Fascial Thickening Is Responsible for Musculoskeletal Pain

Fascial Thickening 

By Warren Hammer, MS, DC, DABCO

An important study in the fascial world by Langevin (2009)¹ proposed that people with chronic and recurrent low back pain had 25 percent greater fascial thickness than a low back pain-free group.

Helene Langevin, MD, is a researcher at the University of Vermont who devotes a considerable amount of time studying connective tissue. She concluded her study by stating: "Increased thickness and disorganization of connective tissue layers may be an important and so-far neglected factor in human LBP pathophysiology."

She is not alone in her findings. Another study in Skeletal Radiology, 2005,² found that pathological Achilles tendonsshowed increased thickness and 89 percent were painful.

Antonio Stecco, MD, recently completed an unpublished study³ using ultrasonography on chronic (longer than 3 months' duration) neck pain patients, evaluating fascial thickness in the distal third of the SCM and scalenus medius. The deep fascia in both muscles were thicker due to the increased amount of loose connective tissue between the layers of the deep fascia (usually three layers) and the loose connective tissue between the deep fascia and the muscle.

There was a correlation between the intensity of the pain and the thickness of the fascia compared to the control patients. The dense-collagen type I fibers remained the same, while the loose connective tissue demonstrated increased GAGs and hyaluronic acid. (Figure 1) The entanglement ofhyaluronic acid (HA) molecules is the apparent cause of increased stiffness and decreased articular ROM.^4-5 (Figure 2)

According to Matteini, et al, "These chain-chain interactions were reported to be reversibly disaggregated by an increase in temperature or by alkalization." Moreover, "Recent infrared spectroscopy studies have suggested the formation of three-dimensional superstructures of HA chains stabilized by water bridges. This water-mediated supramolecular assembly was shown to break down progressively when the temperature was increased to over 40° C, in accordance with previous MRI observations."⁶

The presence of abnormal HA finally explains many of the fascial treatment explanations whereby pressure against tissue allows a "release" of the area from a gel to a solid. But to change HA entanglements, a major requirement is to increase the temperature several degrees. This might also explain an effect of moist heat. The retention of HA after exercise, as well as its endomysial location, is in accordance with the concept that HA is a substance that is present to lubricate and facilitate the movements between the muscle fibers.³

Besides the thickening of fascia beneath the deep fascia and muscle, there may be thickening between the superficial and deep fascia, and the intramuscular fascia surrounding perimysium and endomysium. According to the principles of fascial manipulation, it is essential that there be a gliding of the fascial system around and within the muscular tissue;⁷ otherwise there will be abnormal proprioception, incoordination of muscle function and pain. Graston Technique and deep friction massage are ideal methods to provide the necessary tissue compression and heat for these types of lesions.

References

1. Langevin HM,Stevens-Tuttle D, Fox JR, et al. Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskeletal Disorders, 2009;10:151.
2. Richards PJ, Win T, Jones PW. The distribution of microvascular response in Achilles tendonopathy assessed by color and power Doppler. Skeletal Radiol, 2005 Jun;34(6):336-42.
3. Stecco A. "Evaluation of the Role of Ultrasonography in the Diagnosis of Myofascial Neck Pain." Department of Physical Medicine and Rehabilitation, University of Padua, Italy, 2011.
4. Piehl-Aulin K, et al; Hyaluronan in human skeletal muscle of lower extremity: concentration, distribution, and effect of exercise. J Appl Physiol, 1991 Dec;71(6):2493-8.
5. Stecco A. Slide presentation on the physiology of fascia. Fascial Manipulation Seminar, Part I, Las Vegas; Feb. 17-19, 2012.
6. Matteini P, et al. Structural behavior of highly concentrated hyaluronan.Biomacromolecules, 2009 Jun 8;10(6):1516-22.
7. Stecco L, Stecco C. Fascial Manipulation Practical Part. Piccin, Padova, Italy, 2009.

Soft-Tissue Treatment Is Another Form of Exercise

By Warren Hammer, MS, DC, DABCO

Physical activity restores our body by way of mechanical loading. Mechanical loading is the crux of many methods of soft-tissue treatment.

Mechanical loading by a practitioner is a form of physical activity performed on a patient.

Mechanical loading is the principal way our body maintains itself, especially with regards to tendons, ligaments, bone, muscle and fascia. Lack of mechanical loading results in atrophy and eventual cell death. Years ago, anyone with acute lower back pain was sent to bed for a week. We now know that as soon as a patient can move with minimal discomfort, they should get out of bed and attempt the movement – i.e., mechanical loading. Thus, just rubbing someone’s skin or deeper tissues is mechanical loading that may be considered a localized form of exercise.

The literature is replete with studies on mechanical loading and its resultant effects on the extracellular matrix (ECM), especially connective tissue and its collagen, tissue structure maintenance, release of growth factors, metabolic activity, protein synthesis, cell growth and survival, circulation, and gene expression. This is only a partial list of factors related to the mechanical load created by methods such as Graston, fascial manipulation, acupuncture and others.

Cell proliferation requires cell spreading and exertion of force on the ECM. Even internally, mechanical forces associated with blood flow play important roles in the acute control of vascular tone, the regulation of arterial structure and remodeling, and the localization of atherosclerotic lesions.¹ It is hypothesized, for example, that "stress concentration" on the walls of arteries due to arterial pressure and accompanying stretch relates to the localization of atherosclerotic plaques in particular arterial areas.² So, mechanical forces that are crucial to the regulation of cell and tissue morphology and function could have both positive and negative effects (overuse, trauma, etc.)

