1. Regional Interdependence
Regional Interdependence is a fairly recent term in the Physical Therapy profession . A recent article in PT Advance encouraged the follwing reply. I am posting this in advance of it being printed, though the editor informed me that it would be published.
I just revised the original letter.
Dear Editor,
I enjoyed the article Investigating a new model of assessing musculoskeletal disorder by Brent Swartzlander, DPT, OCS, in the August 11, 2008 edition. The concept of "Regional Interdependence" may be an old concept which of recent times is being expounded upon, yet unfortunately, it surely is not part of normative Physical Therapy practice, except in the minority. The term Regional Interdependence of course, is fairly recent, and I suspect only used in the first of the 20 references used for the article. I submit that as we are early in our use of this term, and that it may undergo some enhancement over time. What is to be celebrated is the fact that there are an increasing number of case studies and articles that demonstrate benefit from utilization of the concept, such as thoracic mobilization enhancing cervical function and decreasing pain, etc..
I believe that in time the term Regional Interdependence may evolve; perhaps a new term would be Interregional Interdependence. Why? Because distal regions of the body, rather than only proximal regions, do in fact interact. One example, a treatable anterior talus on the right (this mimics left rotation of lowest segments) which will invoke a right rotation of C1, with a typical motion compensatory coupling (motion restriction) at Occiput-C1. This is reflexively driven, as treatment of the primary problem in the foot and ankle can be manually resolved, and the upper cervical pattern will be significantly improved upon retesting. This reflex distal release occurs instantaneously, before the client stands, thus it is not gravity dependant. On occasion, a part of the cervical pattern will tend to recur, as noted on the next follow up visit, and may require specific treatment. When this does occur, it can be the segment below (permutation), and other times it is only one or 2 motion restrictions, a much lesser restriction than noted initially
An alternate name might be Interregional Interdependence Permutation Model. Why? Because the body does undergo permutation during the course of treatment, thus the body responds in a very counter-intuitive manner, in which what you see on initial examination is in fact, not what you get;as you start to treat proximal to distal, inferior to superior, etc. this model of care is much more readily apparent when treating the lowest denominator first, again going from inferior to superior. For example, upon restoring normal costo-vertebral mobility at one segment, the compensatory restriction on the opposite side of the body at a superior costovertebral segment may spontaneously resolve, yet the corresponding thoracic segment may then present anew, with restricted mobility, which was not encountered initially.
Noteworthy is the fact that the body can have different restrictions of the musculoskeletal system in different positions. Thus it is important to evaluate the structures in neutral weight bearing (WB) and in flexion and extension WB, in non weight bearing extension and flexion, etc. One of the most relevant postures is "Muslim Prayer Position", in which the entire spine, pelvis and lower extremities are fully flexed. This posture often reveals restrictions that are not noted in other positions or contexts. So perhaps a working model might be titled the Interregional Multiple Context Interdependence Permutation Model. How nice it would be if all case studies and research articles mentioned the proximal and distal compensations and adaptations to the primary musculoskeletal dysfunction. It is somewhat surprising that at present, this is extremely rare. Thank you for allowing me to share my thoughts.
Sincerely,
Jerry Hesch, MHS, PT
Revised after submitted to PT Advance Magazine jh 09/04/08
2. Hypomobility/Hypermobility: Different Body Types Require a Different Approach
Hypomobility/Hypermobility: Different Body Types Require a Different Approach
In this discussion of different body types, I am not referring to the three basic body types, which are Ectomorphic, Mesomorphic and Endomorphic. Rather, I am speaking of different body types based on connective tissue types. This is a very brief general article.
Hypermobility
One extreme is Hypermobility Syndrome in which the connective tissue is very slack. There are several types of collagen, a protein that makes up our connective tissue such as tendon, ligaments, fascia, etc.. An excessive amount of elastin, a more "stretchy" connective tissue affects hypermobility. Hypermobility Syndrome is sometimes referred to as Erlos-Danlos Syndrome. People with general laxity have excessive motion in their joints. their posture may reflect this with hyperextension of the knees and elbows, excessive valgus of the elbows and knees, hyperextended hip joints, etc.. Passive motion testing will reveal greater than normal mobility at all (or nearly all) joints. for example, the typical person can extend their 5th metacarpo-phalaneal joint 45 to 60 degrees, the hypermobile can go 90 degrees and beyond. these body types are wonderful for circus acrobatics and gymnastics, because of the profound flexibility. They are able to protect themselves because they work out daily and have incredible strength and endurance.
