Monthly Archives: July 2014

A Side of the Neck Too Painful to Touch: Another Tool in the Toolbox

27 Sunday Jul 2014

Posted by in Neck, Nerves

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I went on a mission to look for an article to assist me with patients that have neck pain, radicular symptoms into the arms, and hypersensitivity to touch.  The greatest obstacle to overcome would be the nerve pain and hypersensitivity.  Patients can get flared up with certain movements of the neck or pressure at the wrong areas.  Sometimes it is tough to manage symptoms if you cannot get your hands on the affected side when the symptoms are at their most extreme.  So then what can you do to calm down the nerves while still working on the origin of the problem?

The article I came across assessed effects of using a contralateral lateral glide to the unaffected side of the problem cervical vertebrae.  This allows you to improve the mobility of the affected joint/s by working on the unaffected side while avoiding a flare up.  The researchers used Grade 2 and 3 mobilizations to the unaffected side of the problem vertebrae for an average total time of 4.5 minutes.  They also placed the arm in a progressively abducted position to tension the nerve if the subject could tolerate the position.  I would combine this treatment technique with soft tissue massage to the affected upper extremity and light compression of the radiocarpal, humeroulnar, and glenohumeral joints to implement aspects of the gate theory. (Joint compression has been shown to create a calming effect on the body.)

(Click the link below for access to the article)

The Immediate Effects of a Cervical Lateral Glide Treament Technique in Patients with Neurogenic Cervicobrachial Pain

Purpose: To analyze the immediate treatment effects of cervical mobilization and therapeutic ultrasound in patients with neurogenic cervicobrachial pain.

Methods: This was a randomized controlled trial.  Inclusion criteria consisted of individuals that had an active movement dysfunction related to noncompliance of the median nerve (active neurotensioning causing pain), a passive movement dysfunction correlating with the active dysfunction (passive neurotensioning causing pain), an adverse response to median nerve palpation, a positive Upper Limb Tension Test A, and a sign of a local musculoskeletal dysfunction that would indicate a possible cause of the neurogenic disorder.  The researchers compared subjects treated with cervical mobilizations to subjects treated with ultrasound to affected upper extremity.  The subjects received cervical segmental contralateral lateral glide at one or more cervical spine segments (C5-T1) in supine for an average of 4.5 minutes at Grade 2 initially and eventually Grade 3.  The tester placed pressure for 2-3 seconds/repetition during the mobilization.  They made sure to avoid cervical side flexion or rotation during the mobilization.  The subject was placed in a nerve tensioning position (shoulder abduction) during the mobilizations if they can tolerate it and if not the upper extremity was placed on the abdomen.

Results: They found significant improvements with elbow range of motion (average increase of ~19.4 degrees), area of symptom provocation (average reduction of ~43.3%), and pain intensity (average reduction of ~1.5 points).  Pain intensity was measured using the Visual Analog Scale 0-10 point scale.

Reducing Lower Back Muscle Activation While Increasing Gluteus Maximus and Hamstring Muscle Activations

19 Saturday Jul 2014

Posted by in Low Back Pain

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Prone hip extension

Some individuals with lower back pain tend to have over activation of their lumbar extensors with excessive lumbar extension and lack proper activation of the hip extensor muscles; such as the gluteus maximus and hamstrings.  Usually this discrepancy is most prominent during hip extension motions.

I wanted to find information that will help modify this motor pattern during dynamic exercises and eventually functional tasks.  I came across an article that focused on an abdominal drawing-in maneuver (ADIM).  The idea is that while performing an ADIM when completing a hip extension exercise the lumbar extensors will not be as active and the hip extensor muscles will complete most of the task.

There are a couple theories to the cause of this adjustment in muscle activation with abdominal hollowing.  One is less anterior pelvic tilt causes a poor length tension relationship for the lumbar extensors and a more optimal one for the hip extensors.  Another theory is due to reciprocal inhibition, which means that when the agonist muscles (e.g. abdominal muscles) are activated the antagonist muscles (e.g. lumbar extensors) naturally become less active, so the hip extensor muscles must take over to complete the task.