In order for mechanical load to exert its effects, it is necessary for a process of mechanotransduction to occur, whereby stressed cells convert mechanical stimuli into chemical responses. The description as to how all this works is very complicated, but certain terminology should be part of our lexicon.³ In the field of biochemistry, a receptor is a molecule most often found on the surface of a cell, which receives chemical signals originating externally from the cell. Through binding to a receptor, these signals direct a cell to do something; for example, to divide or die, or to allow certain molecules to enter or exit.

Receptors are protein molecules embedded in the plasma membrane (cell surface receptors), or the cytoplasm or nucleus (nuclear receptors) of a cell, to which one or more specific kinds of signaling molecules may attach. A molecule that binds (attaches) to a receptor is called a ligand, and may be a peptide (short protein) or other small molecule, such as a neurotransmitter, a hormone, a pharmaceutical drug or a toxin. A ligand is a signal-triggering molecule, binding to a site on a target protein (receptor).

Numerous receptor types are found within a typical cell and each type is linked to a specific biochemical pathway. Each type of receptor recognizes and binds only certain ligand shapes (an analogy to a lock and key, with the lock representing the receptor and the key, its ligand). Hence, the selective binding of a specific ligand to its receptor activates or inhibits a specific biochemical pathway.

An important receptor is called an integrin; it connects the inner structure of the cell (cytoskeleton) with its surrounding ECM. Integrins sense mechanical forces (stretch and fluid flow) and transmit mechanical stresses across the plasma membrane into the cell. By regulating signaling pathways, they transduce physical forces into chemical signals.

Not only do integrins perform this outside-in signaling, but they also operate in an inside-out mode. Thus, they transduce information from the ECM to the cell, as well as reveal the status of the cell to the outside, allowing rapid and flexible responses to changes in the environment. Integrins are the sensors of tensile strain at the cell surface and play a crucial role in linking the ECM to the cytoskeleton. Mechanical loading creates tensile strain, among other things.

The concept of the receptor-ligand interaction is one of the most basic in all of biology. It is a key element to the functioning of all biological systems. It allows neighboring and distant cells to communicate with each other. One cell may have a receptor in its membrane and when it binds to a matching ligand on a neighboring cell, the receptor performs some action. Typically, this action is to take an existing protein and modify it in some way; to either activate or deactivate it.

It appears that the acupuncture theory of chi and "vital energy" can now be explained by the effect of mechanical load on points located in the fascial system, resulting in a receptor-ligand interaction. Both physical activity and the laying on of hands and/or instruments are stressing and exciting this cellular interaction. It remains for the clinician who uses mechanical load on soft tissue to continually improve their skill by determining – through trial and error, and controlled studies – exactly where to put their hands, and to measure whether the loading of a particular area will improve function.

References

1. Davies PF. Flow-mediated endothelial mechanotransduction. Physiol Rev, July 1995;75(3):519-560.
2. Thubrikar MJ, Robicsek F. Pressure-induced arterial wall stress and atherosclerosis. Ann Thorac Surg, 1995;59:1594-1603.
3. Description of ligand, receptor and integrin. From Wikipedia, the free encyclopedia.

Iliotibial Band Friction Syndrome Is Frictionless

Iliotibial Band Friction Syndrome 

By Warren Hammer, MS, DC, DABCO

Iliotibial band syndrome (ITBS) is the most common cause of lateral knee pain in runners.¹It is described as an overuse injury caused by repetitive friction of the iliotibial band over the lateral femoral epicondyle, with the maximal zone of impingement at about 30 degrees of knee flexion.¹ But if it is found that the ITB does not move anteroposteriorly over the epicondyle, how can friction occur? Rather than friction, it has been determined that at 30 degrees of knee flexion there is internal rotation of the tibia and the ITB is compressed against the lateral epicondyle; while with knee extension, the band is pulled laterally away from the epicondyle.

The ITB is anchored to the distal femur by fibrous strands, which prevents the purported antero-postero movement. Deep to the distal portion of the band is a layer of richly innervated and vascularized fat. Pain may be caused by fat compression beneath the tract instead of friction during flexion and extension. The idea that there is a forward and backward movement of the ITB over the epicondyle is really an illusion due to changing tension in its anterior and posterior fibers.²

In a study by Fairclough, et al., published in the Journal of Anatomy,³ magnetic resonance scans and gross and microscopic anatomy were evaluated in 15 cadavers, six asymptomatic volunteers and two athletes with acute ITB syndrome. Between the ITB and lateral epicondyle, there is adipose tissue containing many blood vessels and nerves (even Pacinian corpuscles that when hypertrophied, become associated with pain) and are more likely affected by compression than a friction movement. The MR scans showed that at 30 degrees of knee flexion, the ITB is drawn medially toward the epicondyle (due to passive tibial rotation) and the vastus lateralis, which, due to an increase in tension, moves the fat deep to the ITB and adds to the compression.

So, the ITB is really moving in a medial-lateral direction. The fatty tissue may be normally acting as a brace to reduce bending stresses on the bone and also convert tensile to compressive loading on the lateral side of the joint.¹ Fatty tissue is often found at many tendon and ligament entheses,⁴ and may be the cause of the local edema.

