A Kinetic Chain Approach to Musculo-Skeletal
Pain Combining Manual Therapies, Nutrition
and Corrective Exercise.
GEOFF LECOVIN DC ND L.Ac CSCS
ADAM RINDE, N.D., ASCM-HFI., CES
Integrative Approaches to Pain
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This class is a synthesis of cutting-edge chiropractic,
osteopathic, naturopathic, massage, nutrition and dry
needling techniques and principles.
Practitioners and students will learn the different phases
of pain and how to effectively assess and manage each
phase with physical medicine, exercise, nutrition and
prescription drugs.
Participants will refine their skills in soft tissue and joint
manipulative therapy and get exposure to dry needling.
They will be able to effectively manage the most
common orthopedic and sports medicine problems
seen in private practice.
Course Objectives
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Understand the different phases of pain
Differentiate between an orthopedic approach and Integrative
approach to musculoskeletal pain
Understand the significance in assessing the kinetic chain
Learn about common distortion patterns
Understand the role of trigger points
Understand the significance of perpetuating factors
Learn how to assess musculoskeletal conditions
Learn how to decide which manual therapy or modality is
indicated
Understand the role of corrective exercise as part of the
treatment plan and prevention
PAIN
“An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described by the patient in
terms of such damage.”
International Association for the Study of Pain
3 PHASES OF PAIN
1. Immediate/Nociceptive
2. Acute/Inflammation
3. Chronic
IMMEDIATE /NOCICEPTIVE
PAIN
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Induced by extrinsic factors where there could
be a threat of tissue damage
Acute onset e.g. cut, burn, slap
Over 90% will recover within a few weeks
Pain messages are carried by A-Delta and C
Fibers
Good prognosis
ACUTE INFLAMMATION
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Actual tissue damage e.g. strain/sprain
Recognized by signs of inflammation- redness,
increased local temperature, and swelling
Occurs as a result of substances released by damaged
tissue cells (*which are necessary for repair)
Pain messages are carried by C-fibers
Self limiting
Responds to Naturopathic therapies or NSAIDS,
analgesics and rest
CHRONIC PAIN
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Ongoing nociception or inflammation
Psychological
Neuropathic- functional and structural
alterations within the Neuromusculoskeletal
system
Structure vs Function
Structure (orthopedic approach)- focuses on the
pathology of static structures; emphasizes diagnosis
based on localized evaluation and special tests.
 Function- recognizes the function of all processes and
systems within the body, rather than focusing on a
single site of pathology.
*The structural approach is necessary and valuable for
acute injury or exacerbation, the functional approach is
preferable when addressing chronic musculoskeletal
pain.
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Traditional Orthopedic Approach
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Isolated joint kinematics
Uniplanar
Isolated muscle strength
Morphologically oriented
Integrative Functional Approach
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Focuses on all kinetic chain components (muscular,
articular, neural)
Optimum acceleration, deceleration and dynamic
stabilization in multiplanar (saggital, frontal, transverse)
movements
Enables synergistic production and reduction of force
and dynamic stabilization
Maintains optimum length-tension and force-couple
relationships of agonists and antagonists
Allows optimum joint arthrokinematics and
neuromuscular efficiency
Regional Interdependence
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Seemingly unrelated impairments in a remote
anatomical region may contribute to, or be
associated with, the patient’s primary complaint
Wainner et al JOSPT 2007
Optimum Alignment
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Alignment of the musculoskeletal system
allowing posture to be balanced with center of
gravity
Ability of the neuromuscular system to
perform functional tasks with the least amount
of energy and stress on the kinetic chain
Optimum muscle length-tension relationships
at which a muscles are capable of developing
maximal tension
KINETIC CHAIN CONCEPTS
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Proprioception- the cumulative neural input to the
CNS from mechanoreceptors (specialized neural
structures that convert mechanical information into
electrical information that is relayed to the CNS)
Length-Tension Relationship- the optimal length at
which a muscle can produce the greatest force
Force-Couple Relationship- the synergistic action of
muscles to produce movement around a joint
Arthrokinematics-The ability of a joint to move
through its biomechanical range of motion
Optimal Neuromuscular Control
Normal length tension relationships
 Normal force couple relationships
 Normal arthrokinematics
*Optimal sensorymotor integration
*Optimal neuromuscular efficiency
*Optimal tissue recovery
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Example of Kinetic Chain
Dysfunction and Pain
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Excessive pronation- metatarsalgia, bunion, PF, neuroma
Excessive tension in tibialis posterior and peroneous
longus- shin splints
Knee stress- tendonitis, injury susceptibility
Lateral thigh tension- tight hamstrings, ITB, TFL (e.g. PFS)
Abnormal L-P rhythm- anterior pelvis rotation
Increased lumbar lordosis- tight psoas, erector spinae and
latissimus dorsi- Lumbago
Downward traction of the scapula with shoulder movement
Excessive tension in outer shoulder muscles
Neck and shoulder pain
MUSCLE ACTION
CLASSIFICATIONS
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Agonists- prime movers
Antagonists - act in direct opposition to prime
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Synergists - assist prime movers during functional
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movers
movement patterns.
