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Study Title:

Authors: G. Bronfort, R. Evans, A. Anderson, K. Svendson, Y. Bracha, R. Grimm

Journal: Annals of Internal Medicine

Date: 2012

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My thoughts

• First of all, seeing this study capture the attention of many manual and rehabilitation therapists through the power of the internet reminded me of the old “Start the Car” ikea commercial.

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• As a chiropractor that highly values exercise and rehabilitation, most would assume that I too would take this paper, “start the car”, and run away with it. Unfortunately, I wanted to read the actual paper and see what all the hype was about beyond the good publicity from the New York Times.
• There’s no question that I strongly believe manipulation and exercise may be better alternatives to medication in some if not many “pain” presentations, however, overtime I have learned to become more attached to patient-specific care more than anything else. Patient-specific care may indeed call for meds, manipulation and exercise – but patient-specific care may also call for reassurance, education, and / or soft tissue therapy.
• Now having read the actual study, the authors did do a relatively good job to prescribe individually based exercises but I do think they could have been more thorough. Gentle stretching and scapular retraction exercises, as well as neck and possibly (although not convincing in this paper) thoracic manipulations don’t cut it when it comes to sending a message that SMT and exercise are better than meds. I understand that this is a research paper so I will accept some limitations in the study.
• While there was significant difference in follow up at 6 months, no significant differences were found at the 1 year mark of follow up when compared to baseline. To me, this likely indicates symptomatic relief or treating the DP (which I think is ok)…but what about the root cause? And what about integrated care? Because how often do you just manipulate or just rehab? I know quite well many of you who read this blog also combine the two. But you probably combine other therapeutic approaches as well. What I don’t want to see is manipulating people’s necks for the simple reason that this paper said it was more beneficial. If it is indicated, and the patient consents, then by all means. But if not, don’t “start the car”. We need to be more precise and we need to be accountable.
• Again, it is a research study and I get that we can’t control for everything in research but I do think we can be a little more responsible when drinking the kool-aid. And responsibility means taking an objective, rather than emotional opinion…especially on social media. So please feel free to advocate that SMT and Exercise may sometimes be better a alternative than medication for neck pain (and that meds are often unnecessary), but please also recognize that generalizing the study’s results to all of your patients is an act that is no different than advocating for meds alone.

Bronfort, G et al. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine, vol 156; 1-10.…

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So far, experts, non-experts, and wanna-be-experts have all shared their opinions on what should and could be done to curtail the incidence of head injuries and concussions in the NHL. From eliminating fighting to modifying equipment to tactical rule changes, there have been countless ideas rendered of what the league can do differently to protect their players as well as the game itself.

Unfortunately, making changes isn’t easy. We all know that. Even the NHL’s arm-chair executives (the fans) know that. But collectively, I believe most if not all of us can agree that something must be done. Or else…

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While our knowledge base is still relatively limited with respect to the ramifications of sustained concussions, let alone early return to play from head injuries, we do know, as Mr Dryden stated, that:

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“Better helmets, more muscular necks and shoulders, MRIs and Rule 48 haven’t offered the answer to 220-plus-pound players moving 30 miles an hour.”

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220-plus pound players moving 30 miles an hour? Really?

The game of ice hockey has changed dramatically over the last 30 years, but what hasn’t changed, and perhaps what has been staring at us in the face the entire time, is the size of the rink. Simple physics will tell you that an ice rink measuring 200 feet by 85 feet containing the same amount of players (let alone one extra referee) that now weigh an approximate average of 20 pounds heavier and travelling approximately 15 more miles per hour may no longer be the appropriate size.

So maybe…just maybe…we need a larger fish tank.

When our pet koi outgrow their tank, we get a larger tank. And when our children outgrow their skuuts, we get them a bike.

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Now I’ll admit that I do not have the epidemiological data on concussions over in Europe where they play on larger ice surfaces, but only because of the simple reason that there hasn’t really been any significant studies published in recent times. Remember, studies take several years before the collected data turns into published research. And the only studies currently available are ones published the 90s. A lot has changed since then.

