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Rehabilitation

In addition to manipulative therapy, sports rehabilitation is probably our most useful tool at Camp4. The manipulative therapy, dry needling, and soft tissue treatments are all adjunctive procedures to rehabilitation and allow us to get our patients out of pain and improve tissue glide so they can be trained to move better. If you recall from the manipulative therapy page, joint movement is essential for nervous system function and life itself. Movement drives nutrients into the cartilage of your joints, adequately mineralizes bones for strength, regulates blood flow, stresses and makes the heart stronger, regulates hormonal control, and is the best natural means to treat stress. It is no secret to anyone that exercise is nothing less than amazing for our bodies. This is something that we are extremely passionate about at Camp4 and our goal is to get all of our patients back to their life’s next adventure. Patients at our clinic undergo a very thorough functional movement analysis to assess joint function, tissue tone, and movement quality in order to guide our treatments. If your interested in learning more about what rehabilitation and our category 1, 2, 3 program can do you for you, continue reading. If you have been referred to our clinic and want to schedule an appointment for sports rehabilitation in Taylorsville UT simply click here.

We first need to define a term we just used, and that is functional movement. This has been the focus of rehabilitative medicine for the last few decades and needs some clarification. This concept has also sprouted a wide variety of “movement screens” in the last couple of decades, which are designed to assess the quality and coordination of movement as it’s primary goal. This is very different then making an assessment of strength and power through manual muscle testing, or a 1-rep maximum, which have little to do with function believe it or not. At Camp4 we don’t affiliate with any one particular group in respect to which screen we think is useful, instead we think they all have some value. However, we do not think that everyone needs to be able to complete the same complicated screen in order to be adequately assessed or to show improvement of their condition. Some screens are far too complicated for the majority of the population, thus making them less functional. Look for more on this topic in the blog section of the website.   

 Few patients fall into the “complete fit” of any screen for a functional diagnosis. Being attuned to the subtleties of improper mechanics is more important than the number of movements performed. 

We design our functional assessment and rehabilitation based on your personal age, nutritional status, lifestyle, fitness level, and most importantly your personal goals. Our #1 focus is to get our patients back to doing what they love so their families and everyone else can benefit. The amazing thing about functional movement assessment is the establishment of a baseline, and the ability to re-test our patients function every visit. You will learn quickly in our clinic that it is not all about pain relief. In fact, pain is not a great indicator for improvement of your condition. It has been documented multiple times that the level of low back pain does not have a linear relationship with the amount of tissue healing (cross-sectional area), or normalized muscle firing patterns. Many patients with little to no pain are often found to have what would seem to be significant MRI findings, and the opposite is also true, patients can have negative findings on advanced imaging and have significant amounts of pain. 

qmark So what is functional movement 

It is best to understand this concept by defining function as distinct from structure. Structure is all the physical components of your body, all the way down to each one of your cells. Function is the way in which those parts go about performing their designed role by interacting with one another. In respect to human movement, function is the result of your bodies ability to consume oxygen, coordinate blood flow, and properly engage neural messaging to muscles efficiently in order for you to perform every given movement in your day. It is obviously much more complicated than that but we have to develop a base from which to build on. For this page in particular we want to emphasize nervous system function, for it has the most powerful effect on movement, and has good support in the literature. 

ico_info Wow, did you say every movement is a functional movement? Yes, most of you wouldn’t think that you need to pay as much attention to your bodies position while washing the dishes, compared to performing a cross fit movement. Actually, the opposite is true. You spend way more time washing the dishes or picking up your children than you do exercising, so why don’t we train for those movements? It also brings into question a lot of the exercises we call “functional”. Instead, we hurry through the day trying to get things accomplished as quickly as possible, use poor movement, and overload tissues to failure. Rehabilitation is all about preparing you for the endurance task of daily life. Remember, this has very little to do with strength. 

Lets get another important definition under our belts, and that is the concept of ‘faulty movement’. Now once you hear us say it in the clinic you will now that faulty movement is just like it sounds, only a bit more complicated. The efficiency and quality of your body to perform any particular movement, whether it be walking, breathing, or bending over, is governed by the neurological pathways that you have created over time to perform that movement. It is really like any acquired skill that you know which required a lot of repetitive practice. For example, you only learn to catch a ball by training your hand and eye to be in the same place at the exact same time. The problem is that many times we fall into a routine, or we are forced to sit all day at work, and do the same repetitive tasks while utilizing muscles in an improper sequence, which actually does more harm than good in the long run. This improper muscle firing sequence causes faulty movements which can continue long term until you consciously change them. These faulty movements are responsible for muscle imbalances throughout the spine and extremities, trigger point development, and spinal de-conditioning syndromes. There is a section on the acupuncture page discussing postural decompensation and the creation of muscular tender points that would be good for you to review if you haven’t read it already.