 Stabilizers- support or stabilize the body while the
prime movers and the synergists perform the
movement patterns
 Neutralizers- muscles that counteract the unwanted
action of other muscles
Functional Muscle Division
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Stabilization Group
Movement Group
Stabilization Group
(Local Muscles/Inner Unit)
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Peroneals
Tibialis posterior/Anterior
VMO
Gluteus Medius
Pelvic floor muscles
Transverse Abdominus
Internal Oblique
Multifidus
Deep erector spinae
Transversospinalis group
Diaphragm
Serratus anterior
Middle/Lower Trapezius
Rhomboids
Teres Minor
Infraspinatus
Posterior deltoid
Lomgus Coli/Capitus
Deep cervical Stabilizers
Movement Group
(Global/Outer Unit)
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Gastocnemius/Soleus
Adductors
Hamstrings
Gluteus Maximus
Psoa
TFL
Rectus Femoris/Quadriceps
Piriformis
Erector Spinae
QL
Rectus abdominus
External oblique
Pectoralis Major/Minor
Latissimus Dorsi
Teres Major
Upper Trapezius
Levator Scapulae
SCM
Scalenes
FUNCTIONAL MOVEMENT
DIVISION SUMMARY
Stabilization System (inner core)
􀂃 Local muscles for joint support and posture
􀂃 Being prone to weakness and inhibition
􀂃 Less activated in most functional movement patterns
􀂃 Fatigue easily during dynamic activities
􀂃Predominantly slow twitch
 Movement System (outer core)
􀂃 Global muscles for movement
􀂃 Being prone to developing tightness
􀂃 Readily activated during most functional movements
􀂃 Overactive in fatigue situations or during new movement patterns
􀂃 Compensate (synergistic dominance) during fatigue states
􀂃 Predominantly fast twitch
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Low Back Pain
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Chronic low back pain represents 85-95% of the
population
Lack of appropriate neuromuscular response of the
muscles stabilizing the LPHC
Patients unable to preferentially recruit the inner unit
musculature of the LPHC
Recruitment of motor units from the outer unit leading
to synergistic dominance, altered normal force couple
relationships, length-tension relationships, joint
kinematics and neuromuscular control
CAUSES OF MUSCLE
IMBALANCES
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Pattern overload
Aging
Decreased recovery and regeneration following an
activity
Repetitive movement
Lack of core strength
Immobilization
Cumulative trauma
Lack of neuromuscular control
Postural stress
Postural Distortion Patterns
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Altered Reciprocal Inhibition- The process whereby a tight or overactive
agonist inhibits its functional antagonist. This results in altered force couple
relationships and synergistic dominance and leads to the development of
faulty movement patterns and poor neuromuscular control.
Synergistic Dominance-The process whereby synergists compensate for a
weak or inhibited prime mover in attempts to maintain force production and
functional movement patterns. This causes faulty movement patterns, which
leads to tissue overload, decreased neuromuscular efficiency and injury.
Arthrokinetic Dysfunction- A biomechanical dysfunction in two articular
partners, resulting in abnormal joint movement (arthrokinematics), muscle
inhibition and proprioception disturbance.
Myofascial dysfunction (trigger points)
CNS changes
MYOFASCIAL PAIN
SYNDROMES
A myofascial trigger point is a highly
localized and hyperirritable spot in a palpable
taut band of skeletal muscle fibers.
