Back Clinic Chiropractic. This is a form of alternative treatment that focuses on the diagnosis and treatment of various musculoskeletal injuries and conditions, especially those associated with the spine. Dr. Alex Jimenez discusses how spinal adjustments and manual manipulations regularly can greatly help both improve and eliminate many symptoms that could be causing discomfort to the individual. Chiropractors believe among the main reasons for pain and disease are the vertebrae’s misalignment in the spinal column (this is known as a chiropractic subluxation).
Through the usage of manual detection (or palpation), carefully applied pressure, massage, and manual manipulation of the vertebrae and joints (called adjustments), chiropractors can alleviate pressure and irritation on the nerves, restore joint mobility, and help return the body’s homeostasis. From subluxations, or spinal misalignments, to sciatica, a set of symptoms along the sciatic nerve caused by nerve impingement, chiropractic care can gradually restore the individual’s natural state of being. Dr. Jimenez compiles a group of concepts on chiropractic to best educate individuals on the variety of injuries and conditions affecting the human body.
Consider the following, sciatica is a medical term used to describe a collective group of symptoms resulting from the irritation or compression of the sciatic nerve, generally due to an injury or aggravated condition. Sciatica is commonly characterized by radiating pain along the sciatic nerve, which runs down one or both legs from the lower back. The following case vignette discusses Mr. Winston’s medical condition, a 50-year-old bus driver who reported experiencing chronic, lower back and leg pain associated with sciatica during a 4-week time period. Ramya Ramaswami, M.B., B.S., M.P.H., Zoher Ghogawala, M.D., and James N. Weinstein, D.O., provide a comprehensive analysis of the various treatment options available to treat sciatica, including undergoing lumbar disk surgery and receiving nonsurgical therapy.
On a personal note, as a practicing doctor of chiropractic, choosing the correct treatment care for any type of injury or condition can be a personal and difficult decision. If the circumstances are favorable, the patient may determine what is the best form of treatment for their type of medical issue. While nonsurgical therapies, such as chiropractic care, can often be utilized to improve symptoms of sciatica, more severe cases of sciatica may require surgical interventions to treat the source of the issue. In most cases, nonsurgical therapies should be considered first, before turning to surgical therapies for sciatica.
Case Vignette
A Man with Sciatica Who is Considering Lumbar Disk Surgery
Ramya Ramaswami, M.B., B.S., M.P.H.
Mr. Winston, a 50-year-old bus driver, presented to your office with a 4-week history of pain in his left leg and lower back. He described a combination of severe sharp and dull pain that originated in his left buttock and radiated to the dorsolateral aspect of his left thigh, as well as vague aching over the lower lumbar spine. On examination, passive raising of his left leg off the table to 45 degrees caused severe pain that simulated his main symptom, and the pain was so severe that you could not lift his leg further. There was no leg or foot weakness. His body-mass index (the weight in kilograms divided by the square of the height in meters) was 35, and he had mild chronic obstructive pulmonary disease as a result of smoking one pack of cigarettes every day for 22 years. Mr. Winston had taken a leave of absence from his work because of his symptoms. You prescribed 150 mg of pregabalin per day, which was gradually increased to 600 mg daily because the symptoms had not abated.
Now, 10 weeks after the initial onset of his symptoms, he returns for an evaluation. The medication has provided minimal alleviation of his sciatic pain. He has to return to work and is concerned about his ability to complete his duties at his job. He undergoes magnetic resonance imaging, which shows a herniated disk on the left side at the L4�L5 root. You discuss options for the next steps in managing his sciatica. He is uncertain about invasive procedures such as lumbar disk surgery but feels limited by his symptoms of pain.
Treatment Options
Which of the following would you recommend for Mr. Winston?
Undergo lumbar disk surgery.
Receive nonsurgical therapy.
To aid in your decision making, each of these approaches is defended in a short essay by an expert in the field. Given your knowledge of the patient and the points made by the experts, which option would you choose?
Option 1: Undergo Lumbar Disk Surgery Option 2: Receive Nonsurgical Therapy
1. Undergo Lumbar Disk Surgery
Zoher Ghogawala, M.D.
Mr. Winston�s case represents a common scenario in the management of symptomatic lumbar disk herniation. In this particular case, the patient�s symptoms and the physical examination are consistent with nerve-root compression and inflammation directly from an L4�L5 herniated disk on his left side. The patient does not have weakness but has ongoing pain and has been unable to work for the past 10 weeks despite receiving pregabalin. Two questions emerge: first, does lumbar disk surgery (microdiskectomy) provide outcomes that are superior to those with continued nonoperative therapy in patients with more than 6 weeks of symptoms; and second, does lumbar microdiskectomy improve the likelihood of return to work in patients with these symptoms?
The highest quality data on the topic come from the Spine Patient Outcomes Research Trial (SPORT). The results of the randomized, controlled trial are difficult to interpret because adherence to the assigned treatment strategy was suboptimal. Only half the patients who were randomly assigned to the surgery group actually underwent surgery within 3 months after enrollment, and 30% of the patients assigned to nonoperative treatment chose to cross over to the surgical group. In this study, the patients who underwent surgery had greater improvements in validated patient-reported outcomes. The treatment effect of microdiskectomy was superior to that of nonoperative treatment at 3 months, 1 year, and 2 years. Moreover, in an as-treated analysis, the outcomes among patients who underwent surgery were superior to those among patients who received nonoperative therapy. Overall, the results of SPORT support the use of microdiskectomy in this case.
Results of clinical trials are based on a comparison of treatment options in study populations and may or may not apply to individual patients. SPORT did not specify what type of nonoperative therapy was to be used. Physical therapy was used in 73% of the patients, epidural injections in 50%, and medical therapies (e.g., nonsteroidal antiinflammatory drugs) in more than 50%. In the case of Mr. Winston, pregabalin has been tried, but physical therapy and epidural glucocorticoid injections have not been attempted. Despite widespread use of physical therapy for the treatment of lumbar disk herniation, the evidence supporting its effectiveness is inconclusive, according to published guidelines of the North American Spine Society. On the other hand, there is evidence that transforaminal epidural glucocorticoid injection provides short-term relief (30 days) in patients with nerve-root symptoms directly related to a herniated disk. Overall, there is evidence, from SPORT and from a randomized trial from the Netherlands published in the Journal, that early surgery between 6 and 12 weeks after the onset of symptoms provides greater alleviation of leg pain and better overall pain relief than prolonged conservative therapy.
The ability to return to work has not been formally studied in comparisons of operative with nonoperative treatments for lumbar disk herniation. Registry data from the NeuroPoint-SD study showed that more than 80% of the patients who were working before disk herniation returned to work after surgery. The ability to return to work may be dependent on the type of vocation, since patients who are manual laborers may need more time to recover to reduce the risk of reherniation.
It is well recognized that many patients who have a symptomatic lumbar disk herniation will have improvement spontaneously over several months. Surgery can alleviate symptoms more quickly by immediately removing the offending disk herniation from the affected nerve root. The risk�benefit equation will vary among individual patients. In the case of Mr. Winston, obesity and mild pulmonary disease might increase the risk of complications from surgery, although in SPORT, 95% of surgical patients did not have any operative or postoperative complication. For Mr. Winston, a patient with pain that has persisted for more than 6 weeks, microdiskectomy is a rational option that is supported by high-quality evidence.
2. Receive Nonsurgical Therapy
James N. Weinstein, D.O.
This case involves a common presentation of low back pain radiating to the buttock and posterolateral thigh that might represent either referred mechanical pain or radiculopathy. Classic radiculopathy resulting from compression of a lower lumbar nerve root (L4, L5, or S1) results in pain that radiates distal to the knee and is often accompanied by weakness or numbness in the respective myotome or dermatome. In this case, the pain is proximal to the knee and is not associated with weakness or numbness. In SPORT, surgery resulted in faster recovery and a greater degree of improvement than nonoperative treatment in patients with pain that radiated distal to the knee and was accompanied by neurologic signs or symptoms. However, since Mr. Winston would not have met the inclusion criteria for SPORT, the results of diskectomy in this case would be somewhat unpredictable. He does not have radiculopathy that radiates below the knee, and he does not have weakness or numbness; nonoperative treatment should be exhausted before any consideration of a surgical procedure that in most cases has not been shown to be effective in patients with this type of presentation. In this issue of the Journal, Mathieson and colleagues report the results of a randomized, controlled trial that showed that pregabalin did not significantly alleviate pain related to sciatica. Mr. Winston has been treated only with pregabalin; therefore, other conservative options should be explored.