Surely, some will argue that the European game is completely different than the North American game. And I would agree. But I would also counter that there are many North Americans playing over in Europe, with my brother-in-law as an example. But I would also state that perhaps the difference in style of play across the ocean may actually be secondary to rink size more than any other significant reason. Perhaps?

Now others would argue that it would cost millions and millions of dollars to alter the ice rinks in each of the 30 North American cities where teams are located. Again I would agree. But I would also counter that millions and millions of dollars are equally spent on player salaries as well. And what good is the NHL when its highest paid players are sitting on the sidelines suffering from concussions?

So Gary Bettman states,

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“I will go where science takes me”

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As a health care practitioner, that exact statement is what I am trained to follow. But in the case of the NHL, what if the scientists are asking the wrong question? Or, maybe they are asking the right questions, but what if other specific questions aren’t being asked?

Perhaps science can take us down the path that soccer (football) in Europe and other countries around the world have taken for several years and study the area covered by players during 60 minutes of regulation play. Total distance as well as peak and average speeds can be determined via global positioning systems relative to the area of play to determine whether a need for a larger ice surface is actually necessary. And sound science must utilize comparative data so perhaps the exact same study (or studies) can be performed in the KHL, DEL, Swedish Elite leagues to name a few. Simply put, I would hypothesize that players would a) cover the same total amount of ice, travelling at the same current speed, but in a less confined area or b) cover less amount of ice in total, travelling at the same current speed, AND in a less confined area. Further, I would also hypothesize that the puck would change directions with less frequency on the larger ice surface leading to more predictable play.

And should these types of studies conversely reveal that a larger ice sheet results in a greater total amount of ice covered, then perhaps this may equate to less frequency of collisions.

I know this may seem far fetched but it is an idea. One that, in my humble opinion, may have at least an ounce of sound merit to it.

*UPDATE*

A colleague directed me to this research study. Seems as though my thoughts are not too far off!

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For more information on concussions, please check out ThinkFirst Smart Hockey’s online education program or their resource page.

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Study Title:

Authors: DD. Juehring & MR. Barber

Journal: Journal of Bodywork and Movement Therapies

Date: October 2011

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• A relatively low level of evidence but a good read nonetheless. This recent case study published in the Journal of Bodywork and Movement Therapies described the use of the Vojta/Dynamic Neuromuscular Stabilization treatment strategy for chronic migraine symptoms in a 49-year old female. Hypothesized to be triggered via neural mechanisms, this type of headache has been described to be modulated supraspinally and often has been elusive to conventional treatment strategies. The specific treatment strategy reported was described (although not directly stated) to be via reflex stimulation of the breast zone in the first phase of reflex turning. For those of you who are unaware, the breast zone is located at the widest intercostal space between ribs 5-8, nearby the mamillary line. Subjective improvement was reported over the 12-week course of therapy via the Headache Disability Index and VAS pain scale measures, although there was no mention of any cognitive approach to care. Several other unsuccessful treatment strategies previously undertaken over the span of 20 years were mentioned, however, unfortunately no statements pertaining to follow up of this particular strategy could be found. Overall, I thought this was a good start to getting the efficacy of DNS in the English published literature, but I do recognize its limitations and that we still have a long way to go. In particular, I would like to see more advanced forms of DNS utilized in the literature, especially utilized in athletic populations, as well as published research with higher levels of evidence. That said, I myself have utilized this treatment approach in a variety of patients (athletic injuries, neurological pathologies, chronic pain, etc) often with very successful results, so I have no doubt of its positive effect on this 49-year old woman.

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Juehring DD & Barber MR. (2011). A case study utilizing Vojta/Dynamic Neuromuscular Stabilization therapy to control symptoms of a chronic migraine sufferer. Journal of Bodywork and Movement Therapies, 15; 538-541

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Authors: W. Meehan

Journal: Clinics in Sports Medicine

Date: 2011

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Summary:

• Here is a little review of potential interventions in one of the most influential and highly discussed injuries in ice hockey today, concussion. While the current state of the literature may still be in its infancy, each incident of this “traumatic brain injury”, particularly in professional hockey, seems to make front page news and cast a shadow of doubt on the safety of our sport. This paper by Meehan discusses various therapeutic options that may be rendered in the presence of such injury.