When treating a person with hypermobility, there are several considerations. It is important to screen for Fibromyalgia as there does seem to be a correlation. A complete biomechanical evaluation should be performed to determine if there are any underlying problems, and they can have dysfunctional stiff, hypomobile joints secondary to trauma, posture, muscle imbalance, etc.. It may sound paradoxical, yet indeed, they can present with joint that is hypomobile. Will it be symptomatic? Typically not, it is usually the joint above or below, or the joint that reflexively compensates/adapts. Alternately, an excessively hypermobile joint can move to its end-range and become stuck. Therapy is directed at restoring motion, and then, very importantly; constraining motion. General strengthening, avoiding end-range is important. although there is very little data to support that teaching proper body mechanics is helpful in reducing reinjury and reducing symptoms, I submit that we have a moral obligitation to do so, and to do so thoroughly. I proudly teach a few "extras" which are not the norm, yet in my opinion; very relevant. Please see relevant section in my workbook. anything and everything that can be done to enhance biomechanical function should be considered. An example: the typical foot orthotics may be inadequate, wheras the type that are casted in greater supination (includes greater arch support)may be more helpful. stretching is rarely indicated, but when utilized it must be done gently, and for shorter times than is typical. More often than not, sustained end-range is to be avoided. These clients can easily hurt themselves performing passive stretches. More will be added to this topic in time.
Hypomobility
That describes me! I have very dense, very stiff connective tissue. When I stretch I often have to use a fulcrum and I have to sustain the stretch for a long time, typically 2-5 minutes and sometimes much longer! I will elaborate more in time.
Hypomobility of the 3RD Rib, and Relation with the Thoracic 2-3 facet Joint Example:
One example, is the discovery of a very stiff rib (costovertebral) joint. The 3rd rib lacked anterior glide and anteromedial glide. I used a fulcrum, but had to be very cautious about body position. Logic would tell me to lie supine on a firm ball, such as solid rubber 2-3" (5-7.5cm) diameter. however, this would give a limited response due to discomfort with muscle guarding. Therefore, treatment position was sitting with the lateral portion of the rib (just lateral to thoracic spinous process) agains an outside corner of the wall. Applying a posterior-anterior force lifted the rib anteriorly in a loose-pack position and I remained for 3 minutes. I then applied a vector at a 45 degree angle to move the rib anteriorly and medially, in essence, closing the rib at the costo-transverse and costo-corporal joints for 3 minutes.
After that I felt much freer, rotation of the thoracic spine and even extension was greater and easier. Furthermore, self manipulation of the 3-4 thoracic facet joint was much easier and much more lasting. I hope this serves as a good example. As a rule, I always consider the rib joints whenever I perform a thoracic manipulation. sometimes the rib acts as a long lever and controls the thoracic segment, necessitating a rib mobilization first. Othertimes, the rib is secondary, and after mobilizing the thoracic segment the rib restriction becomes more apparent, perhaps as a permutation. The rib is then mobilized. Of course I then check the rest of the body for compensations and adaptations. Please see seperate section on "Regional Dependence".
It is noteworthy that the 3rd costovertebral joint is remarkably close to the thoracic 2-3 facet joint, and joint dysfunction can at times be confusing if only one of them is implicated. Always evaluate and treat (as indicated) the thoracic joint AND the rib joint. I marvel at published case studies and research articles that treat the thoracic spine using manipulation with no mention at all of the relevant relationship with the costotransverse and costovertebral joints. These joints are rather dense with losts of connective tissue and of cours have a variable angle segment to segment. The intercostal muscles (one of 2) angle at least 45 degrees away from the angle of the joint. The take home message: it takes creep (deformation over time) to properly mobilize these joints. Therefore, I take 3-5 minutes whenever I mobilizea rib joint and I do not believe that a grade 5 thrust is adequate. by design, the anatomy mandates creep.
