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Depends on the success rates you want to obtain in laser therapy. Higher power allows for a greater range of clinical applications, leading to patient satisfaction. Not to mention, your financial satisfaction. Next to an accurate diagnosis and proper clinical training in laser therapy application, dosage is the single most important parameter for a successful outcome in laser therapy. Too little energy produces no effect. The primary factor in lasers that determine dosage is power. 

DOSAGE = Power x Time 

While power is the amount of energy measured at the source of the beam, dosage is the amount of energy delivered to the skin. Dosage may also be referred to as energy density or fluence. Its unit of measure is the Joule. Higher power gives a higher power density, which very often is beneficial.  Insufficient power cannot be compensated with more treatment time!  Positive results require more than increasing time. By itself dosage cannot adequately describe laser treatment. One must ask several questions. What is the depth of the target tissue? Is the laser power strong enough to reach this target? 65% of laser energy is absorbed by the subcutaneous tissues, so you must take this into account when determining the laser power options. 

Example:

Given enough time a 500mW laser could administer a dosage equal to that given by a 2 watt instrument. Yet results will be very different. The higher power density of the 2 watt laser will penetrate far more deeply and with greater effect. 

Dosages and power at higher ends typically provide better results, as long as treatment intervals are not too close together. 

I often meet doctors who do not know what type of laser they should purchase. When asked, it is not unusual for them to respond 3B. Make sure to investigate the option of Class 4 lasers too. Trust the science, not the sales brochures!

Perry Nickelston, DC

www.k-laserusa.com

www.painlasercenter.com

1-866-595-7749 Ext. 102

Tags: Integrative Treatment Strategies, Class 4 Laser Therapy, General by Dr. Perry
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COMMON KINETIC DYSFUNCTIONS

There are three common kinetic chain dysfunctions you must be aware of to treat a patient effectively. These include the Lower Crossed Syndrome, Upper Crossed Syndrome, Pronation Distortion Syndrome.

LOWER CROSSED SYNDROME

A patient with lower crossed syndrome shows increased lumbar lordosis and an anterior pelvic tilt. There are muscles that are too tight and others that are too weak. The muscles that are too tight include gastrocnemius, soleus, hamstring complex, adductor complex, hip flexor complex (psoas, rectus femoris, tensor fascia latae), and the erector spinae. The muscles that are commonly weak or inhibited include posterior tibialis, anterior tibialis, gluteus maximus, gluteus medius, transverse abdominus, internal oblique, multifidus, and deep erector spinae. This pattern of tightness and weakness causes predictable patterns of joint dysfunctions, movement imbalances, and injury patterns.

Joint dysfunctions include:

• Subtalar joint • Proximal tibio-fibular joint

• Tibio-femoral joint • Iliofemoral joint

• Iliosacral joint • Sacroiliac joint

• Lumbar facet joint

Common movement dysfunctions include decreased stabilization of the lumbar spine characterized by excessive lumbar lordosis. This is caused by tightness in the hip flexors and lumbar extensors as well as weakness in the lower abdominals and lumbar stabilizers. Common injuries include hamstring strains, anterior knee pain, low back pain, sacroiliac pain, and hip pain.

Dr. Perry Nickelston, DC

www.k-laserusa.com

www.painlasercenter.com

1-866-595-7749 Ext. 102

 

Tags: Integrative Treatment Strategies, Practice Tips of the Day, General by Dr. Perry
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 Whys is this topic on my chiro blog? Because most people with chronic back pain are overweight and clinically obese. Duh! That’s why. You need to offer them advice and guidance to a positive end result. If you don’t a more successful doctor will. How is that for a reality kick in the pants? Here a 6 ways to begin.