Saal and Saal reported that more than 80% of patients with radiculopathy associated with a lumbar disk herniation had improvement in a matter of months with exercise-based physical therapy. In the nonoperative SPORT cohort, patients had significant improvement from baseline, and approximately 60% of those with classic radiculopathy who initially received nonoperative treatment avoided surgery. Mr. Winston has had minimal treatment and has had symptoms for only 10 weeks. He should undergo a course of exercise-based physical therapy and a trial of a nonsteroidal antiinflammatory medication and may consider a lumbar epidural glucocorticoid injection. Although there is little evidence of the effectiveness of these nonoperative options alone, the combination of these treatments and the benign natural history of the patient�s condition could result in alleviation or resolution of symptoms. If these interventions � and time � do not resolve his symptoms, surgery could be considered as a final option, but it may not have long-term effectiveness and could in and of itself cause the possibility of more harm than good. Mr. Winston has risk factors, such as obesity and a history of smoking, that have been shown to contribute to poor surgical outcomes of certain spinal procedures.
Mr. Winston has symptoms of back pain that interfere with his quality of life. He would need to understand, through shared decision making, that a nonsurgical approach is likely to be more effective than surgery over time.
Information referenced from the National Center for Biotechnology Information (NCBI) and the New England Journal of Medicine (NEJM). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Cited by Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
1. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA2006;296:2441–2450
2. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA2006;296:2451–2459
3. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J2014;14:180–191
4. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med2010;11:1149–1168
6. Ghogawala Z, Shaffrey CI, Asher AL, et al. The efficacy of lumbar discectomy and single-level fusion for spondylolisthesis: results from the NeuroPoint-SD registry: clinical article. J Neurosurg Spine2013;19:555–563
8. Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976)2014;39:3–16
11. Pinto RZ, Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ2012;344:e497–e497
12. Pearson A, Lurie J, Tosteson T, et al. Who should have surgery for an intervertebral disc herniation? Comparative effectiveness evidence from the Spine Patient Outcomes Research Trial. Spine2012;37:140–149
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Upper Trapezius
Lewit (1999) simplifies the need to assess for shortness by stating, �The upper trapezius should be treated if tender and taut.� Since this is an almost universal state in modern life, it seems that everyone requires MET application to this muscle. Lewit also notes that a characteristic mounding of the muscle can often be observed when it is very short, producing the effect of �Gothic shoulders�, similar to the architectural supports of a Gothic church tower (see Fig. 2.13).
Assessment for Shortness of Upper Trapezius (13) (Fig. 4.30)
Figure 4.30 Assessment of the relative shortness of the right side upper trapezius. One side is compared with the other (for both the range of unforced motion and the nature of the end-feel of motion) to ascertain the side most in need of MET attention.
Test for upper trapezius for shortness (a) See scapulohumeral rhythm test (Ch. 5) which helps identify excessive activity or inappropriate tone in levator scapula and upper trapezius, which, because they are postural muscles, indicates shortness (Fig 5.13A, B). Greenman (1996) describes a functional �firing sequence� assessment which identifies general imbalance and dysfunction involving the upper and lower fixators of the shoulder (Fig. 4.31).
Figure 4.31 Palpation assessment for upper and lower fixators of the shoulder, including upper trapezius (Greenman 1996).
The patient is seated and the practitioner stands behind. The practitioner rests his right hand over the right shoulder area to assess firing sequence of muscles. The other hand can be placed either on the mid-thoracic region, mainly on the side being assessed, or spanning the lower back to palpate quadratus firing. The assessment should be performed at least twice so that various hand positions are used for different muscles (as in Fig. 4.31).
Greenman bases his description on Janda (1983), who notes the �correct� sequence for shoulder abduction, when seated, as involving: supraspinatus, deltoid, infraspinatus, middle and lower trapezius and finally contralateral quadratus. In dysfunctional states the most common substitutions are said to involve: shoulder elevation by levator scapulae and upper trapezius, as well as early firing by quadratus lumborum, ipsilateral and contralateral.
Inappropriate activity of the upper fixators results in shortness, and of the lower fixators in weakness and possible lengthening (see Ch. 2 for discussion of postural/phasic, etc. muscle characteristics).
Test for upper trapezius for shortness (b) The patient is seated and the practitioner stands behind with one hand resting on the shoulder of the side to be tested and stabilising it. The other hand is placed on the ipsilateral side of the head and the head/neck is taken into contralateral sidebending without force while the shoulder is stabilised (see Fig. 4.30).
The same procedure is performed on the other side with the opposite shoulder stabilised. A comparison is made as to which sidebending manoeuvre produced the greater range and whether the neck can easily reach 45� of side-flexion in each direction, which it should. If neither side can achieve this degree of sidebend, then both trapezius muscles may be short. The relative shortness of one, compared with the other, is evaluated.
Test for upper trapezius for shortness (c) The patient is seated and the practitioner stands behind with a hand resting over the muscle on the side to be assessed. The patient is asked to extend the arm at the shoulder joint, bringing the flexed arm/elbow backwards. If the upper trapezius is stressed on that side it will inappropriately activate during this movement. Since it is a postural muscle, shortness in it can then be assumed (see discussion of postural muscle characteristics in Ch. 3).
Test of upper trapezius for shortness (d) The patient is supine with the neck fully (but not forcefully) sidebent contralaterally (away from the side being assessed). The practitioner is standing at the head of the table and uses a cupped hand contact on the ipsilateral shoulder (i.e. on the side being tested) to assess the ease with which it can be depressed (moved caudally) (Fig. 4.32).
Figure 4.32 MET treatment of right side upper trapezius muscle. A Posterior fibres, B middle fibres, C anterior fibres. Note that stretching in this (or any of the alternative positions which access the middle and posterior fibres) is achieved following the isometric contraction by means of an easing of the shoulder away from the stabilised head, with no force being applied to the neck and head itself.
There should be an easy �springing� sensation as the practitioner pushes the shoulder towards the feet, with a soft end-feel to the movement. If depression of the shoulder is difficult or if there is a harsh, sudden end-point, upper trapezius shortness is confirmed.
This same assessment (always with full lateral flexion) should be performed with the head fully rotated away from the side being treated, half turned away from the side being treated, and slightly turned towards the side being treated, in order to respectively assess the relative shortness and functional efficiency of posterior, middle and anterior subdivisions of the upper portion of trapezius.
MET Treatment of Chronically Shortened Upper Trapezius
MET treatment of upper trapezius, method (a) (Fig. 4.32) In order to treat all the fibres of upper trapezius, MET needs to be applied sequentially. The upper trapezius is subdivided here into anterior, middle and posterior fibres. The neck should be placed into different positions of rotation, coupled with the sidebending as described in the assessment description above, for precise treatment of the various fibres.
The patient lies supine, arm on the side to be treated lying alongside the trunk, head/neck sidebent away from the side being treated to just short of the restriction barrier, while the practitioner stabilises the shoulder with one hand and cups the ear/mastoid area of the same side of the head with the other:
With the neck fully sidebent and fully rotated contralaterally, the posterior fibres of upper trapezius are involved in the contraction (see below). This will facilitate subsequent stretching of this aspect of the muscle.
With the neck fully sidebent and half rotated, the middle fibres are involved in the contraction.
With the neck fully sidebent and slightly rotated towards the side being treated the anterior fibres of upper trapezius are being treated.
The various contractions and subsequent stretches can be performed with practitioner�s arms crossed, hands stabilising the mastoid area and shoulder.
The patient introduces a light resisted effort (20% of available strength) to take the stabilised shoulder towards the ear (a shrug movement) and the ear towards the shoulder. The double movement (or effort towards movement) is important in order to introduce a contraction of the muscle from both ends simultaneously. The degree of effort should be mild and no pain should be felt. The contraction is sustained for 10 seconds (or so) and, upon complete relaxation of effort, the practitioner gently eases the head/neck into an increased degree of sidebending and rotation, where it is stabilised, as the shoulder is stretched caudally.
When stretching is introduced the patient can usefully assist in this phase of the treatment by initiating, on instruction, the stretch of the muscle (�as you breathe out please slide your hand towards your feet�). This reduces the chances of a stretch reflex being initiated. Once the muscle is being stretched, the patient relaxes and the stretch is held for 10�30 seconds.
CAUTION: No stretch should be introduced from the cranial end of the muscle as this could stress the neck. The head is stabilised at its side-flexion and rotation barrier.
Disagreement
There is some disagreement as to the head/neck rotation position as described in the treatment method above, which calls (for posterior and middle fibres) for sidebending and rotation away from the affected side.
Liebenson (1996), suggests that the patient �lies supine with the head supported in anteflexion and laterally flexed away and rotated towards the side of involvement�.
Lewit (1985b) suggests: �The patient is supine � the therapist fixes the shoulder from above with one hand, sidebending the head and neck with the other hand so as to take up the slack. He then asks the patient to look towards the side away from which the head is bent, resisting the patient�s automatic tendency to move towards the side of the lesion.� (This method is described below.)
The author has used the methods described above with good effect and urges readers to try these approaches as well as those of Liebenson and Lewit, and to evaluate results for themselves.
MET treatment of acutely shortened upper trapezius, method (b) Lewit suggests the use of eye movements to facilitate initiation of PIR before stretching, an ideal method for acute problems in this region.