The authors found no bursa in the area; it is possible that the swelling is really due to the irritation of the fatty tissue, rather than a bursitis. It was also found that there were two separate types of tissues at the distal ends – "tendinous" type was found proximal to the lateral femoral epicondyle and a "ligamentous" type was identified between the epicondyle and Gerdy's tubercle.³ The tendinous part of the ITB, therefore, does not cross the knee joint, indicating that the tensor fascia latae muscle has no effect on the knee joint and actually exerts most of its effect by tensing "the fascial envelope around the thigh to promote optimal muscle function on the hip joint."²

The ITB is really not a separate band. It is a thickening of the fascia lata that covers the whole thigh. The ITB is also continuous with the lateral intermuscular septum, which is anchored to the linea aspera of the femur. So, the ITB is really a fascial structure. There are fibrous bands that attach from the ITB to the distal femur and to the lateral epicondyle. These strands pass through to the periosteum and have been likened to a tendon enthesis. The ITB is therefore anchored at the distal end and would not rub over the lateral epicondyle in overuse injuries.

This information questions the use of surgery, breaking down adhesions around the epicondyle or even stretching the distal area. In order for stretching of the area to be therapeutic, "the fascia lata, the lateral intermuscular septum and the distal fibrous bands anchoring the ITB to the femur would all need to be stretched for the ITB to be lengthened."² Probably the effect of stretching is the stretch of the hip abductors occurring during the ITB stretch, indicating that the primary problem is at the hip and the pain at the lateral epicondyle area is only secondary.

It has been found that hip abductor weakness is related to the ITBS.⁵ Therefore, hip ranges of motion and the myofascia should be evaluated for possible weakness and adhesions. This represents another instance of a proximal problem in the kinetic chain affecting a distal area, which is routinely found in the use of fascial manipulation.

References

1. Fredericson M, Wolf C. Iliotibial band syndrome in runners, innovations in treatment.Sports Med, 2005;35(5):451-459.
2. Fairclough J, Hayashi K, Toumi H, et al. Is iliotibial band syndrome really a friction syndrome? J Sci & Med in Sport, 2007;10:74-76.
3. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome.J Anat, 2006;208:309-316.
4. Benjamin M, Redman S, Milz S, et al. Adipose tissue at entheses: the rheumatological implications of its distribution. A potential site of pain and stress dissipation? Ann Rheum Dis, 2004;63:1544-55.
5. Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med, 2000;10:169-75

The Subluxation - More Than a Single Vertebral Misalignment

By William Shepherd

The concept of a subluxation as a single vertebra out of alignment with the vertebra above and below it is well-accepted within our profession. However, it is not accurate. When stress or injury occurs in one area of the spine, the whole spine becomes involved in the process of adaptation to that injury or stress.
Muscles-from the toes to the skull-are involved in this adaptive process. This has driven us into divisiveness that should not have happened, as most researchers have concentrated on one element in this adaptive process, and found conflict with other researchers who have concentrated on other elements. We have also developed a variety of techniques that have concentrated on adjusting according to the findings their research has yielded. Thus, we have multiple techniques, with everything from Basic to Grostic being used with effectiveness. These techniques all deal with some portion of this complex total-body adaptive mechanism, and would not be in conflict if we understood this process better. My attempt here is to shed some light on this process.

My particular area of inquiry has been in the study of motion in joints; the muscles involved in that motion; how motion varies from normal when a subluxation is present. That variation from normal is, in my opinion, the only way a subluxation may be properly assessed. Any technique that normalizes motion in joints and increases muscle tone throughout the body is an acceptable technique.

The next question is, "What is the definition of normal mechanical function, and how may it be assessed accurately?" Some have defined a normal spine as one that shows no misalignment on an x-ray and little, if any, curvature. This would be true if our spines had not had to adapt to strains so severe that self-correction did not occur in a short span of time after the trauma. Unhappily, most people ignore discomfort until it becomes too painful to tolerate. During this interval, adaptation can reshape the muscles, ligaments and disc tissues to better accommodate the distress. If accommodation has been successful and pain is decreased, and nothing is done to assess the cause of the prior discomfort, the body accepts the reshaping of the spine. Thus a misalignment shows up on the x-ray, which may be very difficult (if not impossible) for a return to normal alignment.

However, many techniques do use misalignment as the way to adjust a subluxation with too much success for me to argue that it is wrong. On the other hand, we cannot x-ray patients each time they come in, so an easier and more reliable method should be found to assess whether a subluxation is present in that person on that date, and the approximate location of the subluxation. I believe this can be done with motion palpation and muscle testing.

We use the reflex neuromuscular distortion, always accompanying a subluxation, to find that it exists. This neuromuscular distortion affects the movement of the sacroiliac joints very specifically. Normal motion, when the spine bends forward, when it bends side to side, and when one leg is raised and then the other leg is raised, was established 50 years ago by Dr. Henri Gillet.

In any flexion subluxation in any vertebra in the spine, the distorted movement in the sacroiliacs is a lateral flexion distortion in which the ilia follow the lumbar spine, indicating increased muscle tension in the flexors of the lumbar spine (the iliopsoas muscles). Normal movement of the ilia is away from the lumbar spine on lateral flexion of the trunk.

Any extension subluxation in any vertebra in the spine distorts movement in the sacroiliacs, by the ishium moving toward the sacrum when the knee is bent on that side. When the other knee is bent, the sacrum moves toward the ischium on that side. Normal movement is for the ischium to move away from the sacrum when that knee is bent. When the other knee is bent, the sacrum should move away from the ischium.

Rotational subluxation in any vertebra in the spine distorts movement in the sacroiliacs, by moving the ilium toward the sacrum when the torso bends forward. The normal movement is for the ilium to move away from the sacrum on forward bend of the torso.

These three directions of subluxations - flexion, extension and rotation - are the usual misalignments found. It is true that degrees of flexion or extension can vary 180 degrees rotationally, and rotation subluxations can have degrees of flexion and extension, but the major direction of distortion will follow the distorted sacroiliac movement I have just outlined.