• First introduced is the role of physical rest in the recovery process. The stepwise return to play protocol is discussed although it is mentioned that studies have begun investigating the role of light physical activity during recovery. Since quantitative cognitive deficits have been demonstrated in the presence of such injury, academic accommodations via cognitive rest were suggested for student athletes.

• Often considered an “invisible injury”, Meehan proposes that education regarding the typical recovery process be one of the mainstays of therapeutic intervention. Studies have demonstrated fewer symptoms at follow up in those that were informed about their symptoms, coping strategies, and the likely course of recovery.

• While most athletes achieve spontaneous recovery of symptoms within days to weeks, some experience prolonged recovery to which pharmaceutical intervention may be warranted. It should be noted that the evidence for such interventions is very minimal and the following information should be taken as a summary rather than a recommendation of care. Meehan suggests that pharmacologic treatment only be considered in the presence of the following:

1. Symptoms exceeding the typical recovery period,
2. Symptoms negatively affecting quality of life to the degree that the treatment benefits outweigh its risks, and
3. The clinician rendering treatment is both knowledgeable and experienced in the management of (sport) concussion.

• Meehan asserts that pharmacologic treatment has yet to be demonstrated to speed the recovery process and that standard approaches are lacking. Instead, he reports that medications are utilized for the treatment of its signs and symptoms. Since previous literature has grouped symptoms related to sport concussion in the categories of sleep disturbance, somatic (i.e. headache), emotional, and cognitive, chosen medications must be specific to the symptom experienced.

• In the presence of sleep disturbance, sleep hygiene that includes the elimination of constant stimuli (i.e. television, computers, caffeine, etc) is strongly considered. Medically, Meehan’s first line of defence for the presence of sleep disturbance is Melatonin. Other considerations are discussed although benzodiazepines seem to be advocated against due to their negative arousal and cognition effects.

• Somatic symptoms such as headaches are common in the presence of sport concussion. Meehan discusses the potential roles of antidepressants (i.e. amitriptyline – his preferred treatment) as well as the potential negative effects (“rebound”) of analgesics such as ibuprofen. Other medications are introduced as well as physical therapy, psychotherapy, and trigger point injections.

• For athletes suffering from emotional disturbance, for example stemming from participation restrictions, Meehan suggests tricyclic antidepressants and serotonin reuptake inhibitors as a complementary intervention to coping strategies, familial support and psychological counseling.

• Finally, since cognitive symptoms are common complaints in those suffering from sport concussion, potential pharmacologic treatment may include methylphenidate for attention and speed processing deficits as well as the domaminergic agent amantadine for executive function and prefrontal cortex glucose metabolism, in addition to cognitive rehabilitation.

• It should be noted that the majority of athletes recovery both spontaneously and quickly from sport concussions. The preceding review merely discusses potential medical interventions that may have complementary roles to physical and cognitive rest and rehabilitation. It must be reiterated that the above MUST NOT be taken as prescription but merely as a review of Meehan’s academic paper, intended for medical professionals. If you or your family member has sustained a concussion, you MUST consult a physician for care.
  

Meehan WP. (2011). Medical therapies for concussion. Clinics in Sports Medicine, 30; 115-124.

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Dynamic Neuromuscular Stabilization, or “DNS” as it is commonly referred to, is a manual and rehabilitative approach to healthcare grounded in the scientific principles of developmental kinesiology. One of the key tenets of this approach is the activation of the “integrated stabilizing system” in order to facilitate optimal functioning of the locomotor system.

This particular course was primarily instructed by Clare Frank, co author of “Assessment and Treatment of Muscle Imbalance” and Prague-based physiotherapist, Lucie Oplova.

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Page, Frank, & Lardner

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As I mentioned above, this approach to rehabilitation focuses primarily on the activation of the integrated stabilizing system of the spine. That is, the short intersegmental spinal muscles, the deep neck flexors, the diaphragm, the abdominal wall, and the pelvic floor. Many of you may be familiar with the research from Australia indicating the importance of a “feedforward mechanism” for spinal stabilization, and while we may not be convinced of the Transversus Abdominis in being the only important muscle for such mechanism, this approach views the relative interplay of the above musculature as being integral in the stabilization of the spine.