A Mix of Both
The average person is a mixture of both hypermobile and hypomobile. evaluating the whole body will reveal those structures that need to be treated form the perspective of a hypermobile structure and which need to be treated from the perspective of a hypomobile structure. There are several reflexes that can come into play and make treatment challenging. An example would be a hypomobile craniocervical junction that is only partially responsive to soft tissue work, stretching, and joint mobilization. What is missing? Something below is influencing the occulopelvic reflex (also has other names) such as a transverse plane rotation of the pelvis (so called sacroiliac joint dysfunction). the same is true for hip rotation due to muscle spasm or shortening, and anterior talus, a rib dysfunction enhancing trunk rotation, etc.. again, a whole body screen is essential. To focus only on what hurts for example, is to be somewhat incomplete with regards to how the body functions.
3. Reflections on a Recent Case: Connecting the Pelvis and Upper Cervical Spine Sacrum and Sternum
I had a wonderful opportunity to spend a day with a Physical Therapist Deena Goodman from Los Angeles, CA. She is learning my work via distance learning, which I am just developing and it is not yet ready for prime time. It was fortunate that she was coming to Las Vegas to visit some friends. Here is a link to her web site
www.goodmanphysicaltherapy.com. I will ask her to provide some feedback to post at the bottom.
In demonstrating the spring tests on her, I came to realize that she lacked passive side glide of the pelvis moving from the left to the right. I test this movement in supine and do so because there are cases which are too subtle to be observed with gait and standing posture. This is not a sacroiliac motion dysfunction, but rather a motion dysfunction of the entire pelvis; the pelvis as a unit. Given her motion restriction, I predicted (based on experience) that she would have an upper cervical restriction as a compensation and she affirmed that she was aware of it every time she performed a Gyrotonic exercise which she demonstrated. This Gyrotonics exercise involves a combined movement of cervical right rotation with thoracic and lumbar spine rotation, maximizing end range spinal motion to the right.
Passive testing revealed these motion restrictions (Grade 2-):
blocked left side-glide of C1 (first cervical vertebrae)
reduced left rotation of C1
blocked right rotation of occiput on C1
blocked left side-bending of occiput
blocked right side-glide of occiput
I explained that this was a reflex phenomenon and that most likely it would resolve in response to correcting the pelvic side-glide restriction. I had her lie on the left side with 3 pillows underneath the left side of her pelvis for 5 minutes. Retesting revealed that side-glide of the pelvis was restored and immediate retesting of the upper cervical spine revealed that all the previous restrictions motions were normal. She then demonstrated an ability to perform the exercise that usually provokes her of the cervical restriction; now done with ease. This highlights why I never treat the upper cervical spine first, instead I make sure that there is no postural/movement dysfunction below that is contributing to an upper cervical compensation. Since the body responds in this manner, it would be ideal if published case studies mentioned the proximal/distal compensation, and reevaluated it after treating the primary dysfunction, to assure that it did in fact resolve. There are in fact times in which the distal compensation does require a seperate, specific treatment.
Mild soreness and mild tightness in the right trochanteric region told us there might be more work to be done. Palpation in prone and supine revealed increased soft tissue tone over the right pubic bone and over the right lower quadrant of the sacrum, and just below. I predicted that there might be a sacroiliac motion dysfunction, and if so; it may announce itself at end range flexion (Muslim Prayer Position). It did, she had a sacral torsion about an oblique axis. I will avoid the traditional nomenclature which many find to be confusing. I will describe it in terms of position, movement restriction, and treatment.
right lower sacral quadrant prominent (posterior)
right lower sacral quadrant blocked to P-A spring
left sacral ILA inferior
left sacral ILA lacked superior spring
TREATMENT: Patient maintained Muslim Prayer Position. P-A glide to right lower quadrant for 2 minutes and then 3 superior oscillations to left sacral ILA with lumbar spine side-bent right.
Prior to treating the sacrum I explained that sacral movement dysfunction often has a corresponding restriction at the sternum. I think that came from the book Osteopathic Lesions of the Sacrum by Richards. Bill Brooks, DO and his colleagues have published research on sternal mobility. Spring testing of the anterior chest wall revealed a very distinct motion block of A-P spring at the right lower sternum, extending to the costochondral segments. It was not subtle. This sternal motion block resolved immediately in response to treating the sacrum. Deena reported that she was then able to inspire more fully and more freely.