1. Eat Five or Six Small Meals.
Despite compelling information arguing to the contrary, many people still consume most of their food in two or three large meals every day, often going for hours at a time eating nothing in between. Sure, you can lose weight and fat on a reduced-calorie trio of meals, but you can’t train your body to burn fat efficiently, which is key to maintaining weight loss.  A nutritious meal or snack every three hours or so provides a number of metabolism-enhancing benefits, stabilizes your blood-sugar levels, ensures adequate nutrients are constantly on hand, and helps control hunger-induced cravings for sweets and fats. It also leads to more effective glycogen storage in the liver and muscle tissues; thus, your body won’t cannibalize muscle as an energy source during training.

2. Drink The Right Amount Of Water

Did you know that being dehydrated makes you fatter?  Why?  Muscle Glycogen (stored sugar energy created from ingested carbohydrates) is stored along with water.  For every gram of Glycogen in the muscle there should be three of water.  Dehydration forces Glucose to remain in the bloodstream instead of muscle until it reaches the liver for overflow storage.  When the liver is full, the Glycogen (sugar) has no place to go but your FAT cells.  Not good!!  So how much should you drink? (.55 x your bodyweight in pounds = # ounces day                                                                                                                                    

3. Never Skip Breakfast

I guarantee if you skip breakfast you will NEVER get a lean, toned sexy physique!  Let me repeat, NEVER!  Why? Just like Mom used to say, breakfast is the most important meal of the day.  Gotta love Mom!  Breakfast sets the tone for your metabolic rate the entire day.  Skipping this meal sets your metabolism low and Insulin will spike with the first large meal you ingest.  Then get ready for the sugar high crash and burn feeling.  Your largest carbohydrate meal should be eaten at breakfast.  Load up on the complex carbs and remember to combine them with protein.

4. Cheat On Your Diet
Once in a while you should let loose and give yourself a break from the rigors of dieting and scale watching. In fact, it’s helpful in losing weight. That’s because continual dieting eventually leads to roadblocks where the body responds by slowing its metabolic rate. Strict dieting also takes its toll on you mentally, and can leave you feeling deprived. That’s a bad combination! Taking in a couple of high calorie meals once every 7-10 days not only provides a mental break from dieting, but helps you side-step roadblocks by preventing the body from entering a starvation state where the metabolic rate slows.

5. Do Smart Cardio
What happens to someone who performs 1-2 hours of cardio a day? (We know you’re out there!) They send their body into a tailspin, a state where the “starvation hormones” secreted by the body skyrocket (it’s your body’s survival mechanism, a response to too much exercise!) causing fat cells to try to hoard their energy! Moderate cardio is the way to go. Four to five 20-30 minutes sessions per week is all that it takes. Any more than that and you run the risk of losing precious muscle tissue, which negatively affects your metabolic rate and your ability to burn fat.

6. Start Weight Training

Some people avoid weight training because they don’t want to bulk up. However, strength training is a critical element to maintain a healthy weight and strengthen your body.  The average person who strength trains two to three times a week for eight weeks gains 2.75 pounds of lean weight…and loses 10.5 pounds of fat.  Muscle is a metabolically active tissue that requires calories for support.  Meaning, the more muscle you have the more body fat you burn at rest. Always do cardio work AFTER weights, NEVER before!  Why? You burn about 300% more body fat. 

BONUS TIP:

COCONUT OIL Start with one tablespoon per day and work up to three tablespoons per day. Coconut oil raises your metabolism, which helps detoxify your body. It stabilizes the blood sugar levels which decreases physical cravings. It also protects the heart cells from damage. Next to mother’s milk, it is nature’s highest source of medium chain fatty acids (MTC’s), which raise the body’s metabolism, leading to weight loss. It has fatty acids such as lauric acid and monoglycerides. When lauric acid is consumed in the body, it enhances the immune system to help the body fight infections, bad bacteria and underlying yeast invasions. Lauric acid is known to be anti-viral, anti-fungal and anti-bacterial.

Here are two athletes I took care of with laser therapy at the Arnold Scwarzenneger Bodybuilding Expo. Specializing in treating athletes and fitness competitors is my niche market. Get one too and you will always be successful. Why? You are delivering value to a specified marketplace. Mine is laser. What is yours?