Lack of specific breath motion is also an indicator of the presence of subluxation. Breath motion is measured by using a goniometer with at least seven-inch prongs. With this goniometer, one degree is equal to 3mm. If the goniometer prongs are placed with one on the ilium and the other on the scapulae, the measured motion on a deep breath should be 45mm. Anything less on either side indicates a subluxation somewhere in the spine is present. There should be 6mm of breath motion between vertebrae. No breath motion of this magnitude between vertebrae is also a prime indicator that a subluxation exists. This does not indicate the position of the subluxation, because there can be many breath motion locks in many different areas of the spine from a single subluxation.

Lack of breath motion between skull bones can also be prognosticative for a variety of directional misalignments. A lack of motion between occiput and temporal bones can indicate an extension subluxation somewhere in the spine.

A lack of breath motion between the occiput and parietal bones can also indicate a flexion subluxation somewhere in the spine.

A lack of breath motion between the sphenoid and the occiput bones can indicate a rotational subluxation.

After we have ascertained the direction of the subluxation from the sacroiliac tests, we move the spine in the direction opposite the indicated movement. Reluctance in movement is found to exist from the atlas down to near the subluxation, below which the spine seems to have free movement. In this area, a vertebra will be found in either flexion, extension or rotation, depending on the direction indicated on the x-ray.

Rotation subluxations, as indicated by the sacroiliac tests, exhibit rotary reluctant movement misalignment from the atlas down to an area in the spine, and normal rotary movement below. Since rotary subluxations involve from two to four vertebrae, exact positions of the vertebrae need the x-ray to be sure of the position needing release. Palpation may sometimes be quite close to the vertebra, since rotary muscles of the spine, when unbalanced in a subluxation, will be quite tender on the spastic tendon of the rotary muscle involved. A rotary subluxation will often have shoulder blades at varying levels, which can be easily observed by placing thumbs on the spine of the scapulae.

Flexion subluxations, as indicated by the sacroiliac tests, exhibit poor extension from the atlas down to the offending injury in the spine, and normal extension below the offending injury.

Extension subluxations, as indicated by the sacroiliac tests, exhibit poor flexion from the atlas down to the injury, and normal flexion below this point.

The Derefield leg-length tests have been used for the past 40 years to indicate that a subluxation is present in the spine. When present, it is a fine indicator. We have found that it is not present in a rotary subluxation; therefore, it should not be relied upon when a rotary subluxation is primary.

Muscle strength tests have been used to assess spinal subluxation as well. We have found that weakness in muscle strength follows exactly the scenario of being opposite the bend toward which the vetebra has moved: flexion subluxations have weak extensors; extension subluxations have weak flexors; and rotation subluxations have weak rotary muscles of shoulders, hips, forearms and knees.

I have used and advocated this method of spinal evaluation for the past 40 years. I have not found it in error.

Manual Muscle Testing and Postural Imbalance

Manual Muscle Testing and Postural Imbalance

By Kim Christensen, DC, DACRB, CCSP, CSCS

The best posture is one in which the body segments are balanced in the position of optimal alignment and maximum support, with full mobility available. Optimal posture allows for pain-free movement with a minimum of energy expenditure, and is a sign of vigor and harmonious control of the body.¹ One of the most useful diagnostic procedures in chiropractic practice is the manual testing of the muscles responsible for maintaining postural alignment. 
This part of an examination provides valuable clinical information, which can be correlated with a patient's history and reported symptoms.

Postural patterns are maintained by a complex arrangement of proprioceptive input, modified by habits, somatotype, and even psychogenic factors, such as self-esteem. Deviations from the ideal, efficient alignment eventually result in the production of chronic pain symptoms, which have been shown to be predictable.² chiropractic adjustments can improve the segmental misalignments, but comprehensive and effective treatment requires that the muscle imbalances be addressed.

Postural Muscles and Alignment Problems

Persistent faulty postural alignment is almost always associated with an imbalance in the surrounding musculature. Sustained misalignments result in some muscles becoming shortened and others developing a constant overstretch. And, of course when certain muscles are used more frequently (at work, or during sports), they get stronger and tighter, while the underutilized opposing muscles are, by comparison, weaker. The eventual consequence is a malposition of the involved joint(s). Trying to determine which came first - the alignment problem or the muscle imbalance - may in some instances matter, however both will generally need to be addressed. In fact, they are usually bound together into neurological habit patterns that are imperceptible and unnoticed by the patient. The doctor must identify the structures and the muscles that are involved, so that the patient can begin to work on a corrective exercise program.

Common Muscle Imbalances

Many of us develop a similar, almost standardized configuration of muscle imbalance. While there are many individual variations, due to work habits and sport activities, there is a consistent pattern that is primarily the result of the way we customarily use our postural muscles. There also seems to be a neurological developmental component, since these patterns are very common and widespread.³

Upper Body Patterns

The postural muscles of the neck, upper and middle back, and shoulder girdle demonstrate this type of configuration, as discussed. It is very common to find tightness and trigger points in the neck extensor muscles, the upper trapezius, and the levator scapulae muscles. The opposing groups (longus colli and capitis and lower trapezius) are frequently lax, and in need of strengthening. In the shoulder, the muscles in the front (pectoralis major and minor) are usually tight and hypertonic, while the infraspinatus, teres minor, rhomboids, and thoracic erector spinae muscles are inhibited. These muscle imbalances develop into the very common postural pattern of forward shoulders and increased kyphosis, with a forward head and loss of the cervical lordosis.

