 I.U.

Selenium 200mcg

Joint Complex 1-2 tablets

Detoxifcation

• “Foot Bath”

- Bohr Effect =

(-) charge: causes RBC to grab

CO2 and toxins

(+) charge: causes RBC to grab

more O2

Detoxifcation

• “Foot Bath”

– 60% of toxins out through the lungs

– 30 % water/sweat

– 7% colon

– 3% bladder

Practice Management

• Every office is unique…so make every patient’s

experience as unique as your office.

• Cater somewhat to the patient’s specific

symptoms as well as your interpretation of the

causes of those symptoms.

• “The only easy day was yesterday” and

tomorrow is another day you can help

someone!!!

Conclusion

• Global distortions

– Patterns exist with all manner of secondary

effects to all the systems of the body

– Proper evaluation, treatment, stabilization and

rehab will help the patient achieve their health

goals better & faster with longer lasting results

– Managing your practice is reflected by the

way you perceive each patients problems and

address them accordingly…

you get back what you put into it.

Conclusion

Good = adjusting the spine only

Better = adjusting the spine and extremities

Best = adjusting the spine, extremities, rehab, and

spinal pelvic stabilization

from the ground up…c.ymcdn.com/.../griffeth_from_the_ground_up_.pdf · · 2015-04-23from the...

Documents