My last article discussed movement screening. We compared movement screening and assessment for a patient’s conditions to typical static evaluations methods (ie. orthopedic testing, isolated muscle testing, etc.). Movement screens look at how the body moves as a whole compared to static evaluations looking at the body as individual parts. The movement screen is analogous to taking someone’s blood pressure.
Physician’s use blood pressure as a screening tool for cardiovascular disease to see if there is an underlying problem requiring further assessment. If the cardiovascular screen is normal (ie. 120/80, the physician proceeds with the rest of the examination. If the cardiovascular screen comes out abnormal (ie. 220/160), the physicians perform an assessment to identify the CAUSE of the abnormal blood pressure. The physician may do blood work, urinalysis, etc. to identify the cause of their patients abnormal blood pressure.
- The examination of a group of usually asymptomatic individuals to detect those with a high probability of having or developing a given disease or disorder.
- The initial evaluation of an individual, intended to determine suitability for a particular treatment modality or activity.
- A preliminary procedure, such as a test or examination, to detect the most characteristic sign or signs of a disorder that may require further investigation.
- An objective review of an individual’s mobility…It is used to establish a baseline, to predict rehabilitation outcomes.
Movement screening is used the same way. If a patient has an abnormal movement screen, assessing why the movement screen is abnormal is the next step prior to treatment strategy. One assessment method for abnormal movement is joint range of motion testing. If the range of motion testing is abnormal in a weight bearing posture, moving the person to non-weight bearing will give great information.
For example, if the patient lacks at least 40 degrees of active big toe dorsiflexion while standing, lay the person down and reassess. If the range of motion changes greater than 10 degrees, the bone or soft tissue is not limiting standing or weight bearing range of motion. If the bone or soft tissue is not limiting the range of motion, the brain is not allowing full range of motion. The brain limits joint range of motion in the body as a protective mechanism.
Much like a governor on a golf cart slows the cart down on a golf course to avoid bodily damage to the golfers who ride in it, the brain limits motion in joints to help us avoid injury by slowing the body down through joint restriction.
Ultimately, the information discovered in the above example allows one to break down movement dysfunction into three distinct categories:
- Joint Issue – Is the joint fixated and needs to be manipulated? The can be determined by bony restriction at end range of motion, even with overpressure by the clinician.
- Soft Tissue – Are soft tissue structures truly shortened and need to be lengthened? This can be determined by applying overpressure at end range of the joint and the joint continues to move but less than 10% over active range of motion. In addition, the end range feel is soft compared to a bony restriction.
- Neurological – Is the brain not communicating with the tissue well or is the brain asking muscles to tighten the tissue surrounding the joint for stability? This can be determined by looking at range of motion weight bearing versus non weight bearing and seeing if passive end range motion is greater than 10 percent of active range of motion.
Understanding how a person moves in space will help identify areas that need to be mobilized, stabilized, or strengthened. Figure 1 shows my progressions from assessment through treatment. If you notice the base of the treatment is assessment that gets broken down into the three components or silos (joint, neurologic, soft tissue). If you are doing an evaluation on a patient in pain, it is an assessment. Asymptomatic patients are typically screened. If you are doing general screenings on uninjured clients or patients it would have its place under the assessment.
For example, if I have a patient who is presenting with arch pain and can’t dorsiflex their big toe greater than 40 degrees,
they will be prescribed self soft tissue mobilization (Figure 2), joint mobilization and stretching for their plantar fascia, taping for their arch/foot, and exercises to groove the pattern. Patients love soft tissue modalities and are easily convinced to add them to their arsenal of home care appliances. Please note, these strategies do not replace what clinicians do in their office. These recommendations are for patients home care.
The power of understanding where most of the dysfunction is coming from allows me to maximize my treatment in the office. In addition, knowing what silo is the common denominator gives me confidence in prescribing a home exercise program.
After the ball mobilization, have the patient sit down and cross the involved leg over the uninvolved knee. Grab the big toe proximal to the first metacarpalphalangeal. Have them apply traction to the big toe while taking the joint through maximal dorsiflexion. Have them repeat that for 1 minute. Then apply a stretch to the big toe in dorsiflexion for an additional minute.
Consider using kinesiology tape after any joint or soft tissue mobilization and before therapeutic exercise. The results are two-fold. First, the brain will now interact with the taped area at a higher level for as long as the tape is on (and possibly longer). This increased awareness of the brain expands the time frame in which the motor control enhancement that was achieved with the joint and/or soft tissue mobilization. Second the patient sees the tape on the body and remembers they have to do their part (home exercise) to make the rehabilitation process proceed swiftly. Taping can also provide a ‘trail map’ on the skin of where you want the rolling to occur. See Figure 4 for the ‘trail map’ of flexor hallucis longus and flexor digitorum brevis which the patient may need to roll to improve toe touch range of motion.
After taping, I used a term ‘grooving the pattern’. What is grooving the pattern? In my opinion, anytime we put more mobility into the system (rolling with ball, foam rolling, active release technique, tool assisted soft tissue therapy, etc.) we have to apply some resistance training to let the brain adapt this new mobility. Without this crucial step, the brain will just begin to tighten the structures as the were prior to the tissue mobilization. I prefer to use eccentric (lengthening) exercises to accomplish this task. Eccentrics are hard in this part of the body so I chose resistance exercises for flexor digitorum brevis and flexor halluces longus.
In future articles, I will break down certain areas of the body and conditions and discuss how I attack them from one of the three silos and then combine treatments for optimal patient outcomes.
Keeping your home exercises simple and relevant to your treatment in the office will increase patient compliance and improve outcomes. Patients love when outcomes improve because they get out of pain and can get back to activities that they love.
Please note: A YouTube video with the ball soft tissue mobilization, joint mobilization, and resistance band exercises can be seen on the authors YouTube Channel, KinetikChain.
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