News & Blog Items

An Out of the Box Case Study

Recently, I had the opportunity to work with a patient who had traumatically injured her elbow. As many of you know, my rehabilitation style is non-traditional. I use Pilates-based rehabilitation to perform functional movements which focus on coordination of breathing and core stability to achieve appropriate body mechanics. So, you might be asking yourself “How in the world can that style of physical therapy be effective in helping an elbow injury?

Let me give you a little background about the patient. She is a newly married, nurse who enjoys strength training and running. She sustained a substantial strained ligament and nerve injury to her dominant arm when she fell running. Initially, she was unable to perform simple movements like grasping a fork or sleeping without pain and numbness into her hand. She was given a brace by her doctor and prescribed physical therapy.

At the start of physical therapy treatment, the patient was very guarded due to severe pain, so I was not able approach her care as I would for most sprains and strains. I needed to think outside the box. After brainstorming with Dr. Kelli Velez, I decided to focus on other body parts and the brain!
With any injury, the brain will automatically protect and inhibit movement to an injured area thus changing the awareness of the skin, muscles and joints in the region. No matter how small the movement we were attempting to do, the brain would not allow the arm to move pain free.

For the brain to be on board with treatment, we needed to tell the brain something new! We used mirror therapy and started to write numbers on the patient's skin around the injured area. We used the mirror to reflect the uninjured elbow, which would trick the brain to think it was looking at the injured elbow without pain.

To our brains, visual awareness and tactile touch are different sensations than an injury pain. You may have experienced this when the chiropractors at our office, assess your sensory system by using hot, cold, tapping, eye movements, or a toothpick on your area of pain. These sensations are perceived differently to our brain and affect the movement of the area, thus the entire body’s movement. Using this idea, the patient's pain started to decrease and she was able move her elbow and wrist with far less difficulty; thanks to the brain!

If you have ever been injured or sat on the couch binge watching your favorite show for more than three days, muscles start to atrophy. This also happened to the patient’s entire arm. Using my knowledge of stability and strengthening, it was time to use the Pilates equipment and different functional positions to wake up and activate the entire muscular system.

Your arm itself does not move alone. Your deep core system anticipates movement and stabilizes to create a fixed point for the limbs to move from. Many positions on the Pilates equipment are gravity free. This allows the body to gently strengthen while challenging core stability and awareness, as the equipment and your body move in multiple directions.
As weeks went on, the patient’s entire body began to stabilize and strengthen to support the healing elbow. When she could progress to bearing weight through the arm, crawling around like a baby, was the most effective exercise to strengthen the arm and stabilize the elbow functionally. The act of crawling on hands and knees is a precursor to upright activities.

By involving developmental positions, like crawling, the brain participates to normalize upright movement patterns. This is necessary to return to efficient movement without pain or compensation from other body parts. With enthusiasm, determination and out of the box rehabilitation techniques, the patient could get back to work, with the support of an elbow brace, but with the best core stability, postural strength and improved arm function to do the difficult job of a nurse.

Physical therapists do not need to be cornered into treating only one body part, but should always consider the goals of the person, not the injured region alone. Healthcare practitioners need to remain forward thinking; at times break the rules and think outside the box!

Dr. Amanda Heritage, DPT

Burn Your MRI Report

Just kidding…but not really. If I had a nickel for every time I’ve had to talk a patient off the ledge after seeing his or her imaging report, I’d be a rich woman. The story often goes a little like this. Bob, a 54 year old HVAC repairman, comes in to see me because he hurt his shoulder or foot or whatever and the first thing I notice is that Bob clearly also has pain in his back. When I ask him about it, he says that it has been hurt for a while. Once or twice a year, his back “goes out” and he’s laid up for a few days but there’s nothing he can do about it because he has some bad discs. You see, Bob went to his family doc a couple years ago to get his back checked out. The family doc sent him for an MRI and the MRI showed, you guessed it, degenerative disc disease at L4-L5, disc bulges at multiple levels, perhaps a herniation or two, and maybe some foraminal or central canal stenosis. Although Bob is pretty depressed about the state of his spine, he finds some comfort in the fact that at least he knows why his back has been giving him trouble for years. And here’s where my job gets tricky, I have to tell Bob that there’s a pretty good chance that he’s wrong.