In fact, even more important may be the control via the central nervous system (CNS).

Postural ontogenesis and developmental kinesiology, or the development of muscle function for short, is directly related to CNS maturation. The absence of such maturation or the presence of its disturbance, forms the basis for such neurological pathologies as cerebral palsy. Such conditions typically manifest itself in predictive (aka not random) presentations, resembling functional musculoskeletal pathology we are so commonly familiar with in the modern day lifestyle.

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www.jandaapproach.com

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As a result, it seems evident that the majority of the dysfunctions we so commonly see may be more related to higher level central nervous system functioning than we give credit to. Therefore it is important that rather than taking a local approach to “muscle activation”, we must take a higher approach of CNS engagement.

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Training the brain

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In doing so, we must also pay attention to muscle coactivation patterns such that the optimal balance of said patterns results in functional joint centration. Joint surfaces that are well balanced ensure maximum load bearing is possible.

Note: This likely goes hand in hand with individuals who have difficulties performing the squat maneuver. Commonly we think of a “tight this” and a “weak that” but far too often we fail to realize that this dysfunction may simply be a de-centration of joint surfaces and subsequently, the brain telling that individual that perhaps he or she should not be performing a squat until such joints improve their dynamic positioning. Absolutely muscles are under complete control by the brain but how often is the central nervous system our area of corrective focus?

Therefore, optimal muscle functioning will shape structural maturation (think denerative joint disease) and optimal muscle functioning is based on central nervous system maturation. Remember that the CNS is plastic (or elastic for those of you familiar with Lorimer Moseley) so while someone may have experienced (perceived) optimal development it certainly does not immunize them from dysfunction later in life.

Program (CNS) – Function (muscle) – Structure (bones, joints, etc)

For those of you familiar with movement patterns, according to the DNS approach they are simply a window to examining what occurs at the CNS level. Think about it, problems that we commonly see generally resemble primitive patterns.

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"Early weeks of life"

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Early weeks of life

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Since such postural and functional pathologies mimic developmental maturation and insufficiency and since developmental kinesiology follows a system of sagittal stabilization prior to frontal and transverse stabilization, then it seems reasonable to follow this approach from a rehabilitation and training perspective.

And so while the DNS approach attacks active exercise in three critical positions…

• Based on deficiencies revealed in their testing methods
• Based on critical reflex stimulation positions
• Based on developmental kinesiology

…it is prudent that we take the same approach in the methods we employ. This in fact is one reason why I have incorporated the SFMA approach in practice. But for those of you familiar with the SFMA, the DNS system fits in quite well, especially in those cases where your patients suffer primarily from a fundamental stability deficit. Heck, I’d even be so bold to suggest that the DNS system would fit quite well in the corrective strategies of the FMS. Say it with me;

“Proximal stability for distal mobility”

• Shoulder Mobility…needs proximal stability
• Active Straight Leg Raise…needs proximal stability
• Rotary Stability…well, you tell me
• Trunk Stability Push Up…need I say more?

This does not mean that we must take a mobility problem to a stability fix. Dr. Weingroff states this clearly in his DVD. But optimal (local) mobility will precede optimal (local) stability. And optimal (proximal) stability will facilitate optimal (distal) mobility.

But we do have choices. If integrated spinal stability is warranted, we can train it with any means we choose. We can train the ISS in any of the three suggested DNS approaches. We can train the ISS in the most dysfunctional, non-painful movement pattern. We can train the ISS in 1’s and the asymmetries. We can train the ISS in the McGill Big 3. And the list goes on and on. Just remember, as soon as you have it, you must move on to the next pattern.

Go after it. Get it. Move on.

In hearing about the DNS approach, you may have come across discussions pertaining to reflex stimulation. It should be stressed that reflex stimulation is only a part of DNS. Reflex stimulation (aka the voodoo) is simply a technique utilized to elicit pre-programmed movement patterns and achieve joint centration. As with other manual therapies, reflex stimulation can be thought of as rebooting the system.