Dr. Perry Nickelston, DC VP Practice Devlopment for K-Laser USA and Director of The Pain Laser Center in Ramsey, NJ. 1-866-595-7749 Ext 102

www.k-laserusa.com

www.painlasercenter.com

Tags: Integrative Treatment Strategies, General by Dr. Perry
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“You miss 100% of the shots you never take.”

If you see overweight people in your office, and most of you probably do since they usually have back pain, it is important to evaluate the adrenal glands. They can be a primary cause of chronic pain due to elevated levels of the catabolic hormone Cortisol. Ignore them at your own peril. I have found Ionic Footbaths to be a great way to help detoxify the body and improve hormone function. Worth invbestigating!

Hormones and Weight Loss

Adrenal Fatigue and the Cortisol Connection

Adrenal Fatigue is a syndrome that results when the adrenal glands function below the necessary level, usually because of intense, prolonged or repeated stress. Its severity can range from a general sense of tiredness and the inability to lose weight, to difficulty getting out of bed for more than a few hours. Every organ and system in the body is more profoundly affected if left untreated.  Changes occur in carbohydrate, protein and fat metabolism (leading to weight gain); fluid and electrolyte balance; nervous system function and even libido. Although it affects millions of people in the U.S., conventional medicine does not yet recognize it as a distinct, treatable condition. Most doctors are not aware of adrenal fatigue. They only recognize Addison’s Disease, which is the most extreme end of low adrenal function. Astute doctors who are familiar with the degrees of adrenal fatigue usually test the adrenal hormone levels in the saliva.

What are the adrenal glands?

The adrenal glands are two small glands, each about the size of a large grape. They are situated on top of the kidneys. Their purpose is to help the body to cope with stress and help it to survive. Each adrenal gland has two compartments. The inner or medulla controls the sympathetic nervous system through secretion and regulation of two hormones called epinephrine and nor epinephrine that are responsible for the fight or flight response. The outer adrenal cortex comprises 80 percent of the adrenal gland and is responsible for producing over 50 different types of hormones.

 Is too much Cortisol bad for you?

Chronically elevated cortisol levels may have a variety of negative effects. Cortisol is catabolic, and elevated cortisol levels can cause the loss of muscle tissue by facilitating the process of converting lean tissue into glucose. An excess of cortisol can also lead to a decrease in insulin sensitivity, increased insulin resistance, reduced growth hormone levels, and reduced connective tissue strength. Chronically elevated levels of cortisol can also decrease strength and performance in athletes.

 Should I take Cortisol supplements?

In my opinion, no, absolutely not. Cortisol suppressing supplements are not a valid solution for losing weight. No pill can replace a healthy program of diet and exercise. Pills do not make you lose fat. Body fat is lost by creating a caloric deficit through exercise and nutrition.

 What can I do naturally?Avoid very low calorie diets, especially for prolonged periods of time. Low calorie dieting is a major stress to the body. Low calorie diets increase cortisol while decreasing testosterone. Avoid overtraining by keeping workouts intense, but brief (cortisol rises sharply after 45-60 min of strength training) Suppress cortisol and maximize recovery after workouts with proper nutrition: Consume a carb-protein meal or drink immediately after your workout. Get plenty of quality sleep (sleep deprivation, as a stressor, can raise cortisol). Avoid or minimize use of stimulants; caffeine, ephedrine, synephrine, etc.  

Dr. Perry Nickelston, Vice President of Practice Development for K-laserUSA and clinic director of the Pain Laser Center in Ramsy, NJ.

www.k-laserusa.com

www.painlasercenter.com

1-866-595-7749 Ext #2

Tags: Integrative Treatment Strategies, General by Dr. Perry
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One of the most effective ways to help the #1 cause of pain is laser therapy. What is the number one cause of pain? Trigger points! Treating a trigger point with 180-250 joules of laser light combined with manual therapy is a fantastic way to relieve chronic pain. As long as you are trained in how to diagnose primary trigger points, have an accurate diagnosis, and are proficient in laser therapy clinical applications. The main reason laser therapy is not successful as a treatment protocol is lack of proper/sufficient dosage to the ‘intended target tissue.’ You can’t heal it if you can’t reach it.