I also treated the L5-S1 motion segment, the thoraco-lumbar junction, and taught self treatment. She reported that the trochanteric soreness and tightness was resolved. She retained a Type 1 (Osteopathic terminology) pattern of lumbar spine in flexion, which did not respond readily, and additional attention may be fruitful.
I think there are several salient points in this very brief case.
Physical Therapist need to get worked on from time to time!
Beyond the SIJ paradigm, the pelvis (as an entire structure) needs to evaluated as a distinct structure that has its own set of biomechanical function and dysfunction.
Palpation of pelvic soft tissue will sometimes indicate that a subtle movement dysfunction is present, yet needs to be evaluated in another position, such as Muslim Prayer Position, at which point it will no longer be subtle.
Pelvic side-glide restriction (and other pelvic/SIJ patterns) causes a reflex muscular compensatory pattern in the upper cervical spine, which reduces passive accessory motion.
Sometimes the distal compensation will not resolve until the cause is isolated and treated. In the above example an upper cervical restriction spontaneously resolved when the pelvic motion restriction was resolved.
It is often appropriate to screen the entire body.
Sacral motion dysfunction often induces a restriction in the sternum and costochondral area with reduced inhiliation.
There is an alternate way of describing sacral torsions about a vertical axis, which for many (based on course feedback) it is less confusing than nomenclature such as "Right on Left" sacral torsion.
Jerry Hesch
October 9, 2007
October 9, 2007
Hi Jerry,
Post treatment by you: I felt sore in my upper cervical spine, especially right side if my memory serves me right! My body continues to feel "light" in my pelvis (yeah!) and no complaints of cervical "tension" or pain so to speak. Lots of crackling in the joints (right side only? vs. more on the right-haven't payed attention to this) with C/S forward bend and side bend motions to stretch my neck. I will try out the Gyro movement tomorrow and let you know if the cervical sx's are gone!!!!!
Deena Goodman, PT
4. Enhancing the Traditional 5 Point Joint Mobilization Scale
ENHANCING THE TRADITIONAL 5 POINT JOINT MOBILIZATION SCALE
Traditional 5-point scale
Grade I. Is a small amplitude movement conducted from the beginning of the available range of motion.
Grade II. Is a large ampl;itude movement conducted within the range. It does not reach either end of the range.
Grade III. Is a large amplitude movement that does reach the end of the range of motion.
Grade IV. Is a small amplitude movement conducted at the very end of the range of motion.
Grade V. Is a high velocity, low-amplitude thrust at the end of the available range and within its anatomical range. Think "joint popping". also called a "manipulation".
I look forward to this topic. I always felt that the 5 point (grades1-5) joint mobilization scale was limiting. for more than 25 years I practiced using an expanded scale that made much more sense to me. the 5 point scale makes a lot of sense for acute conditions, but for chronic conditions I was much more comfortable with 2 more points which I will call Grade 6, and Grade 7. I will be back soon to elaborate and to clean up earlier posts, add video to some, etc.
Key concepts: You MUST keep the slack taken up at all times!
Always oscillate forward from the position of having taken up the slack, and maintained the tightned position throughout the treatment. You must mobilize a joint many times to maximize the gain, e.g. 30 reps.
GRADE 6
Take up the slack in a joint and maintain that position with constant force for 2 minutes to allow creep. Creep is a fundamental property of joints, defined as deformation over time.
GRADE 7
Take up the slack in a joint and perform repeat mobilizations, being gentle, but applying repeated moderate velocity, low amplitude forces. Always keep the slack taken up, as motion is gained, it is followed, such that there is a new position of the slack being taken up. This assures that the energy in the next mobilization will be applied directly against the barrier. Each thrust has the potential to move the joint past the barrier into a new range of motion. Typical number of repetitions for me: 30.
I recognize that the above topic needs to expand into a full position paper. surely this is a topic worthy of debate and may generate some controversy, appropriately labeled as "iconoclastic", the mere suggestion that the traditional 5-point scale is not adequate or at worst; is not understood and therefore not properly applied. I marvel at studies on mobilizing the talus in which a few degrees are gained. I regularly obtain 10 degrees rather easily in similar population using the above techniques. I have often observed other Manual Therapists, and it appears that they perform a small number of oscillations (regardless of the Grade). I submit that 30 reps is optimal, or if utilizing creep; 2 minutes or more.