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CTRL - ALT - DEL

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But what about training the brain? I have mentioned this before and I’ll mention it again. In order to access cortical plasticity, the individual must perform the most appropriate exercise along the specific corrective continuum that is most challenging but also one that they can still perform quite well. This is training the brain.

So reflex stimulation can be thought of as the jumper cables and active training of the most difficult yet appropriate exercise that they can perform well is letting the car run after the jumpstart.

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Click here to watch an introductory video on DNS

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“Zones of Support” and the “Punctum Fixum” as taught by the DNS are the specific areas where movement begins. The direction of muscle pull, in general, project toward these regions and the choices of support zones that our body makes depend on the initial position of that body. Thus, such “fixed point” will be dictated by whether a specific movement pattern is of the open chain or closed chain varieties. Additionally, as Dr. Kolar states in Dr. Liebenson’s text, “Rehabilitation of the Spine“,

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“The muscle may not be weak in itself, but it may not function well because its attachment point is insufficiently fixed. A muscle must have a punctum fixum.”

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Finally, one of the concepts of this approach that I felt was of great importance was the test and re-test. The identification of the faulty movement pattern, the correction, and the subsequent reassessment. This is the clinic audit process. Because as Karel Lewit states in his text,

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“There is no clnical field in the whole of our experience in which the purely clinical examination plays such a decisive role…”

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I cannot thank Drs. Liebenson and Frank enough for recommending this course, especially under the tutelage of Dr. Clare Frank. I have read Dr. Kolar’s chapter  in Dr. Liebenson’s text, have looked at the literature on the Prague School website, and was introduced to some of their testing methods at Dr. Liebenson’s course. Yet while the information learned over the weekend was still relatively novel, at no point did I feel lost. The information was well presented and I cannot wait to integrate this approach into my current regime of care.

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Instructors: Clare Frank, Lucie Oplova, and Kathy Kumagai

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For a more detailed read, here’s an article by Porreca and Price in Scientific American. (I apologize that there’s a fee for this article, but it is a good read).

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This is a fantastic issue with topics such as Thoracic Outlet Syndrome, Neurodynamic testing for Carpal Tunnel Syndrome, and Reciprocal Inhibition (stretching), among others. I highly recommend anyone and everyone in manual therapy and rehabilitation to check it out.

On another note, I just received word that my case study on “costochondritis” has been accepted for publication. That makes two papers in press…AWESOME!

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Joe Przytula recently posted some highlights from the Athletic Trainers’ Society of New Jersey’s (ATSNJ) concussion summit of which Dr. Robert Cantu was the keynote speaker. Here are his notes (as taken directly from his blog):

• VERY important the athlete is permitted appropriate time for healing to take place.
• There is no set number of concussions that is a disqualification for further participation in contact sports.
• 2 man wedge tackling, blindside hits rule changes in American football are in order.
• No way to predict CTE in a live person; lawyers should not be driving decision making.
• Concussion accounts for 6-10% of all athletic injuries. The reported ones are just the tip of the iceberg. Subconcussive blows and their effect is an unknown factor.
• Loss of consciousness is not a good indicator of degree of brain injury.
• You don’t need to grade a concussion to manage them efficiently.
• Time to recovery is a good indicator for risk in subsequent concussions.
• When a player shows any symptoms of concussion, they should discontinue participation at least for that day.
• The cornerstone of concussion management is physical and cognitive rest until symptoms resolve.
• Prolonged post concussion syndrome (1m+) is usually associated with playing with a pevious head injury prior to the concussion.
• Concussion Research- Journal of Neural Trauma: http://www.liebertonline.com/toc/neu/27/7
• Many concussions occur at lower force, 60G’s and below. The new NFL helmet recommendations are suspect because they involved testing at higher G’s. Head and spine biomechanist specialists were not used in the study.
• Since every concussion is different, is legislating concussion guidelines a good idea?

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Part 2: The research behind the technique

Part 3: What is P.A.I.L’s™ and how is it used in this system?

Part 4: Assessment techniques, and how the system sets itself apart

For more information on Functional Range Release and any of Dr. Spina’s other seminars, please visit Functional Anatomic Palpations Systems.

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Suboccipitals: Small but important!

The Clinical Importance of the Anterior Strap Muscles

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