Ever wonder what can be done to help headaches, neck stiffness, carpal tunnel type symptoms, tennis elbow, bursitis, frozen shoulder, back pain, low back stiffness, sciatica, shin splints?  Find a Doctor that is skilled with finding and treating trigger points and you just might find immediate relief for pain that has been afflicting you for years. 

Trigger points are accumulations of waste products around a nerve receptor. Often times they feel like nodules or taut bands of fibers within the soft tissues. Trigger points form in muscles that have been overused, injured due to an accident or surgery. Common characteristics are increased muscle tension and muscle shortening. Increased muscle tension is the primary side effect of trigger points and pain is the most common secondary effect.  

Trigger points can present themselves as referred patterns of sensation (pain that travels away from the trigger points) such as sharp pain, dull ache, tingling, pins and needles, hot or cold, as well as can create symptoms such as nausea, ear ache, equilibrium disturbance, or blurred vision. Trigger points can exist in two states, either active or latent. Active trigger points are those that cause discomfort. Latent trigger points wait silently in the muscle for a future stress to activate them. Aches and pains which began in the past become more frequent and severe in intensity as we age. It is common to attribute this discomfort to arthritis instead of our tight muscles which harbor trigger points.
 

Trigger points are not visible with traditional medical testing such as MRI or X-ray and are frequently over looked by most healthcare practitioners as the cause of your pain.
 

80% of the trigger point locations are common with acupuncture treatment locations. When trigger points are not treated, they will create satellite trigger points in the affected area. For instance, a trigger point in the trapezius muscle may cause a trigger point to appear in the shoulder blade muscle. The trigger point in the shoulder blade is the most common cause of shoulder pain, especially when exercising. And, voilà! - a case of shoulder Rotator Cuff Syndrome.  (Not good) 

To break-up a trigger point, static compression (pressure) is applied for 10 seconds, released, then pressure applied for 10 more seconds in a pumping action while the client breathes deeply. This action flushes the toxins and calms the nerves. Releasing trigger points releases endorphins so the result is elimination of discomfort as well as being energized.

Determining which “one” is causing the pain is where the specialty comes into play.  Not all knots cause pain.  That’s why traditional massages usually DO NOT work.

Trigger point massage is not a relaxing, “fluff and buff” technique. It requires the participation of the client to communicate the presence and intensity of pain and discomfort. The doctor and patient work together as a team to maximize the effectiveness of the treatment to ensure long-term relief.  It is common to find great improvement after one treatment. Repeated treatment may be necessary for those with chronic trigger points. Stretching should be done as “home work” to encourage the muscles that have been treated to stay in a lengthened position.  One reason why people may not have improved with traditional medicine, physical therapy or chiropractic is because these trigger points were never released before treatment began.  You cannot stretch, exercise, or rest away a trigger point.  It must be actively removed by specialized treatment before any other type of therapy will help.

Research lists nutritional deficiencies or inadequacies as “perpetuating factors.” A good multi-vitamin supplement that is high in anti-oxidants and is in an encapsulated form can help ensure that once treated, trigger points do not reform.

Dr. Perry Nickelston, DC

www.k-laserusa.com 1-866-595-7749 Ext. #2

www.painlasercenter.com

Tags: Integrative Treatment Strategies, Class 4 Laser Therapy, General by Dr. Perry
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TMJ Syndrome: An Integrative Treatment Approach

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By Perry Nickelston, DCTemporomandibular joint (TMJ) syndrome can be one of the most difficult and elusive conditions to treat.

Patients can suffer with symptoms, despite years of traditional medical therapy. In order to effectively alleviate the symptoms associated with TMJ, one must use an integrated treatment approach combining various therapeutic modalities.