You see, Bob has become a Victim Of Medical Imaging Technology (thanks APTEI for the witty, yet disgusting, acronym that I have chosen to omit). While MRIs can be invaluable tools when you need to rule out red flags or when frank nerve root compression signs are present, for the most part, they tend to do more harm than good. Why, you may ask? Two reasons:

Reason #1 - What’s on your MRI report often has NOTHING to do with your pain

According to a recent study by Brinjikji et al, “signs of degeneration are present in very high percentages of healthy people with no problem at all. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”1 The chart below indicates the prevalence of MRI findings in people with NO BACK PAIN.1 It shows that if we MRI’ed 10 pain-free 54 year olds, 8 of them would have disc degeneration findings and 6 would have disc bulges just like Bob but he has 7/10 pain and the others have none. How is that possible? Likely because Bob’s MRI findings aren’t what is causing his pain. Don’t get me wrong, there are certainly times where a degenerative disc issue could be the culprit but in the vast majority of cases, disc degeneration is just a normal part of aging, like wrinkles on the spine.2

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Reason #2 - People who know what’s on their MRI report tend to feel WORSE

Seriously, MRIs for low back pain can sometimes do more harm than good! Several studies have shown that patient knowledge of imaging findings leads to more doctor’s visits, longer lasting pain, more disability, and a lesser sense of well-being.3,4 This is likely because many patients interpret their imaging findings to mean that the back needs to be protected, resulting in unnecessary fear avoidance of movement and activity.5 This type of avoidance can actually make the back pain worse. This certainly lends credence to the idea that ignorance is bliss, at least when it comes to your spine.

So what’s the bottom line? You are NOT your MRI findings. Get evaluated by a competent practitioner (like one of the fabulous docs at Nelson Chiropractic and Pilates) who can help you figure out what’s really causing your pain. And when you’re ready to burn that MRI report, give me a call…I’ll provide the matches.

  1. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
  2. Brinjikji W, Diehn FE, Jarvik JG, et al. MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: A systematic review and meta-analysis. AJNR Am J Neuroradiol. 2015 Sep.
  3. Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008 Jun;29(6): 1098-103.
  4. Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005 Nov;237(2):597-604.
  5. Darlow B, Dowell A, Baxter GD, et al. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med 2013;527-34.

 

Dr. Kelli Velez

Building a Strong Foundation

                Recently, as my wife and I were looking for a new home, we found what seemed to be the perfect house in the perfect neighborhood. As we prepared our offer, we asked a contractor to come over to assess how much it would cost to renovate the kitchen. Interestingly, when he got there, the first thing he did was walk around the perimeter of the house. Then he walked through the basement. Before he even looked at the kitchen, he gave us his assessment: find another house. The verdict? The house had a poor foundation, and fixing the kitchen would do nothing to change that.

                While I was disappointed, I completely understood. His assessment mirrored what I do every day in the office. At the beginning and end of every visit, we guide our patients through a movement assessment called the Selective Functional Movement Assessment (SFMA). We do this to determine our patient’s capacity of the most basic and foundational movements. Can they flex, extend and rotate their head, neck and torso with full range of motion and without pain? Can they stand on one leg without falling over? Are they able to squat? These basic movements lay the foundation for the more complex movement patterns that occur in life and in sport. When the simple movements are dysfunctional, everything built on that foundation will be suspect, and only a matter of time before repetition and load lead to injury. Similar to my prospective home, only time stands in between a problematic foundation and a major problem that needs fixing.

                Thankfully, the basic movements of the human body can be much easier to evaluate and fix than the foundation of a house. To differentiate between the two, let’s talk about why these building block movements might be suboptimal. Every joint, muscle, ligament and tendon in the body has a set of responsibilities, all of which are modulated by the brain. When something isn’t quite working properly, the brain seamlessly creates compensatory survival strategies to help us make up for the deficit. The issue occurs when we perpetuate that survival strategy over time, and adopt that strategy as our new normal. When these patterns become problematic, they essentially require a reprogramming or reboot back to normal. That is where we come in.

For example, the glute max is a strong, powerful muscle. It has a main responsibility to extend the leg- a very important component of every step we take. When the glute max is weak, the brain calls upon helpers to help facilitate that movement. Oftentimes one of those helpers is the quadtratus lumborum, or QL. The QL is a stabilizing muscle in the low back, which can also assist in leg extension. The QL can help the glute max out in the short term, but since the QL is a stabilizer and not a powerful mover, it tires quickly. This compensation strategy often results in a weak, tight and tender low back and QL. This compensation can be a common causes of idiopathic low back pain, and can be very easily uncovered and treated with a movement assessment and subsequent treatment.

This example is just one of countless survival strategies that we see every day in our office. When these strategies have been perpetuated for too long, you are left with painful, weak and tight muscles that alter the function of joints, ligaments and tendons. This altered functionality can most definitely be caught by a movement assessment after an injury has occurred. However, the best part is that this it can be caught by a movement assessment BEFORE it ever turns into a debilitating injury. Screening movement on a regular basis can help to reduce the risk of a previous injury recurring, or an injury ever happening in the first place. Once the building block movements are acceptable, other factors like strength, endurance and coordination become significantly more important. Similarly, a new kitchen in my prospective house would only be acceptable if we had first fixed the issues that presented in the foundation of the house.