(Click the link below for access to the article)

Effects of Performing an Abdominal Drawing-in Maneuver During Prone Hip Extension Exercises on Hip and Back Extensor Muscle Activity and Amount of Anterior Pelvic Tilt

Purpose: To measure the electromyographic (EMG) signal amplitude of the hip extensors and erector spinae and the angle of the anterior pelvic tilt during hip extension in the prone position.

Methods: The researchers examined two groups of subjects completing a prone hip extension with the knee extended with an ADIM or without an ADIM.  They measured the muscle activation of the erector spinae and the gluteus maximus and medial hamstring on the dominant side.  They had the subjects sustain the hip extension for 5 seconds.  They placed a pressure cuff underneath the abdomen inflated to 70 mmHg and instructed the subjects to maintain the pressure at about 60 mmHg during the movement.

Results:  The researchers compared the outcome measures of hip extension without an ADIM to hip extension with an ADIM and found a significant decrease in erector spinae activation (49% to 17% MVIC), significant increase in gluteus maximus (24% to 52% MVIC) and medial hamstring activation (47% to 58% MVIC), and a decrease in anterior pelvic tilt (10 degrees to 3 degrees).     *MVIC = maximal voluntary isometric contraction

Limitations: The data cannot be generalized because the subjects were only healthy and no unhealthy subjects were studied.  There is a potential for the EMG to pick up signals from adjacent muscles.  The researchers did not differentiate muscle activation between abdominal muscles, the diaphragm, and the pelvic floor with the abdominal drawing-in maneuver.  Finally, the lumbopelvic hip movement patterns were not measured to see how much movement at those segments were occurring.

What’s Better for Improving Shoulder Internal Rotation; the Sleeper Stretch or Cross-Body Stretch?

14 Monday Jul 2014

Posted by in Shoulder

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I set out to find an effective stretch for improving shoulder internal rotation range of motion (turning your arm in or reaching you hand behind your back).  I came across this article that assessed two common stretching techniques that help to improve that shoulder range of motion; the sleeper stretch and the cross-body stretch.  The premise of these stretches are to lengthen the tightened posterior capsule of the shoulder.  Tightness of the posterior capsule restricts movement of the shoulder and causes the abnormal movement in the superior and anterior direction.  This leads to a decrease in the subacromial space and compression of the tissues leading to shoulder impingement syndrome.  Excessive movement in this direction also places abnormal stress on the superior labrum of the shoulder which can cause injury to that region.  The study concluded that the cross-body stretch, more so than the sleeper stretch, helped to improve movement of the shoulder.  I plan to use this article to help with treatment and rehabilitation efficiency.  My intentions are not to negate the use of the sleeper stretch but to use evidence-based practice and put another tool in my toolbox.

(Click the link below for access to the article)

A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder Tightness

Purpose: To compare the sleeper stretch and cross-body stretch techniques to improve passive shoulder internal rotation range of motion in subjects with limited shoulder internal rotation range of motion due to posterior shoulder tightness.

Methods: This was a randomized controlled trial that studied subjects for 4 weeks.  The subject exclusion criteria consisted of a history of shoulder surgery, shoulder symptoms requiring medical care within the past year, or shoulder pain greater than 5 on a 10 scale.

Sleeper Stretch – 1 time a day, 5 repetitions, holding for 30 seconds each

sleeper stretch

Cross-Body Stretch – 1 time a day, 5 repetitions, holding for 30 seconds each

Cross body stretch

Results: The researchers found that there was a significant increase with shoulder internal range of motion when using the cross-body stretch (20 degrees) when compared to the control group.  There was no significant increase in shoulder internal range of motion when using the sleeper stretch (12.4 degrees) when compared to the control group.  There was no statistical difference the sleeper stretch and the cross-body stretch but the cross-body stretch showed an improvement with shoulder internal rotation of 7.6 degrees more than the sleeper stretch.