Lower Body Patterns

Similar muscle imbalances are frequently found in the lumbar spine and pelvic region. The lumbar erector spinae muscles are often tight and hypertonic, while the abdominal muscles are lax. The hip flexor muscles get tight, while the gluteus maximus muscles become weak, thereby interfering with full hip extension during gait. This combination is suspected to be a contributing factor in hamstring muscle strains and tears.⁴ Tight hip flexors will inhibit the hamstrings, which are under more stress during strenuous hip extension, since the glutei are not being much help. The result is excessive stress on the hamstrings, causing a sudden tear injury. Tight hip adductor muscles are frequently found in conjunction with weakness of thegluteus medius and minimus muscles; this can develop into a chronic groin strain.

Manual Testing Procedures

Standard methods of muscle testing are well described in the textbooks by Kendall and Kendall, and by Walther.5 As is stated in Kendall and Kendall, "Muscle imbalance distorts alignment and sets the stage for undue stress and strain on joints, ligaments, and muscles. Manual muscle testing is the tool of choice to determine the extent of imbalance."6 One important key to be aware of is recruitment, also called substitution. This occurs when a patient has a weakened muscle and tries to use another muscle to pass the test. If a patient changes the angle of the joint or tries to rush the test, a careful repositioning will usually uncover a weak muscle. This is the reason that manual muscle testing requires practice and experience for accuracy. Otherwise, a patient can fool the unsuspecting tester.

Carefully performed manual testing procedures can help to identify the specific muscle groups that are weaker, and those that have become shortened in an individual patient, so that general patterns do not have to be assumed. This permits the doctor of chiropractic to develop an individualized plan to reestablish muscle balance, by combining stretches for shortened muscles and strengthening and neurological stimulating exercises for the inhibited groups. In some cases, the muscle imbalance may be caused by a distant malfunction, such as when the psoas muscle is inhibited by excessive pronation.

Successful treatment programs include individually determined exercises to regain postural muscle balance. Exercises to avoid include those that increase the strength of the tight, strong muscles or that stretch out the weakened, inhibited muscle groups. If pelvic unleveling has been identified during postural evaluation, effective treatment requires careful examination of the structures from the ground upward. Most commonly, the lower extremities are not providing the necessary support for the pelvis. In many cases, custom-made orthotic support for foot pronation may be needed. Manual testing of the postural muscles can provide much of the information needed to plan supportive care as the spine is adjusted.

References 

1. Panzer DM, et al. Postural complex. In: Gatterman MI. Chiropractic Management of Spine Related Disorders. Baltimore: Williams & Wilkins; 1990:256.
   
   
2. Griegel-Morris P et al. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther 1992; 72:425-431.
   
   
3. Lewit K. Chain reactions in the locomotor system: coactivation patterns based on developmental neurology. J Orthop Med 1999; 22:52-57.
   
   
4. Geraci MC. Rehabilitation of the hip, pelvis, and thigh. In: Kibler WB, ed. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg;
   
   
5. Walther DS. Applied Kinesiology, Vol. 1: Basic Procedures and Muscle Testing. Pueblo: Systems DC; 1981.
   
   
6. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function (4th ed.). Baltimore: Williams & Wilkins; 1993:270.

Thoracolumbar Junction Responsible for 40% of Low Back Pain

By Joseph D. Kurnik, DC

The thoracolumbar junction syndrome, also known as Maigne's syndrome, has been thought to be responsible for up to 40 percent of common low back pain. This percentage is based upon R. Maigne's personal statistical study of 500 cases. 
This may not represent a purely scientific study, but it is the observation of a respected practitioner. It is also a fairly awesome statement-when considered in relation to the emphasis chiropractors place upon lower lumbar and sacroiliac adjusting and segmental traction procedures.

I would consider the "40 percent" statement as being conservative. In my experience, I have seen the thoracolumbar region responsible or a contributor to well over half of sacroiliac dysfunction and/or common low back pain. As a result of these observations, I increasingly begin treatment of low back pain with thoracolumbar adjusting.

Volumes can be written and discussed concerning this subject. To keep matters brief, I would like to define the thoracolumbar region. Technically, it would be defined as the thoracolumbar junction. I have seen practitioners enlarge this to include T-10/11 throughout L-1/2, as we are dealing with an approximate region. The posterior rami of the T-12 and L-1 nerve roots innervate the superior gluteal regions and the inferior subcutaneous tissues. The anterior rami innervate the inferior abdomen and groin. A lateral cutaneous branch innervates the trochanteric region. Texts of anatomy, however, show many variations of innervation to these regions, which include roots from higher than T-12 and lower than L-1.

Aside from the subject of nerve roots, my most common finding of segmental fixations from T-10 through L-2 is the formation of bilateral or unilateral fixation of the sacroiliac joints. This can be evaluated and confirmed with seated and standing SI joint motion palpation. It is most common to find SI joint fixations released to some degree or completely with TLJ adjusting. This adjusting may partially or completely clear the subjective symptoms of discomfort. Other contributors to the low back complaints and SI joint dysfunction are: 

• lower lumbar dysfunction/problems;
• mid and upper thoracic dysfunction/problems;
• cervical dysfunction/problems;
• extremities dysfunction/problems;
• the SI joints dysfunction/problems; and
• soft tissue reactions dysfunction/problems.

The simplest visual test of the results of treatment to any of these regions is to utilize seated and standing motion palpation analysis of the SI joints. Understanding the principles of nutation and counternutation in relation to stabilization of the lumbar spine would help in understanding all of these relationships.