Let’s use an easy example so you can better visualize this concept. When you bend over to pick up something off the floor, unless you are conscious about it, you usually bend at the waist, keep your legs straight, twist and pick it up. A more proper way to pick it up would be to stand over the top of it, push your hips back (hip hinge), bend forward slightly and perform a squat with your hips, knees, and ankles. Everybody understands this movement however not many people actually perform this movement properly. It requires good joint mobility in your upper back, hips, knees and ankles as well as good gluteal activation. 

 #1 source for musculoskeletal injuries is faulty movement and improper joint mechanics. This faulty movement is not only in an athletes shoulder but every joint in the body, especially the spine where all the energy must be transferred from the lower to upper extremity when we move about our daily life.

One of the biggest causes we see for musculoskeletal injury is the result of the notion that one exercise program works for everyone. Unfortunately this is not true, and is in fact quite dangerous. Another important thing you need to understand is that many exercises which have been engrained into our culture should actually be removed from our exercise regimens. Some people have joint restrictions to the point where they cannot perform the exercises properly, leading to faulty movement and overuse injuries. The goal to proper movement is to create an association between different painful tissues and the correct functional deficits which caused the fault movement pattern in the first place.

 

As an example, let’s list some common ill-advised rehabilitation recommendations for the low back that actually have been documented to promote injury.

1 – Strengthening the muscles of the torso actually protects your back. (there is little to no evidence to support this)

2 – Bend your knees when you are performing sit-ups (this makes no difference to the compressive load on your back)

3 – Doing sit-ups will increase back health (there are much better ways to challenge the abdominal muscles )

4 – Bend your knees and not your back when lifting (compressive tolerance actually increases with slight flexion of the low back)

5 – Tight hamstrings and leg length inequalities equal back problems (hamstring tension can be mimicked by a lack of abdominal co-contraction)

6 – Single exercise programs work for everyone (exercise is counterproductive unless performed properly)

7 – Sitting with perfect posture will prevent tissue overload and pain in my spine (there is no such posture)

There is no such thing as the perfect exercise as it relates to spinal conditioning and overall health. Repetitive anything is the primary culprit to spinal and extremity pain of any tissue. Emphasis should be placed on sharing the load through varied movements that spare tissue integrity.

It cannot be overstated how important spinal mechanics are in proper movement and rehabilitation. If you loose ‘joint centration’ in your spine, any movement you perform at the extremity is compromised, as well as the joints of the spine where the energy transfer occurred. The spinal joints guide and limit the entire kinematic chain. This is the reason why category 1 in our rehabilitation program is all about spinal stability and a normalized range of motion. Normalized range of motion does not mean stretching the low back per se, often times patients with low back complaints have too much mobility in their spine both above and below the level of true restriction. Refer to the manipulation page for more information on this topic.  

Before we get into exactly what you will expect in our rehabilitation program at the clinic, I would like to discuss quickly what the research tells us about neuroplastic changes and how it relates to rehabilitation. Remember from the beginning of this discussion, any exercise can be a rehabilitation exercise if done properly and consciously. The expertise that sports medicine doctors have is staying current with what the research tells us is well documented and valid. 

Learning theory and neuroplasticity – developing movement patterns through stages

1. Cognitive kinesthetic stage – this is when patients have a conscious awareness of poor postures and faulty movement patterns as would be assessed by a trained physician. Essentially this is the results of our functional movement screens.

2. Associative stage – this is when patients have an awareness of proper movements and also proper muscle firing sequences. This is the demonstrative and educational component of the rehabilitation program. At this stage our staff demonstrates and educates patients how to activate muscles in the proper sequence so as to optimize control and efficiency of movement. Again, this is not about strengthening muscles.

You only need to use less than 50% of your maximum voluntary muscle contraction (strength), approximately 8-10 reps, 2x/day, with 5-6 second holds, for 4-6 weeks to make a plastic change

3. Autonomous stage – this results after many weeks when your central nervous system forms new movement patterns!! This is the goal, and it must be noted that this takes much vigilance and concentration on your part. This is the most complicated thing about rehabilitation programs in general. They are not “hard” to do, like working out, but require dedication and perseverance. That is why our dedicated staff offer group rehabilitation programs, because we realize that sometimes we need each other to stay motivated.