Travell and Simons
TRIGGER POINT SYMPTOMS
1. Onset after micro or macro trauma
2. Local or referred pain (RPP)
3. Pain with muscle contraction
4. Muscle stiffness and restricted joint motion
5. Muscle weakness
6. Paresthesia and numbness
7. Proprioceptive disturbance- dizzy, lack of balance
8. Autonomic dysfunction- pilomotor reflex
9. Edema and celllulite- decreased circulation and waste
accumulation
10. Sleep disturbance
Pathogenesis
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Over stretching/over shortening
Overloading of tissue
Micro-trauma
Destruction of sarcoplasmic reticulum
Release of calcium++
Sustained muscle contraction
Physical Findings of MTrPs
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Taut band
Tender and painful nodule to palpation
Patient pain recognition
Local twitch response
Limited range of motion
Muscle weakness
Positive stretch sign- pain of mechanical or neural
origin exhibited during myofascial stretching that can
be improved with trigger point therapy to the muscle
Classification of Trigger Points
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Satellite
Attachment
Active
*Limit ROM
*Weakness
*Local & Referred pain
Latent
*Limit ROM
*Weakness
*Pain only with compression
Classification of Trigger points
Active TP
*Limit ROM
*Weakness
*Local & Referred
Pain
Latent TP
*Limit ROM
*Weakness
*Pain only with compression
TRIGGER POINTS ARE KNOWN
TO CAUSE
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Headaches
Neck and jaw pain
Low back pain
Carpal tunnel syndrome
Joint pain (arthritis,
tendonitis, bursitis, ligament
injury)
Tennis elbow
Contributing cause of
scoliosis
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Earaches
Dizziness
Nausea
Heartburn
False heart pain
Arrhythmia
Genital pain
Sinus pain/congestion
Colic and bed wetting
Depression, CFS, lowered
resistance to infection
Kinetic Chain Imbalances
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Imbalances in muscle length
Altered normal length-tension relationships
Abnormal force-couple relationships
Altered reciprocal inhibition of the functional
antagonist
Synergistic dominance
Faulty movement patterns
Initiation of the cumulative injury cycle
Cumulative Injury Cycle
Muscle
spasm
Adhesions
Altered neuromuscular
control
Inflammation
Tissue
trauma
Muscle imbalance
Cumulative
injury
cycle
Postural Distortion Patterns
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When a chain reaction evolves in which
some muscles shorten and others weaken,
in predictable patterns of imbalance
Janda
1.
Upper crossed syndrome
Lower crossed syndrome
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Looking at the Body joint-by-joint From the Bottom
Up:
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Ankle mobility (particularly sagittal)
Knee stability
Hip mobility (multi-planar)
Lumbar Spine stability
Thoracic Spine mobility
Gleno-humeral stability
(The joints alternate mobility and stability)
Injuries relate closely to proper joint function
Problems at one joint usually show up as pain in the
joint above or below
Patient History
OPQRST
O- Onset
P-palliative/provocative
Q-quality
R-radiation
S-severity
T-temporal factors
FAOMASH (family hx, accidents, other, meds, allergies,
surgical history, hospitalizations)
*The patient will tell you what’s wrong if you know
how to ask
Patient Examination
IPPIRONEL
I-inspection
P-palpation
P-percussion
I-instrumentation
R-range of motion (active and passive)
O-orthopedic tests
N-neurological tests i.e. motor, sensory
E-extra tests e.g. x-ray, MRI, CT
L-lab
Posture
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Dynamic
Structural efficiency
Neuromuscular efficiency
Balance and equilibrium
Functional strength
Static Posture Landmarks
Side: An imaginary line should run
slightly anterior to the lateral malleolus,
through the middle of the femur, center
of shoulder and middle of the ear
Posterior: An imaginary line should run
from between the medial malleoli, up
through the spine and center of the
head
Anterior: An imaginary line should run
from between the medial malleoli, up
through the sternum and center of the
head
Common Dysfunctional Patterns
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Ankle/Foot- Pronation/Turns out
Knee- Hyperextended/Moves in or out
Hip- Uneven
Lumbar/Pelvis/Hip- Lordosis/scoliosis
Thoracic- kyphosis/scoliosis
Scapulae- Uneven/abducted
Cervical- Lordosis/scoliosis
Head- Forward
Observing Dynamic Posture
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Relates to the basic functions- squatting,
pushing, pulling and balancing
Shows muscle and joint interplay
Can uncover postural distortions and imbalances
in anatomy, physiology and biomechanics that
can lead to injury
Movement assessment
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Identifies movements that consistently causes pain
Identifies altered motor control, abnormal length-tension
relationships, relative flexibility and faulty movement
patterns that can cause pain and can lead to pathology e.g.