The patient is supine, while the practitioner fixes the shoulder and the sidebent (away from the treated side) head and neck at the restriction barrier and asks the patient to look, with the eyes only (i.e. not to turn the head), towards the side away from which the neck is bent.
This eye movement is maintained, as is a held breath, while the practitioner resists the slight isometric contraction that these two factors (eye movement and breath) will have created.
On exhalation and complete relaxation, the head/neck is taken to a new barrier and the process repeated. If the shoulder is brought into the equation, this is firmly held as it attempts to lightly push into a shrug. After this 10 second contraction the muscle will have released somewhat and slack can again be taken out as the head is repositioned before a repetition of the procedure commences.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
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Irritable bowel syndrome, or IBS, is a prevalent condition characterized by abdominal pain or discomfort, bloating, connected to altered stool form (such as diarrhea and constipation) as well as passage. Approximately 4 percent to 30 percent of individuals world-wide suffer from IBS. Small intestinal bacterial overgrowth, or SIBO, which was clinically demonstrated in patients with structural abnormalities in the gut, such as ileo-transverse anastomosis, stricture, fistula, slow motility and reduced gut defense, may also be characterized by abdominal pain or discomfort, bloating, flatulence and loose motion. It’s been recognized that SIBO may occur in the absence of structural abnormalities. These patients may be incorrectly diagnosed with IBS, or irritable bowel syndrome.
How common is SIBO diagnosed in IBS?
Small intestinal bacterial overgrowth has been described as the excessive presence of bacteria, forming 105 units per milliliter on culture of their intestine aspirate. As this is an invasive test, lots of noninvasive techniques like lactulose and glucose hydrogen breath tests (LHBT and GHBT) are broadly used to diagnose SIBO. This issue has been recognized among people with IBS. In a variety of research studies, frequency of SIBO among patients presenting IBS varied from 4 percent to 78 percent, according to Table ?1, more so among patients with diarrhea-predominant IBS. Not only quantitative increase (SIBO) but qualitative change from the gut bacteria (dysbiosis) was reported among patients with IBS. Research studies utilizing antibiotics and probiotics have caused disagreement to care for this disease with lately transplantation which led to a paradigm shift. Nonetheless, it’s essential to understand the wide-variability in frequency of SIBO among people with IBS. A wide-variability in frequency may indicate it is vital to evaluate the evidence carefully to determine whether the association between IBS and SIBO is under-projected in previous research studies.
The research studies are examined by people on discordance with the connection between IBS and SIBO as well as their strength and weakness, such as evidence on exploitation of gut flora on indications of IBS and other issues.
Assessment of Studies on SIBO in IBS
Table ?1 summarizes the outcomes among patients with IBS from research studies on individuals with SIBO. As can be noted in the table, the frequency of people with IBS and SIBO varied from 4 percent to 78 percent and from 1 percent and 40 percent among controls. Frequency of individuals with SIBO and IBS was greater than among controls. It might be concluded that SIBO is correlated with IBS. It’s essential to assess the explanations in various research studies.
Critical Evaluation of Studies on SIBO in IBS
Can IBS phenotype determine frequency of SIBO?
IBS is a state that’s heterogeneous. The sub-types may be diarrhea or constipation-predominant or may be alternating. Patients with diarrhea-predominant IBS have organic cause including SIBO compared to other types of IBS. In a study on 129 patients with non-diarrheal IBS, 73 with long-term diarrhea, for example diarrhea-predominant IBS, and 51 healthy controls, frequency of SIBO with GHBT was 11 (8.5 percent), 16 (22 percent) and 1 (2%), respectively. Similar findings are reported in various studies. Diarrheal IBS needs to be evaluated in comparison to other sorts of IBS for SIBO. Research studies that contained percentage of individuals are extremely likely to reveal frequency of SIBO.
Bloating is a symptom commonly reported among patients with IBS. Frequency of bloating has been reported to vary from Asia by 26 percent to 83 percent in research studies on IBS. The pathogenesis of bloating may be correlated with increased quantity of gas in the gut, its abnormal source and improved gut sense in response to distension of the gut. Patients with SIBO may have increased amount of gas inside the gut, so it’s plausible to believe IBS patients with bloating that is noticeable are expected to have SIBO. There is limited data with this specific circumstance. Evidence also demonstrated that both fasting along with post-substrate (e.g., sugar, lactulose) breath hydrogen is considerably higher compared to individuals with IBS compared to controls. Probiotics and antibiotics, which are demonstrated to reduce gas, are demonstrated to ease bloating. It has been noted that treatment can revert hydrogen breath tests back to normal. Patients with IBS, flatulence and bloating should be evaluated for SIBO. More data is involved with this issue.
Can techniques used to diagnose SIBO determine its frequency?
Several techniques are used to diagnose SIBO; including GHBT LHBT,14C breath test, and culture of aspirate. The principle of hydrogen breath tests is summarized in Figure 1. Dietary carbohydrates produce hydrogen in the gut. In patients with SIBO, the bacteria in the small bowel ferment these carbohydrates, producing hydrogen, which gets absorbed and is exhaled in the breath.
Figure 1
Hydrogen breath test involves giving patients a load of carbohydrate (generally in the sort of glucose and lactulose) and measuring expired hydrogen concentrations in a period of time. Identification of SIBO using hydrogen breath test depends upon the bodily principle of patients with SIBO, glucose may be fermented by bacteria in the intestine resulting in production of hydrogen gas that is consumed and exhaled in expired air (Figure ?1, A1). By contrast, lactulose, which may function as a non-absorbable disaccharide, will produce an early summit due to fermentation in the small intestine (normally within 90-min) or two summit (as a consequence of small intestine fermentation and minute from colon), if SIBO is present (Figure ?1, B2 and B3). There are limits in hydrogen breath test for identification of SIBO. There may be similarities in patients with problems and SIBO employing rapid transit making differentiation difficult. An ancient summit can be positive in people with gut transit time. By way of instance, in a study from India, median oro-cecal transit interval was 65 minutes (variety 40-110 moments) in healthy subjects. In another study from Taiwan, mean transit interval was 85 min. It’s been substantiated in Western individuals recently by simultaneously using LHBT and radio-nuclide method to gauge gut transport. Double summit standards for evaluation of SIBO using LHBT is quite insensitive. Sensitivity of GHBT to diagnose SIBO is 44 percent contemplating the culture of gut aspirate as a regular standard. As a result, it’s estimated that the researchers who used a historic summit standards in LHBT could discover a greater frequency of SIBO among people with IBS along with controls. In contrast, those who would use either GHBT or double summit benchmark in LHBT might locate a minimum frequency of SIBO alike in patients with IBS and controls. It is well worth noting from Table ?1 that the frequency of SIBO among people with IBS and controls on LHBT (early summit standards) varied from 34.5 percent to 78 percent and 7 percent to 40 percent, respectively; in contrast with the frequency GHBT varied from 8.5 percent to 46 percent and 2 percent to 18percent.
Fifteen percent of people might have methanogenic flora in the gut. Methanobrevibacter smithii, Methanobrevibacter stadmanae and perhaps several of those coliform bacteria are methanogens. In these areas, only hydrogen breath tests may not diagnose SIBO, estimation of methane may also be demanded (Figure ?1). Table ?1 shows that 8.5 percent to 26 percent of IBS sufferers and 0 percent to 25 percent of controls exhaled methane inside their breath. Whether methane was not expected in them, SIBO could not have been diagnosed. Methane was not estimated, which could have resulted in underestimation of frequency of SIBO as outlined in a proportion of the research study. Methane production in excess is connected to constipation. Consequently, methane estimation in breath, which is inaccessible in several commercially available hydrogen breath test machines, is particularly vital in patients employing constipation-predominant IBS. Some could have slow transit through the small intestine making prolonged testing as a lot of hours required and many people may not want to undergo such testing. However, a period of testing for them may overlook SIBO’s identification.
The jejunal aspirate culture has traditionally been used as the gold standard to diagnose SIBO, according to Figure ?2. On the other hand, the limitations of this test include invasiveness in addition to the challenges posed by attempting to civilization all strains and species. In fact, usage of air during endoscopy might lead to a false negative impact as anaerobes do not rise when these are exposed to oxygen. Furthermore, a massive percentage of germs are not cultured. By contrast, single lumen catheter passed through the nose or through the biopsy channel of endoscope, may lead to contamination with oro-pharyngeal flora supplying false positive result. Therefore, we left a double-lumen catheter to prevent these oro-pharyngeal contamination (Figure ?2). Studies on SIBO one of patients with IBS using qualitative civilization of small bowel aspirate are scanty (Table ?1). A study by Posserud et al reported that a frequency of SIBO of 4 percent among people with IBS. Taking the result of study using GHBT, the sensitivity of 44 percent to diagnose the intestine aspirate appears to have the incidence of SIBO . More studies are essential on this issue.