One of the primary reasons for a poor outcome in TMJ treatment is a lack of clinical understanding of the relationship between articular, muscular and neurological causes of the condition. If any of these potential causative factors are missing in the treatment approach, poor results can occur. The doctor who diagnoses and treats all factors will notice an increase in positive results and patient satisfaction.

TMJ Anatomy

The temporomandibular joint is the articulation between the condyle of the mandible and the squamous portion of the temporal bone. An internal disk known as the meniscus is a fibrous, saddle-shaped structure that separates the condyle and the temporal bone. The meniscus and its attachments divide the joint into superior and inferior spaces.¹ These disks not only act to separate the hard bones, but also to absorb and cushion vibrations and impact transmitted through the joint.

The TMJ is controlled by muscles. The muscles controlling the TMJ are predominantly the masticatory muscles including the temporalis, masseter, lateral pterygoid, medial pterygoid and buccinator. However, other muscles may have an effect on the functioning of the TMJ such as the neck, shoulder and back muscles.² This is the key area overlooked by physicians when treating TMJ syndrome. Primary muscles include the scalene, sternocleidomastoid, trapezius, levator scapulae, supraspinatus, infraspinatus, rhomboids and latissimus dorsi. There has even been a case in which the soleus muscle affected the TMJ via kinetic-chain dysfunction.

Causes: Arthritis is one cause of TMJ symptoms. It can result from an injury or from grinding the teeth at night. Another common cause involves displacement or dislocation of the disk that is located between the jawbone and the socket. A displaced disk may produce clicking or popping sounds, limit jaw movement and cause pain when opening and closing the mouth.

The disk also can develop a hole or perforation, which can produce a grating sound with joint movement.³ Bruxism (teeth grinding) causes micro-trauma to the joint capsule, ligaments and soft tissue, leading to symptoms from active trigger points and adhesions.

Common symptoms: Clicking or popping, bruxism, headaches, earaches, dizziness, eye pain and neck/shoulder pain.

Integrative Treatment

One must take into consideration all of the physiological and anatomical structures listed above. Starting with a three-day-a-week program, the following therapy approach has proven to be successful in alleviating symptoms associated with TMJ dysfunction.

Laser Therapy

The bio-stimulation, anti-inflammation, and pain-alleviating effects of laser light are what makes this therapy so special and of prime importance. Laser dosages of between 600 and 700 joules per side are recommended. Be sure to aim the laser inside the joint capsule with the jaw open and cover all the trigger points found on palpation. You may also laser the pterygoid muscles from inside the mouth.

If TMJ symptoms are due to arthritis, laser therapy may be the only therapeutic modality to offer lasting pain relief. Due to treatment time constraints and penetration capabilities of low-level cold lasers, higher-power class-4 therapy lasers may be the preferred instrument of choice.

Trigger Points

Check all of the muscles previously listed. You may use ART, MRT, TPT or MFR depending on your skill level. Primary trigger points include the pterygoids, sternocleidomastoid, scalene and temporalis. These points can be excruciatingly painful when treated, so make sure to prepare the patient. Active trigger points may take six to 10 therapy sessions for resolution. If you feel comfortable, do trigger-point therapy with a gloved finger to the pterygoids inside the mouth.

Check the infraspinatus carefully. These points are typically latent and only present pain on palpation. A knotted infraspinatus causes internal rotation of the glenohumeral joint and external rotation of the scapulae, leading to over-recruitment of the rhomboids and trapezius, resulting in forward-head carriage. This abnormal posture over-stimulates the scalene and sternocleidomastoid muscles, causing faulty TMJ mechanics and an elevated first rib.

Check the latissimus dorsi attachment at the thoracolumbar junction. Myofascial adhesions here can restrict normal scapular motion during glenohumeral abduction, resulting in cervical kyphosis and altered righting mechanisms via kinetic-chain dysfunction. MFR and ART can be very successful in this region. A high dose of laser therapy along the entire thoracolumbar region with a dosage of 1,000 joules can break up chronic adhesions that have been lying dormant for years. This can be the “magic bullet” area for unresolved shoulder and neck disorders, too. Don’t overlook it!