If you want to move pain free and with more function you will, its not only a biological phenomenon but a psychological one! Patient reassurance and early functional reactivation are the most promising in patient improvement which means manual therapy + active rehabiliation = best treatment for musculoskeletal complaints (low technology + exercise)

 

Now you are ready to talk about our 3 category protocol at Camp4 

A big concept we emphasize is the idea of range before strength. You have learned this already, and it simply means that you need to have a normalized range of motion before we can start grooving your new movement pattern. What that does not mean is that you need to have the same range of motion as the patient next to you. With few exceptions, the other side of your body serves as the normal range of motion for you. Everyones available joint motion is anatomically different. Your rehabilitative categories are as follows:

1-hoverCategory 1 emphasizes spinal stability and a normalized passive range of motion.  Patients remain in this category until they have reached a 35% improvement in function. During this category we will teach you how to properly hip hinge, activate your deep spinal stabilizers, perform proper lifting and walking mechanics as well as how to properly and safely co-contract your abdominal muscles, all while keeping the compressive load on the spine at a minimum. This is considered the local phase, where we train you how to strip your movements down to their most basic functions. Sometimes patients are in too much pain to even perform any rehabilitation in this phase, in that case we manage your pain before advancing you through the program. 

tentingNow you have been trained how to properly activate and control the load that is transferred through the spine, this category emphasizes proprioception and motor pattern re-programing. Proprioception is the ability of your body to detect where your joints are in space and through proper movement training, proprioception can be increased and sustained for the long-term once the motor program has been mastered. This is the rewiring component of your rehabilitation plan. In this category you will perform similar movements to those of category 1, with the addition of an unstable surface or added movements in order to challenge  more global tissues so as to teach you to ‘manage the load‘ in your extremities, through your spine safely. You will remain in this category until you have reached 65% improvement in your function.

tentingThe final category of your rehabilitation emphasizes ballistic (unexpected) loading protocols. This is where you are challenged with more complicated tasks that emphasize categories 1 & 2 while performing functional tasks for you. This could be pitching a baseball, stocking shelves, or picking up your children. Regardless of the task, we all are caught off guard and are forced to reflexively activate type 2 muscle fibers (fast twitch) in order to manage the load properly. To release patients from care without properly training these muscle fibers, we would not be doing our job. Patients remain in this category until they have reached their personal goals at our clinic.

A few important things to note about our rehabilitation program.

Is everyone a candidate for this particular protocol? Not necessarily. This program can be modified as necessary for each individual patient. The patients with extremity (arms and legs) complaints and mechanical spinal pain are the prime candidates. A very similar protocol would be used for patients with intervertebral disc disorders, and certainly the time frames would vary depending on the severity of each patients condition. At Camp4 we take seriously the idea that we don’t have all the tools necessary to help everyone in house, and we pride ourselves in the integrated approach we have with medical clinics in our area to help co-manage patients when we feel that is necessary. It is all about getting the right patient to the right doctor at the right time. 

ico_attentionNote how there was not much mention of pain in those categories? Let’s in more detail discuss what the research says in regards to musculoskeletal pain and rehabilitation. 

ico-style1 Remission and exacerbations of pain during rehabilitation is expected. You are bound to have good days and bad days.

ico-style1 Hurt does not always = harm.

ico-style1 Pain can be neurogenic in nature. This means there is no injury to your muscular or soft tissues but your nerves have become tensioned or compressed from repetitive overuse which causes temporary pain and paresthesia (tingling). If this continues into the long term, chronic pain conditions can develop.

These conditions cannot be stretched away unfortunately. That will only provide a 20 minute relief of pain, which will return as if nothing was done. We can however do nerve mobilization and flossing through specific joint movements which will provide relief of the pain while rehabilitating the movement.

The only long term treatment for repetitive motion disorders is active rehabilitation!!

ico-style1 It is necessary to remove the source which exacerbates tissue overload. First we must teach you the cause of your pain, then we must work to eliminate it.

Slow continuous improvement of function is expected. There is no panacea in spinal rehabilitative therapy. You can expect good days and bad days, the return of function and reduction of pain is a slow process. Repetitive uncoordinated movements irritate pain sensitive structures.

ico-style1 Fear of movement due to an injury has been demonstrated to actually further inhibit damaged muscles and over activate surrounding musculature. Although protective initially, this has been demonstrated to last far beyond tissue healing leading to chronic pain syndromes.