Figure 2
Figure 3
13C and�14C based tests have also been developed based on the bacterial metabolism of D-xylose (Figure ?3). Of acids containing13C and�14C may be used to diagnose SIBO. The glycocholic acid breath test contains the managing of the bile acid14C glycocholic acid, as well as the discovery of14CO2, which may be increased in SIBO (Figure 3), according to the clinical and experimental data from the various research studies on SIBO associated with IBS. While evidence may appear conclusive, further research studies may be required to properly determine the results.
Information referenced from the National Center for Biotechnology Information (NCBI) and the National University of Health Sciences. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
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These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Pectoralis Major and Latissimus Dorsi
Assessment of Shortened Pectoralis Major and Latissimus Dorsi
Latissimus and pectoral test (a) Observation is as accurate as most palpation for evidence of pectoralis major shortening. The patient will have a rounded shoulder posture � especially if the clavicular aspect is involved.
Or
The patient lies supine with upper arms on the table, hands resting palm down on the lower abdomen. The practitioner observes from the head and notes whether either shoulder is held in an anterior position in relation to the thoracic cage. If one or both shoulders are forward of the thorax, pectoralis muscles are short (Fig. 4.24).
Figure 4.24 Observation assessment in which pectoral shortness on the right is suggested by the inability of the shoulder to rest on the table.
Latissimus and pectoral test (b) The patient lies supine with the head several feet from the top edge of the table, and is asked to rest the arms, extended above the head, on the treatment surface, palms upwards (Fig. 4.25).
Figure 4.25 Assessment of shortness in pectoralis major and latissimus dorsi. Visual assessment is used: if the arm on the tested side is unable to rest along its full length, shortness of pectoralis major is probable; if there is obvious deviation of the elbow laterally, probable latissimus shortening is indicated.
If these muscles are normal, the arms should be able to easily reach the horizontal when directly above the shoulders, and also to be in contact with the surface for almost all of the length of the upper arms, with no arching of the back or twisting of the thorax.
If either arm cannot reach the vertical above the shoulder, but is held laterally, elbow pulled outwards, then latissimus dorsi is probably short on that side. If an arm cannot rest with the dorsum of the upper arm in contact with the table surface without effort, then pectoral fibres are almost certainly short.
Pectoralis major test. Assessment of shortness in pectoralis major (Fig. 4.26) Assessment of the subclavicular portion of pectoralis major involves abduction of the arm to 90� (Lewit 1985b). In this position the tendon of pectoralis major at the sternum should not be found to be unduly tense, even with maximum abduction of the arm, unless the muscle is short.
Figure 4.26 Palpation assessment for shortness of subclavicular portion of pectoralis major.
For assessment of sternal attachment the arm is brought into elevation and abduction as the muscle, as well as the tendon on the greater tubercle of the humerus, is palpated. If the sternal fibres have shortened, tautness will be visible and tenderness of the tissues under palpation will be reported.
Pectoralis Major Test: Assessment for Strength of Pectoralis Major
Patient is supine with arm in abduction at the shoulder joint and medially rotated (palm is facing down) with the elbow extended. The practitioner stands at the head and secures the opposite shoulder with one hand to prevent any trunk torsion and contacts the dorsum of the distal humerus, on the tested side, with the other.
The patient attempts to lift the arm and to adduct it across the chest, against resistance, as strength is assessed in the sternal fibres.
Different arm positions can be used to assess clavicular and costal fibres: for example with an angle of abduction/elevation of 135� costal and abdominal fibres will be involved; with abduction/elevation of 45� the clavicular fibres will be assessed. The practitioner should palpate to ensure that the �correct� fibres contract when assessments are being made.
If this postural muscle tests as weak it may be useful to use Norris�s (1999) approach of strengthening it by means of a slowly applied isotonic eccentric (isolytic) contraction, before proceeding to an MET stretching procedure.
MET Treatment of Short Pectoralis Major
Pectoralis major MET method (a) (Fig. 4.27A, B) The patient lies supine with the arm abducted in a direction which produces the most marked evidence of pectoral shortness (assessed by palpation and visual evidence of the particular fibres involved as described in tests above). The more elevated the arm (i.e. the closer to the head), the more focus there will be on costal and abdominal fibres. With a lesser degree of abduction (to around 45�), the focus is more on the clavicular fibres. Between these two extremes lies the position which influences the sternal fibres most directly.
Figure 4.27A MET treatment of pectoral muscle � abdominal attachment. Note that the fibres being treated are those which lie in line with the long axis of the humerus.
Figure 4.27B An alternative hold for application of MET to pectoral muscle � sternal attachment. Note that the patient needs to be close to the edge of the table in order to allow the arm to be taken towards the floor once the slack has been removed, during the stretching phase after the isometric contraction.
The patient lies as close to the side of the table as possible so that the abducted arm can be brought below the horizontal level in order to apply gravitational pull and passive stretch to the fibres, as appropriate. The practitioner stands on the side to be treated and grasps the humerus.
A useful arm hold, which depends upon the relative size of the patient and the practitioner, involves the practitioner grasping the anterior aspect of the patient�s flexed upper arm just above the elbow, while the patient cups the practitioner�s elbow and holds this contact throughout the procedure (see Fig. 4.27B).
The patient�s hand is placed on the contact (attachments of shortened fibres) area on the thorax so that the hand acts as a �cushion�. This is both more physically comfortable and also prevents physical contact with emotionally sensitive areas such as breast tissue. The practitioner�s thenar or hyperthenar eminence is placed over the patient�s �cushion� hand in order to stabilise the area during the contraction and stretch, preventing movement of it.
Commencing with the patient�s arm in a position which takes the affected fibres to just short of their restriction barrier (for a chronic problem), the patient introduces a light contraction (20% of strength) involving adduction against resistance from the practitioner, for 7�10 seconds.
As a rule the long axis of the patient�s upper arm should be in a straight line with the fibres being treated. If a trigger point has previously been identified in pectoralis, the practitioner should ensure � by means of palpation if necessary, or by observation � that the fibres housing the triggers are involved in the contraction.
As the patient exhales following complete relaxation of the area, a stretch through the new barrier is activated by the patient and maintained by the practitioner. Stretch is achieved via the positioning and leverage of the arm as the contact hand on the thorax acts as a stabilising point only.
The stretch needs to be one in which the arm is first pulled away (distracted) from the thorax, with the patient�s assistance (�ease your arm away from your shoulder�), before the stretch is introduced which involves the humerus being taken below the horizontal (�ease your arm towards the floor�).
During the stretching phase it is important for the entire thorax to be stabilised. No rolling or twisting of the thorax in the direction of the stretch should be permitted. The stretching procedure should be thought of as having two phases: first the slack being removed by distracting the arm away from the contact/stabilising hand on the thorax; second, movement of the arm towards the floor, initiated by the practitioner bending his knees.
Stretching (after an isometric contraction) should be repeated two or three times in each position. All attachments should be treated, which calls for the use of different arm positions, as discussed above, each with different stabilising (�cushion�) contacts as the various fibre directions and attachments are isolated.
Pectoralis major MET method (b) (Fig. 4.28) The patient is prone with face in a face hole or cradle. Her right arm is abducted to 90� and the elbow flexed to 90� palm towards the floor, with the upper arm supported by the table. The practitioner stands at waist level, facing cephalad, and places his non-table-side hand palm to palm with the patient�s so that the patient�s forearm is in contact with the ventral surface of the practitioner�s forearm. The practitioner�s table-side hand rests on the patient�s right scapula area, ensuring that no trunk rotation occurs.
Figure 4.28 MET for pectoralis major in prone position.
The practitioner eases the patient�s arm into extension at the shoulder until he senses the first sign of resistance from pectoralis. It is important when extending the arm in this way to ensure that no trunk rotation occurs and that the anterior surface of the shoulder remains in contact with the table throughout.
The patient is asked, using no more than 20% of strength, to bring her arm towards the floor and across her chest, with the elbow taking the lead in this attempted movement, which is completely resisted by the practitioner. The practitioner ensures that the patient�s arm remains parallel with the floor throughout the isometric contraction.
Following release of the contraction effort, and on an exhalation, the arm is taken into greater extension, with the patient�s assistance, and held at stretch for not less than 20 seconds.
This procedure is repeated two or three times, slackening the muscle slightly from its end-range before each subsequent contraction to reduce discomfort and for ease of application of the contraction.
Variations in pectoralis fibre involvement can be achieved by altering the angle of abduction � with a more superior angle (around 140�) the lower sternal and costal fibres, and with a lesser angle (around 45�) the clavicular fibres will be committed.
Pectoralis major MET method (c) Bilateral MET stretching of pectoralis major (sternocostal aspects) involves having the patient supine, knees and hips flexed, in order to provide stability to the spinal regions, preventing lumbar lordosis. A shallow but firm cushion should be placed between the scapulae, allowing a better excursion of the shoulders during this stretch. The chin should be tucked in and, if more comfortable, a small cushion placed under the neck. Ideally a strap/belt should be used to fix the thorax to the table, but this is not essential.