Articular

Check for a hypomobile occiput and atlas articulation. I have found occiput is the primary culprit, usually subluxated posterior. An elevated first rib may cause a kinetic-chain alteration with the sternoclavicular joint, resulting in overactive neck flexors. Normalizing a subluxated first rib can have an immediate pain-relieving effect on TMJ pain and chronic trapezius muscle spasm. Speed is of utmost importance when adjusting a first rib.

I only recommend manually adjusting a TMJ if you have specialized training in TMJ disorders or if you work directly with a TMJ specialist. Adjusting the wrong side, an incorrect line of drive or a hypermobile joint can have severe pain-inducing consequences.

Cranial

Using a gloved finger/thumb, put superior pressure for five seconds on the center of the hard palate and then bilaterally on the horizontal plate by the back molars. Repeat three times while the patient inhales slowly, releasing pressure as the patient exhales. This technique normalizes function of the sphenoid bone, which can improve TMJ mechanics.

As you can see, success in TMJ treatment involves looking way outside of the proverbial box. The word integrate means “to make something part of a larger whole, or be joined or made part of a larger whole.” Remember to look at the whole patient and don’t get caught up in the vicious cycle of targeted symptomatic care. This integrated treatment protocol can give profound improvement to your patients’ quality of life. Take the time to implement them; your patients will be glad you did, and so will you.

References

1. Basmajian J. Muscles Alive. Baltimore: Williams and Wilkins, 1974.
2. III Gillespie T. TMJ Anatomy. Accessed Oct. 12, 2007 from University of Washington: www.rad.washington.edu/anatomy/modules/ TMJ/TMJAnatomy.html.
3. NYU Medical Center. Accessed Oct. 11, 2007, from www.med.nyu.edu/surgery/oral/patients/ article.html.

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Dr. Perry Nickelston is a 1997 graduate from Palmer College of Chiropractic. He practices in Ramsey, N.J., and is vice president of practice development for K-Laser, USA. He can be reached for clinical questions or discussion at www.k-laserusa.com.

Tags: Integrative Treatment Strategies, General by Dr. Perry
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Here is my very FIRST published article. This one received calls and questions from all over the world. Guess doctors really liked the topic. Shoulders are my favorite condition to treat. They are my ‘Condition Specific Niche’. More on this killer practice strategy later. Start reading the first paragraph below and click the link to finish the article. Enjoy.

One of the most common injuries to afflict athletes of any skill level is shoulder pain. From the “weekend warrior” to the professional athlete, to the average fitness buff getting into shape; no one is immune to injury. 

Beyond obvious traumatic onset, very few clinicians understand the mechanism for acute shoulder injury and chronic pain. The majority of shoulder problems develop from microtraumatic events occurring due to poor joint biomechanics and muscular movement imbalances. It is important for the clinician to be aware that shoulder pain is usually a symptom of deeper problems that, unless corrected, may lead to total functional impairment.

Clinical Perspective

Microtraumatic shoulder injuries happen in a predictable pattern: impingement > tendonitis > bursitis > rotator cuff injury. This leads us to the upper crossed syndrome (UCS). This syndrome is based on Dr. Vladimir Janda’s pioneering work in researching and understanding the predictable pattern of muscular compensation and postural imbalances in the body. He postulated that faulty movement patterns on a poor postural base contribute to habitual overuse in isolated joints, while they minimize normal movement in others, thus creating a self-perpetuating cycle of dysfunction and eventual injury.

UCS leads to a forward head posture causing strain to the muscular attachments of the shoulder and shoulder blade. An anterior tilt and abduction (“flaring out”) of the shoulder blades occurs, producing a rounded shoulder appearance. Due to the rounded shoulder posture, the mechanical axis of rotation of the glenoid fossa (shoulder socket) becomes altered. The humerus (arm) now requires additional stabilization from muscles that typically are quiet: the levator scapulae, upper trapezius, subscapularis, pectoralis minor and supraspinatus muscles. Postural overdevelopment of these muscles creates a deltoid shear (crossing of rotator cuff under AC joint), leading to shoulder impingement, tendonitis and bursitis syndromes.