In previous articles for Dynamic Chiropractic I have presented the processes of SI joint dysfunction, leading to soft tissue reactions, contributing to: 

1. low back pain
2. gluteal complaints
3. groin complaints
4. hip complaints
5. ischial complaints
6. hamstring/quadricep complaints
7. knee complaints

The most common deficiency of all articles, tests, and seminars dealing with this subject is the treatment by adjusting to the thoracolumbar region. It is a difficult region to adjust. With low back and lower extremity complaints in the presence of SI joint dysfunction, I commonly initiate adjustive procedures by adjusting to the dysfunctions (fixations) at the thoracolumbar region. The method of locating the fixations is by utilizing seated and prone motion palpation. Prone motion analysis is the main key to locating these fixations.

The most successful and useful technique of adjusting for the TL region has been the incline adjustment. I can treat 80 percent or more of my patients most effectively with TL region adjusting by utilizing the incline bench. It solves the problem of tissue slack removal, rotational complaints, and painful prone adjusting in this region. It eliminates the problems with extension imbrication of the TL facet joints. The process involves utilization of a standard adjusting bench, where the caudal half elevates to 45-50.( The patient straddles the bench; buttocks against the incline; hands usually interclapsed behind the mid-to-lower neck; with elbows forward. The doctor flexes the torso forward mildly, places his or her fist or hand behind the back, over or under the TL fixation; then pushes the flexed patient back to the incline section and pushes the patient in the anterior to posterior direction, with the vector force directed at the contact point in back. This creates a P to A force upon the selected segment or a fixated intersegmental space. This adjustment can be applied to higher thoracic levels, and I have even reached the L-4 level on some. In order to emphasize rotation, I slightly rotate the patient's torso and position my fist slightly laterally to one side or other. I place a folded hand towel over my hand in order to soften the bony contact.

This adjustment works wonderfully with most patients, but other techniques also may need to be used instead. For example, people with too much flexibility or too little flexibility may not be suitable for this procedure.

It is exciting to use this type of adjustive procedure and pre-analysis and watch the results of mobilization to the TL region. If this procedure is used properly, you will see your treatment successes improve. It will decrease, also, your total or heavy reliance upon treating the low back and lower extremities exclusively with low back adjusting and traction. Very often, traction or specific low back adjusting may not be needed, or they must by supplemented with TL adjusting. This TL adjustive procedure also works very well in treating pregnant women who have TL or low back pain. As a classic '70s TV commercial said, "Try it, you'll like it!"

To Exercise or Not During Pregnancy

To Exercise or Not During Pregnancy

Linda E May1*, Erin M Smith2 and Ehssan Zare-Maivan2

1Department of Foundational Sciences and Research, East Carolina University, Greenville, NC, USA

2Department of Anatomy, Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA

Abstract

There is growing evidence that activity during pregnancy is beneficial for mother and baby; however, less than half of pregnant women meet guidelines for exercise during pregnancy.

Objective: In order to improve the health of women and children, we need a better understanding of the barriers to women participating in activities during pregnancy. Therefore, our aim was to determine women’s perceived barriers to physical activity during gestation. We hypothesize that most women either do not know exercise is safe during pregnancy or women do not know what specifically is safe to do during pregnancy.

Methods: A 16-item questionnaire was placed in several Ob/Gyn clinics in the Kansas City area. Respondents were women between 18 and 40 years of age who were pregnant or had recently delivered and had no pregnancy complications.

Results: Respondents varied in age, BMI, marital status, pregnancies, ethnicity, education, healthcare insurance, and annual household income. We were able to analyze data from 201 surveys. Most participants (97%) perceived their health as good to excellent; yet, 50% were overweight or obese. The most common reason given for women choosing not exercise during pregnancy was lack of time, dislike of exercise, unsure why, and not knowing what to do. However, women who did not exercise spent significantly less time than exercisers doing sedentary and daily living activities than women who exercised while pregnant. If women exercised before pregnancy, then they were 4.5 times more likely to continue during pregnancy. If their health care provider talked about exercise during pregnancy, then women were 7.5 times more likely to continue exercise during gestation.

Conclusions: We found that most women are unsure about exercise during pregnancy or do not know what to do during pregnancy. Although most women feel they do not have time to exercise during pregnancy, non-exercisers spent less time doing daily activities compared to exercisers. Most importantly, women were almost 8 times more likely to exercise if this topic was discussed by their obstetric provider. To increase the number of women exercising while pregnant, future studies should aim at efficient ways to discuss and encourage women to follow the recommended guidelines of safe exercises while pregnant.

Keywords

Pregnancy; Physical Activity; Time; Encourage; Instruction; Pre-Conception; Barriers

Introduction 

In the United States, pregnant women are twice as likely to be sedentary than the average adult [1]. Furthermore, when pregnant women choose to be active, their exercise regimen is of shorter duration and is completed with reduced intensity [1]. In many instances, pregnant women believe rest and relaxation is more important than maintaining an active lifestyle [2]. These beliefs are derived from magazines, family, and friends instead of their obstetric provider [2]. In the United States, most pregnant women are far below the recommended guidelines for activity during pregnancy [3].

There is growing evidence that exercise during pregnancy benefits mother, improves labor and delivery, and benefits the health of her child [1,2,4-10]. In an effort to give children the best start in life, the option to exercise during pregnancy should be considered [5,8,9]. Women who exercise during their pregnancy typically have fewer complaints of somatic pain, reduced subcutaneous weight gain, and an enhanced sense of well-being and self-esteem when compared to non-active pregnant females [6]. Additional benefits for the mother and fetus include a reduced risk of gestational diabetes mellitus, hypertension [6], preeclampsia [10], edema, and preterm delivery [7]. Physical activity during pregnancy improves heart health for mother and baby [8,9]; however, less than half of pregnant women meet recommended guidelines for exercise during pregnancy [3].