The practitioner stands at the head of the table and grasps the patient�s elbows or forearms, which are flexed, laterally rotated and held in a position to induce the most taut aspects of the muscles to become prominent.
Starting from such a barrier or short of it (acute/chronic), the patient is asked to contract the muscles by bringing the arms upwards and towards the table for 10 seconds or so during a held breath.
Following the contraction and complete relaxation, the arms are taken to a new or through the restriction barrier, as appropriate, during an exhalation. Repeat as necessary several times more.
Pectoralis major MET method (d) By adopting the same positions � but with the arms of the patient more laterally placed so that they are laterally rotated and in 90� abduction from the shoulder (upper arms are straight out sideways from the shoulder) and there is 90� flexion at the elbows, with the practitioner contacting the area just proximal to the flexed elbows � a more direct stretch of the clavicular insertions of the muscle can be achieved, using all the same contraction and stretch elements as in (b) above.
Latissimus Dorsi Test for Shortness
To screen latissimus dorsi (12), the standing patient is asked to bend forwards and allow the arms to hang freely from the shoulders as she holds a half-bend position, trunk parallel with the floor.
If the arms are hanging other than perpendicular to the floor there is probably some muscular restriction involved, and if this involves latissimus the arms will be held closer to the legs than perpendicular (if they hang markedly forward of such a position then trapezius shortening is probable, see below).
To screen latissimus in this position, one side at a time, the practitioner stands in front of the patient (who remains in this half-bend position) and, stabilising the scapula area with one hand, grasps the arm at elbow level and gently draws the tested side (straight) arm forwards. It should, without undue effort or excessive bind in the tissues being held, allow itself to be taken to a position where the elbow is higher than the level of the back of the head. If this is not possible, then latissimus is short.
MET Treatment of Short Latissimus Dorsi
Short latissimus dorsi MET method (a) The patient lies supine with the feet crossed (the side to be treated crossed under the non-treated side leg at the ankle). The patient is arranged in a light sidebend away from the side to be treated so that the pelvis is towards that side, and the feet and head away from that side. The heels are placed just off the edge of the table, so anchoring the lower extremities.
The patient places her arm on the side to be treated behind her neck, as the practitioner, standing on the side opposite that to be treated, slides his cephalad hand under the patient�s shoulders to grasp the treated side axilla. The patient grasps the practitioner�s cephalad arm at the elbow, making this contact more secure. The patients treated side elbow should point superiorly. The practitioner�s caudad hand is placed on the anterior superior iliac spine on the side being treated.
The patient is instructed to very lightly take the pointed elbow towards the sacrum and also to lightly try to bend backwards and towards the treated side. This should produce a light isometric contraction in latissimus dorsi on the side to be treated. After 7 seconds they are asked to relax completely as the practitioner transfers his body weight from the cephalad leg to the caudad leg, to sidebend the patient. Simultaneously the practitioner stands more erect and leans in a caudad direction.
This effectively lifts the patient�s thorax from the table surface and introduces a stretch into latissimus (especially if the patient has maintained a grasp on the practitioner�s elbow and the practitioner has a firm hold on the patient�s axilla).
This stretch is held for 15�30 seconds allowing a lengthening of shortened musculature in the region. (Note: starting position is as for Fig. 4.22.) Repeat as necessary.
Short latissimus dorsi MET method (b) The patient is side-lying, affected side up. The arm is taken into abduction to the point of resistance, so that it is possible to visualise, or palpate, the insertion of the shortened fibres on the lateral chest wall.
The condition is treated in either the acute or chronic mode of MET, at or short of the barrier, as appropriate.
As shown in Figure 4.29, the practitioner stands near the head of the patient, slightly behind, and holds the upper arm in the chosen position while applying the other hand to stabilise the posterior thorax area, or the pelvic crest, from where the stretch will be made.
Figure 4.29 Treatment of latissimus dorsi. A variety of different positions are required for the stabilising hand (on the chest wall as well as on the crest of the pelvis) to allow for precise application of stretches of fibres with different attachments, following the sequence of isometric contractions.
A build-up of tension should be palpated under the stabilising hand as the patient introduces an isometric contraction by attempting to bring the arm towards the ceiling, backwards and down (towards their own lower spine) against firm resistance, using only a modest amount of effort (20%) and holding the breath if appropriate (see notes on breathing, Box 4.2).
After 7�10 seconds, both the effort and breath are released and the patient relaxes completely, at which time the practitioner introduces stretch to or through the barrier (acute/chronic), bringing the humerus into greater adduction while applying a stretching/stabilising contact on the trunk (with separate contractions and stretches for each contact) anywhere between the lateral chest wall and the crest of the pelvis.
A downward movement of the humerus, towards the floor, assists the stretch following a separation of the practitioner�s two contact hands to remove all slack. As in the stretch of pectoralis major, there should be two phases � a distraction, taking out the slack, and a movement towards the floor of the practitioner, by flexing the knees � to induce a safe stretch. Repeat as necessary.
Ultimately, it should be possible to achieve complete elevation of the arm without stress or obvious shortness in latissimus fibres so that the upper arm can rest alongside the ear of the supine patient.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Quadratus Lumborum
Assessment of Shortness in Quadratus Lumborum (Figure 4.21)
Figure 4.21 Palpation assessment for quadratus lumborum overactivity. The muscle is palpated, as is gluteus medius, during abduction of the leg. The correct firing sequence should be gluteus, followed at around 25� elevation by quadratus. If there is an immediate �grabbing� action by quadratus it indicates overactivity, and therefore stress, so shortness can be assumed (see details of similar functional assessments in Ch. 5).
Review Lewit�s functional palpation test described under the heading assessment and treatment of tensor fascia lata.
When the leg of the side-lying patient is abducted, and the practitioner�s palpating hand senses that quadratus becomes involved in this process before the leg has reached at least 25� of elevation, then it is clear that quadratus is overactive. If it has been overactive for any length of time then it is almost certainly hypertonic and short, and a need for MET can be assumed.
Quadratus lumborum test (a) (See also Fig. 5.11A, B.) The patient is side-lying and is asked to take the upper arm over the head to grasp the top edge of the table, �opening out� the lumbar area. The practitioner stands facing the back of the patient, and has easy access for palpation of quadratus lumborum�s lateral border � a major trigger point site (Travell & Simons 1992) � with the cephalad hand.
Activity of quadratus is tested (palpated for) with the cephalad hand as the leg is abducted, while also palpating gluteus medius with the caudad hand. If the muscles act simultaneously, or if quadratus fires first, then it is stressed, probably short, and will benefit from stretching.
Quadratus lumborum test (b) The patient stands, back towards crouching practitioner. Any leg length disparity (based on pelvic crest height) is equalised by using a book or pad under the short leg side heel. With the patient�s feet shoulder-width apart, a pure sidebending is requested, so that the patient runs a hand down the lateral thigh/calf. (Normal level of sidebending excursion allows the fingertips to reach to just below the knee.) (See Fig. 3.2A, B, C.)
The side to which the fingertips travel furthest is assessed. If sidebending to one side is limited then quadratus on the opposite side is probably short. Combined evidence from palpation (test a) and this sidebending test indicate whether or not it is necessary to treat quadratus.
Box 4.8 Notes on Quadratus Lumborum
Norris (2000) describes the divided roles in which quadratus is involved: The quadratus lumborum has been shown to be significant as a stabiliser in lumbar spine movements (McGill et al 1996) while tightening has also been described (Janda 1983). It seems likely that the muscle may act functionally differently in its medial and lateral portions, with the medial portion being more active as a stabiliser of the lumbar spine, and the lateral more active as a mobiliser [see stabiliser/mobiliser discussion Ch. 2]. Such subdivision is seen in a number of other muscles for example the gluteus medius where the posterior fibres are more posturally involved (Jull 1994) the internal oblique where the posterior fibres attaching to the lateral raphe are considered stabilisers (Bergmark 1989) the external oblique where the lateral fibres work during flexion in parallel with the rectus abdominis (Kendall et al 1993).
Janda (1983) observes that, when the patient is sidebending (as in method (b)) �when the lumbar spine appears straight, with compensatory motion occurring only from the thoracolumbar region upwards, tightness of quadratus lumborum may be suspected�. This �whole lumbar spine� involvement differs from a segmental restriction which would probably involve only a part of the lumbar spine.
Quadratus fibres merge with the diaphragm (as do those of psoas), which makes involvement in respiratory dysfunction a possibility since it plays a role in exhalation, both via this merging and by its attachment to the 12th rib.
Shortness of quadratus, or the presence of trigger points, can result in pain in the lower ribs and along the iliac crest if the lateral fibres are affected. Shortness of the medial fibres, or the presence of trigger points, can produce pain in the sacroiliac joint and the buttock.
Bilateral contraction produces extension and unilateral contraction produces extension and sidebending to the same side.