Proper rehabilitation of the shoulder must include protocol for reversing the upper crossed syndrome. So, how do you do that? I have found the following program to be the most effective form of rehabilitation treatment.

Treatment Protocol

Due to chronic shortening, tightness and weakness in the primary stabilizers of the shoulder (supraspinatus, infraspinatus, teres minor and subscapularis), muscular adhesions and trigger points develop that must be removed before active/passive stretching. Failure to do so will result in stretch-reflex reciprocal inhibition and increased loss of muscle tone. Performing four to six sessions of myofascial release and trigger-point therapy usually is sufficient. Check all muscles in the UCS chart above. The most commonly affected muscles are the scalenes, pectoralis minor, infraspinatus and subscapularis.

Here are other aspects of this treatment protocol.

• Ultrasound the infraspinatus or subscapularis, depending on the most painful area of palpation and trigger-point referral pattern. Laser therapy also may be used. Typical dose is 170 Joules per point.
• Shoulder-blade retraction exercises for building the serratus anterior/posterior, trapezius and rhomboids, and for restoring scapular stabilization strength.
• Rotator cuff protocol: External rotation (three sets of 12-15 repetitions). Internal rotation not recommended due to the tendency of the subscapularis to become tight and overdeveloped.
• Y,T,W,L exercises on the stability ball to restore and enhance muscular recruitment patterns.
• Manipulation of the 5th and 6th cervical vertebrae and upper thoracics. Check the first rib for superior elevation, which can cause faulty AC joint mechanics, impingement syndrome and unrelenting trapezius muscle spasm.
• At-home treatment consists of rest and TENS to control pain. The tennis ball massage technique on the trapezius and infraspinatus (five to seven times per day) is extremely beneficial for breaking up active/latent trigger points. Self myofascial release with foam rollers on the upper back, lower latissimus dorsi, teres major/minor and infraspinatus will accelerate healing.

Most patients will be asymptomatic by the sixth visit and will demonstrate significant improvement in functional performance. The length of time it took to develop the problem is an indicator of how long you will need to work on correcting the faults before results will be felt. Don’t forget that pain is often only the tip of the iceberg, directing you to the real underlying problem: upper crossed syndrome.

Dr. Perry Nickelston, DC www.k-laserusa.com

Tags: Integrative Treatment Strategies, General by Dr. Perry
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You have a patient with persistent knee pain. Objective tests (X-rays, MRI, orthopedic tests) are unremarkable. Standard physical therapy and rehabilitation protocols have helped minimally at best.

What do you do? Is it time to give up and send them to a specialist? Not just yet. Look a little deeper into the likelihood of a muscular imbalance condition known as the lower crossed syndrome (LCS).

LCS is based on Dr. Vladimer Janda’s work in researching and understanding the pattern of muscular compensation and postural imbalances in the body. These imbalances contribute to habitual overuse in isolated joints and faulty movement patterns, creating repetitive microtrauma, dysfunction and chronic injury.

The primary muscles involved in LCS are as follows (see chart at right). Muscle imbalances can be caused by postural stress, pattern overload, repetitive movement, lack of core strength, lack of neuromuscular control, immobilization, and decreased tissue recoverability following activity. These muscle imbalances result in reciprocal inhibition, synergistic dominance and arthrokinetic (joint) dysfunction.

Reciprocal inhibition is the neuromuscular condition that occurs when increased neural drive in a specific muscle causes decreased neural drive to that muscle’s functional antagonist. For example, if an individual has increased neural drive or tightness in the iliopsoas (very common), then the functional antagonist (gluteus maximus) can have decreased neural drive, resulting in muscular inhibition, weakness and synergistic dominance.