Previous studies have examined daily activities, such as house chores, childcare, [1,10] but did not ask the women why they chose not to exercise during pregnancy. In addition, we examined the reasons pregnant women abstained from exercise. In order to begin to improve the health of women and children, we need a better understanding of the barriers to women participating in activities during pregnancy. Therefore, our aim was to determine women’s perceived barriers to physical activity during gestation. We hypothesize that most women either do not know exercise is safe during pregnancy or women do not know what specifically is safe to do during pregnancy.

Methodology

Subjects

This was a prospective, cross-sectional study designed to determine women’s perceived barriers to physical activity during gestation. Participants were recruited from obstetric practices in the Kansas City metropolitan area. They were asked to complete the survey questionnaire while waiting for their obstetric visit. All participants had to be pregnant or have recently delivered. This study was approved by the Kansas City University of Medicine and Biosciences Institutional Review Board (IRB) and conducted in accord with current ethical practices. Responses to the survey questionnaire contained no links to personal medical information. All participants gave informed consent prior to study participation.

Survey Questionnaire

This study utilized items from the Pregnancy Physical Activity Questionnaire and the Kansas Behavioral Risk Factor Surveillance System Questionnaire [1]. A preliminary version of the questionnaire was pilot-tested with a small cohort of women to insure questions were clear and easy to answer and to insure the questionnaire could be completed in a short period of time.

The final version of the questionnaire contained sixteen items and required approximately ten minutes to complete. Nine items assessed personal descriptive information: age, height, weight, marital status, number or previous pregnancies, education level, healthcare coverage, annual household income, and ethnicity. The remaining seven items assessed respondents’ perceptions of personal health, interactions with their physicians, exercise prior to and during pregnancy, reasons for not exercising, and daily activities.

In order to determine differences between women who exercised during pregnancy and those who did not, we used the American College of Obstetricians and Gynecologists (ACOG) recommendations of previously sedentary women participating in at least 3 days per week of exercise [4]. Based on responds to the question “Do you participate in exercise at least 3 days of the week,” women were classified as Exercisers or Controls.

Data Collection

Questionnaires were placed in the waiting rooms of participating clinics. A cover letter was attached to each survey to explain the purpose of the study, and that every question was optional and participation would not affect their care at the clinic. The cover letter could be kept by participants and contained contact information for the Principal Investigator and Institutional Review Board office. Participants placed completed questionnaires in a locked drop box located in each waiting room.

Data Analysis

Patient demographic data is reported as means + standard deviations (SD) or as percentages, where appropriate. Data are reported as the frequency of occurrence. Differences between self-reported exercisers and control women were examined using t-tests for continuously scaled variables and chi-square tests for categorical variables. Next, logistic models were used to examine the predictors of participation in activities. In the first model, demographic variables, including gravida, education, insurance, and ethnicity, and provider inquiry were entered as predictors. Gravida was coded as first pregnancy, second pregnancy, or more than two pregnancies. Education was stratified as high school degree or less compared to some college up to graduate degree. Insurance status was stratified as private insurance or Medicaid/no insurance. Ethnicity was dichotomized to be white or non-white. In the second logistic model, we entered whether they exercised prior to pregnancy as predictors. Odds ratios along with their 95% Confidence Intervals (C.I.) were calculated for all independent variables in the models. All analyses, statistical significance was defined as a=0.05. Statistical analyses were performed using PASW software (rel. 17, SPSS Inc., Chicago, IL).

Results

We analyzed 201 completed surveys from women between 18 and 40 years of age with healthy, singleton pregnancies (Table 1).

Participant Demographics

The mean age of the entire sample was 28.2 ± 5.6 years. Mean height was 65.0 ± 2.8 inches and mean pre-pregnancy weight is 158.0 ± 39.5 pounds. There was diversity in the sample as far as education (25.5% some high school/diploma, 28.5% trade school/some college, 46.9% college graduate) and household income (27.6% earn <$35,0000, 38,3% earn between $35,001-75,000, 34.1% earn >$75,001). The modal respondent was a white, employed, insured, married college graduate in her first pregnancy. Additional demographic variables are presented in Table 1. There are no statistical differences between group demographics; although, some sub-group sizes are small (i.e. ethnicity), this further demonstrates the diversity of the population in both groups. There were no significant differences between exercise and control for demographic variables (Table 2).

Participant Daily Activities

Participants reported the average amount of time daily used for sedentary activities such as using a computer, watching TV, reading, and talking on the phone (Table 3). Women that did not exercise during pregnancy spent less time using the computer (p=0.04) and reading (p=0.05) compared to exercisers (Table 3). Participants also reported the average amount of time per day used for physically active daily activities, such as: walking (not exercise), meal preparation, childcare, playing with kids, house chores, shopping, and gardening (Table 3). Women that did not exercise during pregnancy spent less time preparing meals (p=0.06), doing house chores (p=0.03), and shopping for the family (p=0.01) compared to exercisers (Table 3).

Participant Health Status 

Using self-reported height and pre-pregnancy weight, the average pre-pregnancy BMI of participants was 26.2 ± 6.0 (Table 2). Almost all women (96.8%) classified their health as good, very good, or excellent, while the remainder classified their current health as fair or poor. Prior to pregnancy, 54.7% of women exercised at least three times per week, but this declined to 21.4% during pregnancy.