The important transition region, the lumbodorsal junction (LDJ), is the only one in the spine in which two mobile structures meet, and dysfunction results in alteration of the quality of motion between these structures (upper and lower trunk/dorsal and lumbar spines). In dysfunction there is often a degree of spasm or tightness in the muscles which stabilise the region, notably: psoas and erector spinae of the thoracolumbar region, as well as quadratus lumborum and rectus abdominis.
Symptomatic differential diagnosis of muscle involvement at the LDJ is possible as follows: psoas involvement usually triggers abdominal pain if severe and produces flexion of the hip and the typical antalgesic posture of lumbago; erector spinae involvement produces low back pain at its caudad end of attachment and interscapular pain at its thoracic attachment (as far up as the mid-thoracic level); quadratus lumborum involvement causes lumbar pain and pain at the attachment of the iliac crest and lower ribs; and rectus abdominis contraction may mimic abdominal pain and result in pain at the attachments at the pubic symphysis and the xiphoid process, as well as forwardbending of the trunk and restricted ability to extend the spine.
There is seldom pain at the site of the lesion in LDJ dysfunction. Lewit (1992) points out that even if a number of these muscles are implicated, it is seldom necessary, using PIR methods, to treat them all since, as the muscles most involved (discovered by tests for shortness, overactivity, sensitivity and direct palpation) are stretched and normalised, so will others begin automatically to normalise.
MET for Shortness in Quadratus Lumborum (�banana�)
Quadratus lumborum MET method (a) (Fig. 4.22) The patient lies supine with the feet crossed (the side to be treated crossed under the non-treated side leg) at the ankle. The patient is arranged in a light sidebend, away from the side to be treated, so that the pelvis is towards that side, and the feet and head away from that side (�banana shaped�). As this sidebend is being achieved the affected quadratus can be palpated for bind so that the barrier is correctly identified.
Figure 4.22 MET treatment of quadratus lumborum utilising �banana� position.
The patient�s heels are placed just off the side of the table, anchoring the lower extremities and pelvis. The patient places the arm of the side to be treated behind her neck as the practitioner, standing on the side opposite that to be treated, slides his cephalad hand under the patient�s shoulders to grasp the treated side axilla. The patient grasps the practitioner�s cephalad arm at the elbow, with the treated side hand, making the contact more secure.
The patient�s treated side elbow should, at this stage, be pointing superiorly. The practitioner�s caudad hand is placed firmly but carefully on the anterior superior iliac spine, on the side to be treated. The patient is instructed to very lightly sidebend towards the treated side. This should produce an isometric contraction in quadratus lumborum on the side to be treated.
After 7 seconds the patient is asked to relax completely, and then to sidebend towards the nontreated side, as the practitioner simultaneously transfers his bodyweight from the cephalad leg to the caudad leg and leans backwards slightly, in order to sidebend the patient. This effectively stretches quadratus lumborum. The stretch is held for 15�20 seconds, allowing a lengthening of shortened musculature in the region. Repeat as necessary.
Quadratus lumborum MET method (b) (Fig 4.23) The practitioner stands behind the side-lying patient, at waist level. The patient has the uppermost arm extended over the head to firmly grasp the top end of the table and, on an inhalation, abducts the uppermost leg until the practitioner palpates strong quadratus activity (elevation of around 30� usually).
Figure 4.23 MET treatment of quadratus lumborum. Note that it is important after the isometric contraction (sustained raised/abducted leg) that the muscle be eased into stretch, avoiding any defensive or protective resistance which sudden movement might produce. For this reason, body weight rather than arm strength should be used to apply traction.
The patient holds the leg (and, if appropriate, the breath, see Box 4.2) isometrically in this manner, allowing gravity to provide resistance. After the 10-second (or so) contraction, the patient allows the leg to hang slightly behind him over the back of the table. The practitioner straddles this and, cradling the pelvis with both hands (fingers interlocked over crest of pelvis), leans back to take out all slack and to �ease the pelvis away from the lower ribs� during an exhalation.
The stretch should be held for between 10 and 30 seconds. (The method will only be successful if the patient is grasping the top edge of the table, so providing a fixed point from which the practitioner can induce stretch.)
Contraction followed by stretch is repeated once or twice more with raised leg in front of, and once or twice with raised leg behind the trunk in order to activate different fibres. The direction of stretch should be varied so that it is always in the same direction as the long axis of the abducted leg. This calls for the practitioner changing from the back to the front of the table for the best results. When the leg hangs to the back of the trunk the long fibres of the muscle are mainly affected; and when the leg hangs forward of the body the diagonal fibres are mainly involved.
Quadratus lumborum MET method (c) Gravity-induced postisometric relaxation of quadratus lumborum � self-treatment (See Fig. 3.2A�C and captions) The patient stands, legs apart, bending sideways. The patient inhales and slightly raises the trunk (a few centimetres) at the same time as looking (with the eyes only) away from the side to which side-flexion is taking place. On exhalation, the sidebend is allowed to slowly go further to its elastic limit, while the patient looks towards the floor, in the direction of the side-flexion. (Care is needed that very little, if any, forward or backward bending is taking place at this time.) This sequence is repeated a number of times.
Eye positions influence the tendency to flex and sidebend (eyes look down) and extend (eyes look up) (Lewit 1999). Gravity-induced stretches of this sort require holding the stretch position for at least as long as the contraction, and ideally longer. More repetitions may be needed with a large muscle such as quadratus, and home stretches should be advised several times daily. Quadratus lumborum MET method (d) The side-lying treatment of latissimus dorsi described below also provides an effective quadratus stretch when the stabilising hand rests on the pelvic crest (see Fig. 4.29).
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Piriformis
Assessment of Shortened Piriformis
Test (a) Stretch test. When short, piriformis will cause the affected side leg of the supine patient to appear to be short and externally rotated. With the patient supine, the tested leg is placed into flexion at the hip and knee so that the foot rests on the table lateral to the contralateral knee (the tested leg is crossed over the straight non-tested leg, in other words as shown in Fig. 4.17). The angle of hip flexion should not exceed 60� (see notes on piriformis in Box 4.6).
Figure 4.17 MET treatment of piriformis muscle with patient supine. The pelvis must be maintained in a stable position as the knee (right in this example) is adducted to stretch piriformis following an isometric contraction.
The non-tested side ASIS is stabilised to prevent pelvic motion during the test and the knee of the tested side is pushed into adduction to place a stretch on piriformis. If there is a short piriformis the degree of adduction will be limited and the patient will report discomfort behind the trochanter.
Test (b) Palpation test (Fig. 4.18) The patient is side-lying, tested side uppermost. The practitioner stands at the level of the pelvis in front of and facing the patient, and, in order to contact the insertion of piriformis, draws imaginary lines between:
ASIS and ischial tuberosity, and
PSIS and the most prominent point of trochanter.
Where these reference lines cross, just posterior to the trochanter, is the insertion of the muscle, and pressure here will produce marked discomfort if the structure is short or irritated.
Figure 4.18 Using bony landmarks as coordinates the commonest tender areas are located in piriformis, in the belly and at the attachment of the muscle.
If the most common trigger point site in the belly of the muscle is sought, then the line from the ASIS should be taken to the tip of the coccyx rather than to the ischial tuberosity. Pressure where this line crosses the other will access the mid-point of the belly of piriformis where triggers are common. Light compression here which produces a painful response is indicative of a stressed muscle and possibly an active myofascial trigger point.
Piriformis Strength Test
The patient lies prone, both knees flexed to 90�, with practitioner at foot of table grasping lower legs at the limit of their separation (which internally rotates the hip and therefore allows comparison of range of movement permitted by shortened external rotators such as the piriformis).
The patient attempts to bring the ankles together as the practitioner assesses the relative strength of the two legs. Mitchell et al (1979) suggest that if there is relative shortness (as evidenced by the lower leg not being able to travel as far from the mid-line as its pair in this position), and if that same side also tests strong, then MET is called for. If there is shortness but also weakness then the reasons for the weakness need to be dealt with prior to stretching using MET.
Box 4.6 Notes on Piriformis
Piriformis paradox. The performance of external rotation of the hip by piriformis occurs when the angle of hip flexion is 60� or less. Once the angle of hip flexion is greater than 60� piriformis function changes, so that it becomes an internal rotator of the hip (Gluck & Liebenson 1997, Lehmkuhl & Smith 1983). The implications of this are illustrated in Figures 4.17 and 4.19.
This postural muscle, like all others which have a predominence of type l fibres, will shorten if stressed. In the case of piriformis, the effect of shortening is to increase its diameter and because of its location this allows for direct pressure to be exerted on the sciatic nerve, which passes under it in 80% of people. In the other 20% the nerve passes through the muscle so that contraction will produce veritable strangulation of the sciatic nerve.
In addition, the pudendal nerve and the blood vessels of the internal iliac artery, as well as common perineal nerves, posterior femoral cutaneous nerve and nerves of the hip rotators, can all be affected.
If there is sciatic pain associated with piriformis shortness, then on straight leg raising, which reproduces the pain, external rotation of the hip should relieve it, since this slackens piriformis. (This clue may, however, only apply to any degree if the individual is one of those in whom the nerve actually passes through the muscle.)