Pain inhibits corticomotor output of the lumber multifidus muscle which is responsible for 2/3 of lumbar intersegmental motion. The deep multifidus muscle fibers showed late firing in one sided low back pain patients, even after symptoms resolved.

 

agonist / antagonist imbalance = synergistic overactivity = altered motor control CNS detects reduced capacity of single muscles so engages synergist. most ST injury not detected w imaging (panjabi). stretch beyond elastic limit = instability/poor healing, vulnerable to repeated strain, Pain presence = decreased activation

-over vilgilance in postural activities should be avoided. Patients tend to loose range of motion. ( it is best o get a full range of motion with light load. **light exercise always better than rest** Pain flare-ups are a normal and does not usually mean further injury. stress about an injury actually decreases your pain threshold.

Developing endurance

Key is to build endurance without ever getting tired. Once you get tired you start recruiting powerful muscles you are not trying to recruit and the neurological gain has been halted. Begin with repeated sets of relatively short holds, 7 or 8 seconds, then build up repetitions, not increase hold times. Use of the reverse pyramid works well because it keeps good form. 7 reps, 6, 5, 4, 3, 2,  done for a couple 2-3 set’s

use of vibrational therapies

 

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Page Citations

1- Jeanine A. Verbunt, Rob J. Smeets, Harriet M. Wittink. Cause or effect? Deconditioning and chronic low back pain. PAIN 149 (2010) 428–430

2- – G. Lorimer Moseley, Paul W. Hodges, and Simon C. Gandevia.  Deep and Superficial Fibers of the Lumbar Multifidus Muscle Are Differentially Active During Voluntary Arm Movements. SPINE Volume 27, Number 2, pp E29–E36 

3- Martijn W. Heymans, Stef van Buuren, Dirk L. Knol, Johannes R. Anema, Willem van Mechelen, Henrica. The prognosis of chronic low back pain is determined by changes in pain and disability in the initial period. The Spine Journal 10 (2010) 847–856

4- David MacDonald, Lorimer Moseley, Paul W. Hodges.  Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. PAIN 142 (2009) 183–188

5- Liebenson, Craig. Functional reactivation for neck pain patients. Journal of Bodywork and Movement Therapies (2002)
6(1), 59-66
Strimpakos, Nikolaos. The assessment of the cervical spine. Part 1: Range of motion and proprioception. Journal of Bodywork & Movement Therapies (2011) 15, 114e124

6- Strimpakos, Nikolaos. The assessment of the cervical spine. Part 2: Strength and endurance/fatigue. Journal of Bodywork & Movement Therapies (2011) 15, 417e430

7- PAVEL KOLÁR, JAN ÊULC, MARTIN KYNCL,JAN ÊANDA, ONDREJ CAKRT, ROSS ANDEL, KATHRYN KUMAGAI, ALENA KOBESOVÁ, Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. April 2012 vol 42(4) Journal of Orthopaedic & Sports Physical Therapy

8- JanBorghuis, L.Hof and KoenA.P.M. Lemmink. The Importance of Sensory-Motor Control in Providing Core Stability Implications for Measurement and Training. Sports Medicine 2008: 38 (11): 893-916

9- Kenneth Anderson and David G. Behm. The Impact of Instability Resistance Training on Balance and Stability. Sports Medicine 2005; 35(1): 43-53

10- Gary L. K. Shum, Jack Crosbie, and Raymond Y. W. Lee. Back Pain Is Associated With Changes in Loading Pattern Throughout Forward and Backward BendingSPINE Volume 35, Number 25, pp E1472–E1478 

11- F. Eckstein, M. Hudelmaier1 and R. Putz. The effects of exercise on human articular cartilage: Review. J. Anat. (2006) 208, pp491–512 

12 – Jesse S. Little and Partap S. Khalsa. Human Lumbar Spine Creep during Cyclic and Static Flexion: Creep Rate, Biomechanics, and Facet Joint Capsule Strain. Ann Biomed Eng. 2005 March ; 33(3): 391–401 

13- Carolyn A. Richardson, Chris J. Snijders, Julie A. Hides, Le ́onie Damen, Martijn S. Pas, and Joop Storm. The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back PainSPINE Volume 27, Number 4, pp 399–405 

 14- SAMUEL R. WARD, Taylor M. WinTers, silvia s. BleMker. The Architectural Design of the Gluteal Muscle Group: Implications for Movement and Rehabilitation. Journal of orthopaedic & sports physical therapy volume 40(2) February 2010