Participant-reported Exercise Inquiry 

More than half (60.7%) of women reported to their obstetric provider discussed with them about exercise during pregnancy. Less than half (40.5%) reported their provider instructing them how to exercise.

Reasons women do not exercise during pregnancy

The most common reason (42.9%) reported for not exercising during pregnancy was lack of time. The next reasons for not exercising were: dislike exercise (16.1%). Not feeling good (tired, sick, pain) 13.1%, don’t know how to exercise 13.0%, not sure 9%, Fear of Exercise 4.5%, and lack of transportation or money 4.5%. There was a significant difference between groups in reasons for not exercising with the control group reporting time (p<0.001), dislike (p=0.007), not sure (p=0.006), and don’t know how to exercise (p=0.02) significantly more often than the exercise group. Logistic regressions indicated that no demographic variables significantly predicted reported behavior (Table 4). Patients who reported exercising prior to their pregnancy were 4.9 times more likely (OR=4.9, 95% CI=1.85-13.07) to exercise at least three times per week during pregnancy (Table 4). Patients who reported their provider talked to them about exercise during pregnancy were 7.5 times more likely (OR=7.5, 95% CI=2.08-27.0) to exercise at least three times per week during pregnancy (Table 4).

Discussion 

We hypothesized that women either do not know exercise is safe during pregnancy or do not know what specifically is safe to do during pregnancy. We found for women that did not exercise while pregnant, the reasons are time, dislike of exercise, unsure, and don’t know how to exercise. Although lack of time and dislike of exercise may not be modifiable during pregnancy, the other two reasons can most likely be modified. For example, the two main predictors of women choosing to exercise during pregnancy are 1) provider talking with them about the benefits and risks of exercise during pregnancy and 2) exercise prior to pregnancy. Based on these findings, we can confirm our hypothesis.

The finding that women reported lack of time as a reason for not exercising during pregnancy is similar to other studies when women reported doing less activities [2,7] and believed that rest, relaxation, and diet are more important than maintaining an active lifestyle [2,11]. Interestingly, these women actually spent significantly less time in sedentary and physically active activities compared to exercisers suggesting they may not be good time managers. Nonetheless, fitness instructors and medical professionals can provide advice on how physical activity during pregnancy can attenuate or alleviate this symptom as well as the (13.1%) feelings of tiredness, sickness, and pain. Similar to other research [12], some women reported either being afraid to exercise or they were not sure why they did not exercise during pregnancy. For women who reported feeling too tired, sick or in pain to exercise, providers can explain how exercise during pregnancy is known to provide more energy, decreased musculoskeletal pain, enhancement of mood, and possibly shorter labor and delivery [5], enhanced sense of wellbeing, and improved sleep [4]. Women that lack transportation and finances to go to a gym, or don’t like exercise can be helped by instructors showing them safe exercises to do at home, checkout videos from library, or find information and instructions online [4,13]. Depending on a woman’s stage within the stages of change model, these factors may not be modifiable, while others can.

This study found that maternal activity prior to pregnancy had a significant impact on maternal activity during pregnancy. This finding is similar to another study in which preconception nutrition modification helped improve pregnancy outcomes relative to during pregnancy behavior modification [14,15]. However, these findings are different based on the study population as well. For example, one study found younger women and women with children were less likely to engage in preconception healthy behaviors [16]. However, women with postgraduate education were more likely to practice preconception care [16]. There should be a focus on educating young preconception women regarding the importance of preconception and during pregnancy exercise [17].

Some women, who do not exercise during pregnancy and report being unsure why they do not exercise or they do not know what to do, may be influenced into a positive behavior change while pregnant. For example, we found provider intervention increased the likelihood of a pregnant patient exercising by almost 8 times. This is similar to other studies related to health care provider intervention as a means to change patient behavior and improve pregnancy outcomes [18-20]. Although a previous study suggests women’s beliefs are derived from magazines, family, and friends [2,21]. A recent study found women are more likely to be active during pregnancy when encouraged by their health care provider [22]. Furthermore, women who had other healthy behaviors (i.e. healthy eating), they were three times more likely to exercise during pregnancy [22].

It is important to mention this study has limitations to consider. First, although we had a diverse participant population, our sample only included 3 large clinics in the greater Kansas City area: 2 in Kansas and 1 in Missouri. An inherent limitation involves the bias of self-reported data. However, our questionnaire was validated and the population data is similar to other studies. Although selection bias is a concern in this type of study design, we tried to minimize this by using a general cover letter not mentioning exercise or activity, but interest in completing a questionnaire for a study; these results may still be generalized. However, in order to verify these results a case control study would be informative.

Conclusion 

Overall we found the most common reason for women not exercising while pregnant is lack of time. In addition to reporting a lack of time, many non-exercisers reported a dislike of exercise. Although, lack of time or interest in exercise is not a new finding and is most likely not modifiable during pregnancy, we found other reasons which might be changed during pregnancy. For example, women also report not exercising during pregnancy due to not knowing how to exercise and being unsure why they should exercise. For women with these reasons, it may be possible to help them choose to exercise. We also found, women were almost 8 times more like to exercise during pregnancy if their obstetric provider discussed this topic with them. Based on these findings, future studies should target increasing the education and awareness of pregnancy women on this topic, such as assessing the effectiveness of different methods to encourage and discuss the current guidelines and instructions for exercise during pregnancy.

Acknowledgements

The authors thank Alan Glaros at Kansas City University of Medicine and Biosciences for his support in formatting the questionnaire, allowing us to use the questionnaire scanner, and running statistical analysis. We are especially grateful to the women who participated in this study.

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