The effects can be circulatory, neurological and functional, inducing pain and paraesthesia of the affected limb as well as alterations to pelvic and lumbar function. Diagnosis usually hinges on the absence of spinal causative factors and the distributions of symptoms from the sacrum to the hip joint, over the gluteal region and down to the popliteal space. Palpation of the affected piriformis tendon, near the head of the trochanter, will elicit pain and the affected leg will probably be externally rotated.
The piriformis muscle syndrome is frequently characterised by such bizarre symptoms that they may seem unrelated. One characteristic complaint is a persistent, severe, radiating low back pain extending from the sacrum to the hip joint, over the gluteal region and the posterior portion of the upper leg, to the popliteal space. In the most severe cases the patient will be unable to lie or stand comfortably, and changes in position will not relieve the pain. Intense pain will occur when the patient sits or squats since this type of movement requires external rotation of the upper leg and flexion at the knee.
Compression of the pudendal nerve and blood vessels which pass through the greater sciatic foramen and re-enter the pelvis via the lesser sciatic foramen is possible because of piriformis contracture. Any compression would result in impaired circulation to the genitalia in both sexes. Since external rotation of the hips is required for coitus by women, pain noted during this act could relate to impaired circulation induced by piriformis dysfunction. This could also be a basis for impotency in men. (See also Box 4.7.)
Piriformis involvement often relates to a pattern of pain which includes: pain near the trochanter; pain in the inguinal area; local tenderness over the insertion behind trochanter; SI joint pain on the opposite side; externally rotated foot on the same side; pain unrelieved by most positions with standing and walking being the easiest; limitation of internal rotation of the leg which produces pain near the hip; and a short leg on the affected side.
The pain itself will be persistent and radiating, covering anywhere from the sacrum to the buttock, hip and leg including inguinal and perineal areas.
Bourdillon (1982) suggests that piriformis syndrome and SI joint dysfunction are intimately connected and that recurrent SI problems will not stabilise until hypertonic piriformis is corrected.
Janda (1996) points to the vast amount of pelvic organ dysfunction to which piriformis can contribute due to its relationship with circulation to the area.
Mitchell et al (1979) suggest that (as in psoas example above) piriformis shortness should only be treated if it is tested to be short and stronger than its pair. If it is short and weak (see p. 110 for strength test), then whatever is hypertonic and influencing it should be released and stretched first (Mitchell et al 1979). When it tests strong and short, piriformis should receive MET treatment.
Since piriformis is an external rotator of the hip it can be inhibited (made to test weak) if an internal rotator such as TFL is hypertonic or if its pair is hypertonic, since one piriformis will inhibit the other.
Box 4.7 Notes on Working and Resting Muscles
Richard (1978) reminds us that a working muscle will mobilise up to 10 times the quantity of blood mobilised by a resting muscle. He points out the link between pelvic circulation and lumbar, ischiatic and gluteal arteries and the chance this allows to engineer the involvement of 2400 square metres of capillaries by using repetitive pumping of these muscles (including piriformis).
The therapeutic use of this knowledge involves the patient being asked to repetitively contract both piriformis muscles against resistance. The patient is supine, knees bent, feet on the table; the practitioner resists their effort to abduct their flexed knees, using pulsed muscle energy approach (Ruddy�s method) in which two isometrically resisted pulsation/contractions per second are introduced for as long as possible (a minute seems a long time doing this).
Figure 4.19 MET treatment of piriformis with hip fully flexed and externally rotated (see Box 4.6, first bullet point).
Figure 4.20 A combined ischaemic compression (elbow pressure) and MET side-lying treatment of piriformis. The pressure is alternated with isometric contractions/stretching of the muscle until no further gain is achieved.
MET Treatment of Piriformis
Piriformis method (a) Side-lying The patient is side-lying, close to the edge of the table, affected side uppermost, both legs flexed at hip and knee. The practitioner stands facing the patient at hip level.
The practitioner places his cephalad elbow tip gently over the point behind trochanter, where piriformis inserts. The patient should be close enough to the edge of the table for the practitioner to stabilise the pelvis against his trunk (Fig. 4.20). At the same time, the practitioner�s caudad hand grasps the ankle and uses this to bring the upper leg/hip into internal rotation, taking out all the slack in piriformis.
A degree of inhibitory pressure (sufficient to cause discomfort but not pain) is applied via the elbow for 5�7 seconds while the muscle is kept at a reasonable but not excessive degree of stretch. The practitioner maintains contact on the point, but eases pressure, and asks the patient to introduce an isometric contraction (25% of strength for 5�7 seconds) to piriformis by bringing the lower leg towards the table against resistance. (The same acute and chronic rules as discussed previously are employed, together with cooperative breathing if appropriate, see Box 4.2.)
After the contraction ceases and the patient relaxes, the lower limb is taken to its new resistance barrier and elbow pressure is reapplied. This process is repeated until no further gain is achieved.
Piriformis method (b)1 This method is a variation on the method advocated by TePoorten (1960) which calls for longer and heavier compression, and no intermediate isometric contractions.
In the first stage of TePoorten�s method the patient lies on the non-affected side with knees flexed and hip joints flexed to 90�.The practitioner places his elbow on the piriformis musculotendinous junction and a steady pressure of 20�30 lb (9�13 kg) is applied. With his other hand he abducts the foot so that it will force an internal rotation of the upper leg.
The leg is held in this rotated position for periods of up to 2 minutes. This procedure is repeated two or three times. The patient is then placed in the supine position and the affected leg is tested for freedom of both external and internal rotation.
Piriformis method (b)2 The second stage of TePoorten�s treatment is performed with the patient supine with both legs extended. The foot of the affected leg is grasped and the leg is flexed at both the knee and the hip. As knee and hip flexion is performed the practitioner turns the foot inward, so inducing an external rotation of the upper leg. The practitioner then extends the knee, and simultaneously turns the foot outward, resulting in an internal rotation of the upper leg.
During these procedures the patient is instructed to partially resist the movements introduced by the practitioner (i.e. the procedure becomes an isokinetic activity). This treatment method, repeated two or three times, serves to relieve the contracture of the muscles of external and internal hip rotation.
Piriformis method (c) A series of MET isometric contractions and stretches can be applied with the patient prone and the affected side knee flexed. The hip is rotated internally by the practitioner using the foot as a lever to ease it laterally, so putting piriformis at stretch. Acute and chronic guidelines described earlier are used to determine the appropriate starting point for the contraction (at the barrier for acute and short of it for chronic).
The patient attempts to lightly bring the heel back towards the midline against resistance (avoiding strong contractions to avoid knee strain in this position) and this is held for 7�10 seconds. After release of the contraction the hip is rotated further to move piriformis to or through the barrier, as appropriate. Application of inhibitory pressure to the attachment or belly of piriformis is possible via thumb, if deemed necessary.
Piriformis method (d) A general approach which balances muscles of the region, as well as the pelvic diaphragm, is achieved by having the patient squat while the practitioner stands and stabilises both shoulders, preventing the patient from rising as this is attempted, while the breath is held. After 7�10 seconds the effort is released; a deeper squat is performed, and the procedure is repeated several times.
Piriformis method (e) This method is based on the test position (see Fig. 4.17) and is described by Lewit (1992). With the patient supine, the treated leg is placed into flexion at the hip and knee, so that the foot rests on the table lateral to the contralateral knee (the leg on the side to be treated is crossed over the other, straight, leg). The angle of hip flexion should not exceed 60� (see notes on piriformis, Box 4.6, for explanation).
The practitioner places one hand on the contralateral ASIS to prevent pelvic motion, while the other hand is placed against the lateral flexed knee as this is pushed into resisted abduction to contract piriformis for 7�10 seconds. Following the contraction the practitioner eases the treated side leg into adduction until a sense of resistance is noted; this is held for 10�30 seconds.
Piriformis method (f) Since contraction of one piriformis inhibits its pair, it is possible to self-treat an affected short piriformis by having the patient lie up against a wall with the non-affected side touching it, both knees flexed (modified from Retzlaff 1974). The patient monitors the affected side by palpating behind the trochanter, ensuring that no contraction takes place on that side.
After a contraction lasting 10 seconds or so of the non-affected side (the patient presses the knee against the wall), the patient moves away from the wall and the position described for piriformis test (see Fig. 4.17) above is adopted, and the patient pushes the affected side knee into adduction, stretching piriformis on that side. This is repeated several times.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Tensor Fascia Lata
�Assessment of shortness in tensor fascia lata (TFL)
The test recommended is a modified form of Ober�s test (see Fig. 4.14).
Figure 4.14 Assessment for shortness of TFL � modified Ober�s test. When the hand supporting the flexed knee is removed the thigh should fall to the table if TFL is not short.