As Gray Cook states, “Our bodies are miracles capable of unbelievable durability and resiliency, with an amazing performance and physical capacity.” When our foundational movements are without limitation and pain free, we can fully grasp how truly amazing our bodies can be.

 

David Velez, DC

Act Like a Baby and Get Stronger

It's pretty amazing, if you've ever stopped to think about it, that a human baby can go from lying helplessly when born to crawling, standing and walking within the span of about 15 months without ever being taught.

Imagine what that rapid progression would mean to an adult! The medical/rehabilitation profession studying the development of human movement has identified milestones in the baby's first year that represent ideal posture and stabilization. More importantly, we can use these milestone positions to not only rehab movement dysfunction, but enhance performance!

At the core of these findings is the Integrated Spinal Stabilization System or ISSS which is made up of the diaphragm, pelvic floor, abdominal muscles and short stabilizers of the spine. They work together to increase pressure in the abdomen which creates better congruency at joint surfaces and balances the back extensors for an elongated and upright posture. Using the ISSS while practicing milestone movements from a baby's development integrate the entire movement system and will trigger familiar pathways in your brain that helped you learn how to walk when you were a baby.

At Nelson Chiropractic and Pilates Center, DNS is the foundation of our rehabilitation program. Everyone can benefit from practicing functional movement. Physical therapy is for everyone! From relieving pain to enhancing performance, we are here to help! If you have any questions or would like to learn how to improve your function, please give us a call to set up an appointment with our doctor of physical therapy! 856-767-8800

Check out this progression called the Czech Get Up. It's a variation of the Turkish Get Up using the principles of developmental kinesiology and Dynamic Neuromuscular Stabilization (DNS).

Click here to watch a video of The Czech Get Up

Slow Down to Heal

We treat a lot of athletes at Nelson Chiropractic & Pilates Center. The last thing we want to do is to have an athlete stop all activity. Unfortunately, sometimes, based on the issue, there aren’t many options and an athlete needs to withdraw from all painful activity. Before getting to that point, however, we recommend that an athlete slows down to heal.

If you have shoulder pain related to overhead motion, it’s best to avoid activity that irritates it.  Therefore, lifting weights overhead is probably not a good idea. Doing pullups could also further irritate your condition. Following this logic, snatches are probably not the best idea either. If you continue doing these activities, you will prolong your recovery or even make the problem worse. In either case, you will be out of action for a longer period of time.

I previously worked with a triathlete that had a possible stress fracture in her foot, a warning sign that she was overtraining.  She didn’t want to slow down and eventually the injury turned into a full blown stress fracture. Instead of modifying her workout, she continued cycling at full intensity with her boot on. As a result, she developed a stress fracture in her other foot! Instead of being sidelined for 8 weeks. She was out of action for 18 months! Lesson learned!

If you have an injury, aside from complete withdrawal from an activity, what can you do to stay in the game? The answer is simple. You can regress to progress. Find an exercise or movement that you can perform that is similar to your activity but puts less stress on the area and causes no pain or compensation. We call this working within your neural edge. For example, if heavy squats cause back pain, squat with less weight. If using less weight still causes pain, squat without weight. If squatting without weight causes pain, you need to regress even more.

To determine if you are within your neural edge, you need to be able to maintain your intra-abdominal pressure (IAP) throughout the movement. If you cannot, you are working outside of your capacity. If you are unsure what IAP is, you are most likely working outside of your capacity! A person/athlete needs to be able to breathe, stabilize, and move without load (weight) before considering adding load. If you can’t crawl, how can you walk, let alone perform heavy squats?

Time and time again, I see athletes with shoulder, neck, or back pain who continue to lift weight overhead, yet they cannot maintain their IAP in an overhead position even without weight. These patients need to regress to progress. While we don’t like telling people to stop performing an activity, it is usually vital to their care that they initially withdraw from the offending activities. Our goal is to help them get back “in the game”, as quickly as possible.

We work with many excellent coaches and trainers in South Jersey. They are well skilled in regressing their athletes. If you have an issue related to a specific movement, please talk to your coach/trainer about regressing that activity. At Nelson Chiropractic & Pilates Center every patient treatment plan is based on the ability to breathe, stabilize, and move better.  While our focus is usually getting you out of pain, it is also to teach you to become aware of IAP and how to apply this concept in your daily activities, exercise, and sports.

At Nelson Chiropractic & Pilates Center we have four sports chiropractors and a physical therapist who are trained in multiple techniques to help you achieve your goals. Our unique blend of chiropractic adjustments, Active Release Technique (ART), Dynamic Neuromuscular Stabilization (DNS), NeuroKinetic Therapy (NKT), Proprioceptive Deep Tendon Reflex (P-DTR), Restorative Breathing, rehabilitative exercises, and more will help you get back in the game! Remember, it’s better to slow down to heal then to crash and burn.

 

Eric Nelson, DC DACBSP

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