Typically Tighten and Shorten

Iliopsoas

Rectus femoris

Erector spinae group: thoracolumbar lumbosacral L5-S1

Quadratus lumborum

TFL/iliotibial band

Short adductors

Hamstrings

Piriformis

Gastrocnemius

Typically Weaken

Abdominal group

Gluteus medius

Gluteus maximus

VMO

Tibialis anterior

Plantar fascia

Synergistic dominance occurs when synergists take over function for weak or inhibited prime movers, causing faulty movement patterns and tissue overload. In the above example, if the gluteus maximus has decreased neural drive, synergist (hamstrings), stabilizers (erector spinae), and neutralizers (piriformis) substitute and become overactive. This leads to altered force-couple relationships, joint dysfunction and chronic subluxations.

Having tightness or hyperactivity in the iliopsoas can cause knee pain. The gluteus maximus (GM) is primarily responsible for eccentric deceleration of hip flexion, internal rotation and adduction. Weakness or inhibition of the GM increases sacral rotation and stresses the tibiofemoral joint, leading to patellar tendonitis. This alters the length-tense relationship of several muscles. The gluteus medius is weakened, taking away its ability to perform hip abduction. The TFL and iliotibial band begin to compensate, and this overactivity inhibits the vastus medialis oblique (VMO), increasing femoral flexion, internal rotation and adduction. This increases stress to the tibiofemoral joint and the patellofemoral joint. And to think, all of this resulted from weak and overactive muscles.

So, how do you fix it? Good question. The following protocols have proven to be very effective in helping to reverse this syndrome.

• Muscular adhesions and active/latent trigger points must be removed before attempting any stretching or strengthening program. Failure to do so will result in further muscular inhibition. Perform myofascial release (MFR) and trigger-point massage (TP) to muscles in the LCS chart above. Pay special attention to the gluteus muscles, iliopsoas and TFL. Be sure to check the soleus muscles, too. An overactive soleus can result in decreased toe-off motion of the foot during the gait cycle, causing faulty lower back mechanics.
• Ultrasound 5 minutes (1.5 W.c2 constant) on the gluteus medius and/or TFL, or you may substitute laser therapy, 150 joules per point. The sacrotuberous ligament also may require attention.
• Self-myofascial release with biofoam roller massage on all muscles listed in the chart.
• Chiropractic adjustments to the hypomobile sacroiliac joint and lumbar spine. Be careful not to adjust the hypermobile sacroiliac side. Hypermobility can result from lack of muscular support due to the reciprocal inhibition, thus mimicking a subluxated joint.
• Wobble and/or BAPS board for five minutes, two to three times per week. Start with both legs and then progress to single-leg stance. Progress to the patient performing the routine with eyes closed.
• Patients should be instructed on core stabilization exercises for the transverse abdominus muscle (TA) and lumbar multifidus. Perform the “draw-in” maneuver daily for five minutes by alternating 30-second intervals while breathing normally.
• Yoga poses: warrior #1 and #2. Patient must actively contract the gluteus maximus during these maneuvers to inhibit the iliopsoas, allowing for a more effective stretch. Progress to isometric frontal and side plank maneuvers for the TA.

To stay on the cutting edge of patient care today, you need to follow a comprehensive, systematic and integrated functional approach to kinetic-chain diagnosis. A comprehensive LCS rehabilitation program improves dynamic postural control, ensures appropriate muscular balance and improves neuromuscular efficiency throughout the entire kinetic chain. So, the next time you have a patient with persistent knee pain, don’t forget to look “outside of the box,” or in this case, outside of the knee.

Dr. Perry Nickelston, DC www.k-laserusa.com

Resources

1. Clark MA. “Integrated Flexibility Training.” National Academy of Sports Medicine: Thousand Oaks, CA, 2000.
2. Janda V. Muscle spasm – a proposed procedure for differential diagnosis. Manual Medicine, 1991:6136-6139.
3. Alter MJ. Science of Flexibility, 2^nd Edition. Human Kinetics, 1996.

Tags: Integrative Treatment Strategies, General by Dr. Perry
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