Patient is side-lying with back close to the edge of the table. The practitioner stands behind the patient, whose lower leg is flexed at hip and knee and held in this position, by the patient, for stability. The tested leg is supported by the practitioner, who must ensure that there is no hip flexion, which would nullify the test.
The leg is extended only to the point where the iliotibial band lies over the greater trochanter. The tested leg is held by the practitioner at ankle and knee, with the whole leg in its anatomical position, neither abducted nor adducted and not forward or backward of the body.
Box 4.5 Notes on TFL
Mennell (1964) and Liebenson (1996) say that TFL shortness can produce all the symptoms of acute and chronic sacroiliac problems.
Pain from TFL shortness can be localised to the posterior superior iliac spine (PSIS), radiating to the groin or down any aspect of the thigh to the knee.
Although the pain may arise in the sacroiliac (SI) joint, dysfunction in the joint may be caused and maintained by taut TFL structures.
Pain from the band itself can be felt in the lateral thigh, with referral to hip or knee.
TFL can be �riddled� with sensitive fibrotic deposits and trigger point activity.
There is commonly a posteriority of the ilium associated with short TFL.
TFL�s prime phasic activity (all postural structures also have some phasic function) is to assist the gluteals in abduction of the thigh.
If TFL and psoas are short they may, according to Janda, �dominate� the gluteals on abduction of the thigh, so that a degree of lateral rotation and flexion of the hip will be produced, rotating the pelvis backwards.
Rolf (1977) points out that persistent exercise such as cycling will shorten and toughen the fascial iliotibial band �until it becomes reminiscent of a steel cable�. This band crosses both hip and knee, and spatial compression allows it to squeeze and compress cartilaginous elements such as the menisci. Ultimately, it will no longer be able to compress, and rotational displacement at knee and hip will take place.
The practitioner carefully introduces flexion at the knee to 90�, without allowing the hip to flex, and then, holding just the ankle, allows the knee to fall towards the table. If TFL is normal, the thigh and knee will fall easily, with the knee contacting the table surface (unless unusual hip width, or thigh length prevent this).
If the upper leg remains aloft, with little sign of �falling� towards the table, then either the patient is not letting go or the TFL is short and does not allow it to fall. As a rule the band will palpate as tender under such conditions.
Lewit�s TFL Palpation
(Lewit 1999; see also functional assessment method in Ch. 5)
Patient is side-lying and practitioner stands facing the patient�s front, at hip level. The practitioner�s cephalad hand rests over the anterior superior iliac spine (ASIS) so that it can also palpate over the trochanter. It should be placed so that the fingers rest on the TFL and trochanter with the thumb on gluteus medius. The caudad hand rests on the mid-thigh to apply slight resistance to the patient�s effort to abduct the leg.
The patient�s table-side leg is slightly flexed to provide stability, and there should be a vertical line to the table between one ASIS and the other (i.e. no forwards or backwards �roll� of the pelvis). The patient abducts the upper leg (which should be extended at the knee and slightly hyperextended at the hip) and the practitioner should feel the trochanter �slip away� as this is done.
If, however, the whole pelvis is felt to move rather than just the trochanter, there is inappropriate muscular imbalance. (In balanced abduction gluteus comes into action at the beginning of the movement, with TFL operating later in the pure abduction of the leg. If there is an overactivity (and therefore shortness) of TFL, then there will be pelvic movement on the abduction, and TFL will be felt to come into play before gluteus.)
The abduction of the thigh movement will then be modified to include external rotation and flexion of the thigh (Janda 1996). This confirms a stressed postural structure (TFL), which implies shortness.
It is possible to increase the number of palpation elements involved by having the cephalad hand also palpate (with an extended small finger) quadratus lumborum during leg abduction. In a balanced muscular effort to lift the leg sideways, quadratus should not become active until the leg has been abducted to around 25�30�. When quadratus is overactive it will often start the abduction along with TFL, thus producing a pelvic tilt.�(See also Fig. 5.11A and B)
Method (a) Supine MET treatment of shortened TFL (Fig. 4.15) The patient lies supine with the unaffected leg flexed at hip and knee. The affected side leg is adducted to its barrier which necessitates it being brought under the opposite leg/foot.
Figure 4.15 MET treatment of TFL (see Fig. 1.4 for description of isolytic variation). If a standard MET method is being used, the stretch will follow the isometric contraction in which the patient will attempt to move the right leg to the right against sustained resistance. It is important for the practitioner to maintain stability of the pelvis during the procedure. Note: the hand positions in this figure are a variation of those described in the text.
Using guidelines for acute and chronic problems, the structure will either be treated at, or short of, the barrier of resistance, using light or fairly strong isometric contractions for short (7 second) or long (up to 20 seconds) durations, using appropriate breathing patterns as described earlier in this chapter (Box 4.2).
The practitioner uses his trunk to stabilise the patient�s pelvis by leaning against the flexed (nonaffected side) knee. The practitioner�s caudad arm supports the affected leg so that the knee is stabilised by the hand. The other hand maintains a stabilising contact on the affected side ASIS.
The patient is asked to abduct the leg against resistance using minimal force. After the contraction ceases and the patient has relaxed using appropriate breathing patterns, the leg is taken to or through the new restriction barrier (into adduction past the barrier) to stretch the muscular fibres of TFL (the upper third of the structure).
Care should be taken to ensure that the pelvis is not tilted during the stretch. Stability is achieved by the practitioner increasing pressure against the flexed knee/thigh. This whole process is repeated until no further gain is possible.
Method (b) Alternative supine MET treatment of shortened TFL (Fig. 4.16) The patient adopts the same position as for psoas assessment, lying at the end of the table with non-tested side leg in full hip flexion and held by the patient, with the tested leg hanging freely, knee flexed.
Figure 4.16 MET treatment of psoas using Grieve�s method, in which there is placement of the patient�s foot, inverted, against the operator�s thigh. This allows a more precise focus of contraction into psoas when the hip is flexed against resistance.
The practitioner stands at the end of the table facing the patient so that his left lower leg (for a right-sided TFL treatment) can contact the patient�s foot. The practitioner�s left hand is placed on the patient�s distal femur and with this he introduces internal rotation of the thigh, and external rotation of the tibia (by means of light pressure on the distal foot from his lower leg).
During this process the practitioner senses for resistance (the movement should have an easy �springy� feel, not wooden or harsh) and observes for a characteristic depression or groove on the lateral thigh, indicating shortness of TFL.
This resistance barrier is identified and the leg held just short of it for a chronic problem, as the patient is asked to externally rotate the tibia, and to adduct the femur, against resistance, for 7�10 seconds. Following this the practitioner eases the leg into a greater degree of internal hip rotation and external tibial rotation, and holds this stretch for 10�30 seconds.
Method (c) Isolytic variation If an isolytic contraction is introduced in order to stretch actively the interface between elastic and non-elastic tissues, then there is a need to stabilise the pelvis more efficiently, either by use of wide straps or another pair of hands holding the ASIS downwards towards the table during the stretch.
The procedure consists of the patient attempting to abduct the leg as the practitioner overcomes the muscular effort, forcing the leg into adduction. The contraction/stretch should be rapid (2�3 seconds at most to complete). Repeat several times.
Method (d) Side-lying MET treatment of TFL The patient lies on the affected TFL side with the upper leg flexed at hip and knee and resting forward of the affected leg. The practitioner stands behind patient and uses caudad hand and arm to raise the affected leg (which is on the table) while stabilising the pelvis with the cephalad hand, or uses both hands to raise the affected leg into slight adduction (appropriate if strapping used to hold pelvis to table).
The patient contracts the muscle against resistance by trying to take the leg into abduction (towards the table) using breathing assistance as appropriate (see notes on breathing, Box 4.2). After the effort, on an exhalation, the practitioner lifts the leg into adduction beyond the barrier to stretch the interface between elastic and non-elastic tissues. Repeat as appropriate or modify to use as an isolytic contraction by stretching the structure past the barrier during the contraction.
Additional TFL Methods
Mennell has described superb soft tissue stretching techniques for releasing TFL. These involve a series of snapping actions applied by thumbs to the anterior fibres with patient side-lying, followed by a series of heel of hand thrusts across the long axis of the posterior TFL fibres.
Additional release of TFL contractions is possible by use of elbow or heel of hand �stripping� of the structure, neuromuscular deep tissue approaches (using thumb or a rubber-tipped T-bar) applied to the upper fibres and those around the knee, and specific deep tissue release methods. Most of these are distinctly uncomfortable and all require expert tuition.
Self-Treatment and Maintenance
The patient lies on her side, on a bed or table, with the affected leg uppermost and hanging over the edge (lower leg comfortably flexed). The patient may then introduce an isometric contraction by slightly lifting the hanging leg a few centimeters, and holding this position for 10 seconds, before slowly releasing and allowing gravity to take the leg towards the floor, so introducing a greater degree of stretch.
This is held for up to 30 seconds and the process is then repeated several times in order to achieve the maximum available stretch in the tight soft tissues. The counterforce in this isometric exercise is gravity.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
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