Limitations: The researchers described two main limitations.  They used asymptomatic subjects rather than individuals who were throwers or had shoulder pain.  They also recommend future research to assess the effects of the stretches on a long-term basis.

Spinal Mobilization or Press-Ups?

08 Tuesday Jul 2014

Posted by in Low Back Pain

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lower_back_pain-293x300

There are many treatments that can be used to help treat low back pain. Two treatments that physical therapists use are spinal posterior to anterior (P-A) mobilizations and prone press-ups. I was curious about the effectiveness of both of these treatments and which one has the better outcome. I came across this article that helped to answer this question.

(Click the link below for assess)

Effects of a single session of PA spinal mobilization and press-up exercise on pain response and lumbar spine extension

The researchers compared a single session of P-A segmental mobilization to press-ups and measured pain with a visual analog scale and lumbar extension range of motion with an MRI on individuals with nonspecific low back pain.  They found significant improvement in pain and lumbar extension range of motion but no difference between the two treatment options.  Even though there was no significant difference between the two treatment options the participants treated with P-A mobilizations had an average reduction of pain by 41% and an average increase in lumbar extension motion of 17.8% and the press-up group reduced pain by 30% and increased motion by 11.7%.

Purpose: To examine the immediate effects of P-A mobilization and a press-up exercise on pain with standing extension and lumbar extension in people with nonspecific low back pain.

Methods: The participants consisted of 30 individuals between the ages of 18 and 45 years old.  Inclusion criteria consisted of a recent onset of back pain (<3 months), localized low back pain at or above the waist level, decreased lumbar extension during standing, and increased low back pain with standing lumbar extension.  Participants were excluded if they had spinal malignancy, cardiovascular disease, evidence of cord compression, aortic aneurysm, hiatal hernia, uncontrolled hypertension, spinal infection, severe respiratory disease, pregnancy, abdominal hernia, prior low back surgery, gross spinal deformity, spondylolisthesis, rheumatic joint disease, and implanted devices that may be affected by MRI.  Other exclusion criteria consisted of radiating pain below the buttocks, sensation changes in the lower extremities, diminished reflexes, low extremity weakness, neurological signs, urinary or fecal incontinence, or increased pain with repetitive lumbar extension.

  • P-A Spinal Mobilization – The mobility of the lumbar spinal segments were assessed and the segments with hypomobility and a reproduction of symptoms were the target areas.  The subject was placed in prone with a pillow under the stomach.  Each segment was assessed with 1-2 Grade I mobilizations.  If there were no reproduction in symptoms then mobilizations increased to Grade III and IV.  If there was no reproduction in symptoms then the next segment was assessed until a painful segment was found.  Once a painful segment was found the examiner completed 3 sets of 40 second oscillations to a Grade IV intensity or just shy of pain reproduction.
  • Press-ups – A press-up was completed as far as possible without a reproduction of symptoms.  The subject was prone on a table and extends the arms to lift the chest.  The hips and pelvis may lift from the table and sag due to gravity.  The subject was instructed to hold for 5 seconds and repeat 10 times.  The subject was encouraged to go higher each time.  If the symptoms reduced or were unchanged then 2 more sets were completed.

Limitations: The study had 5 reported limitations.  They stated that the participants were relatively young which allowed for greater absolute lumbar extension range of motion which would not be possible with more elderly individuals.  The inclusion criteria was quite selective making the results difficult to generalize to other people with low back pain.  The examiners only assessed the immediate effects of the treatments and not the long term effects.  The study did not have a sham group to assess the placebo effect of treatment.  Finally, they mentioned that they were not able to exactly reproduce the pretreatment resting position during the post-treatment MRI assessment.