arthritis
Movement impairment is classified by the direction of
movement that causes pain
e.g. movement classifications in the spine: flexion, extension,
rotation, flexion/rotation, extension/rotation
Testing is performed sitting, standing, side-lying, prone, supine
and in a quadruped position; bilaterally and unilaterally
Reproducing the pain is the key to both identifying the problem
and effective treatment through therapy and corrective
exercises/activities
Kinetic Chain Check Points
(anterior/posterior/lateral)
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Foot/Ankle– Straight ahead w/ neutral position at the
ankle
Knee– Straight ahead in line w/ 2nd and 3rd toes
Lumbo-Pelivic-Hip Complex– Neutral spine with
abdominals drawn in
Shoulder and cervical spine– Neutral, center of
shoulder in line with center of hip joint
Head– Neutral, center of ear in line with center of
shoulder
Dynamic Inspection
(Overhead Squat)
SPECIAL IMAGING
Help or Hindrance?
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Lumbar MRI’s were done on 98 people with no
hx of back or leg pain. 36% had normal discs at
all levels, 52% had bulging discs at one or more
levels, 27% had a disc protrusion and 1% had an
extrusion.
“The discovery by MRI of bulges or protrusions
in people with low back pain may frequently be
coincidental.”(NEJM,1994)
GOAL OF TREATMENT
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Control the pain and break the pain cycle
Break chemical and Mechanical feedback loop that
maintains muscle contraction
Increase circulation that has been restricted by
contracted tissue
Lengthen shortened muscles
Reconditioning and strengthening weak muscles
Correct movement patterns
Prevention of recurrence through an appropriate
exercise program
TREATMENT
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Provocative
Active
Resisted
Functional
Proprioceptive
Effective Treatment Options
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Ischemic compression
Injection techniques
Dry needling
Soft tissue manipulation
Muscle energy technique (MET)
Joint manipulation
Friction massage
Ultrasound
Spray and Stretch
Contrast therapy
Corrective exercise
Supportive taping
Diet and nutrition to aid in repair
Progressive Pressure Release
Technique
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Apply progressive pressure to point of tissue resistance
for 45-60 seconds. Hold until resistance dissipates.
Repeat procedure 3-4 times each time moving to a
deeper barrier
Pressure is to patient tolerance
Have patient deep breathe
Release pressure quickly to produce vasodilation and
elimination of the local ischemia
Identify and treat satellite trigger points
Follow by stretching (30 sec) and breathing
Post treatment heat or cold applications
SOFT TISSUE RELEASE
TECHNIQUE (NMR- 97112)
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Specific contact is made on the muscle
Traction is applied to the tissue in order to
trap the lesion
The muscle is moved either actively or
passively through the line of injury
The stretch is held for 1-2 seconds
Repetitions are done in different positions and
planes of motion (8-10 times)
EFFECTS OF SOFT TISSUE
RELEASE
1. STR stretches and softens scar tissue/adhesions
2. Pain input messages to limbic system are
reprogrammed
3. Muscle length, flexability and memory are
regained
Manipulation Considerations
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Doctors position
Patients position
Doctors contact
Patients contact
Line of drive
Joint type and normal motion
Respiration
Patient’s eye position
Psycho-somatic influences
Distraction techniques
ACTIVE ISOLATED
STRETCHING (Mattes)
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Myofascial stretching of isolated muscles
which avoids activating the protective myotatic
reflex contraction
Stretch through anatomical plane of
attachments
Contract the antagonistic muscle to facilitate a
release in the stretched muscle (reciprocal
inhibition)
Ten repetitions for two seconds
HYDRATION & RESPIRATION
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The connective tissue matrix is an important
water storage compartment
Hydration promotes smooth, non-friction
mechanical movement and effective nerve
conduction
Respiration expedites water absorption
Tissue Pressure
Lengthening
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Stretching used to increase the
extensibility of muscle and connective
tissue, resulting in increased range of
motion at a joint
Static- passive
Active- using agonists and synergists
Neuromuscular- PNF
Functional- using the body’s momentum
Neurodynamic- neural structures
Activate
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Isolated (intramuscular) Strengthening:
Exercises used to isolate a particular muscle in
order to increase the force production
capabilities through concentric-eccentric muscle
actions e.g. Scaption exercises
*Strengthening exercises to start after a 70% of the
normal range of motion has been achieved
(empirical observation)
Integrate
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Integration Techniques (Intermuscular):
Re-educating the nervous system on movement
patterns and muscle synergies in a dynamic
manner (eccentric, isometric, concentric)
e.g. Squat to row
PERPETUATING FACTORS
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Mechanical Stresses
Nutritional/Dietary factors
Metabolic and Endocrine Inadequacies
Psychological factors
Chronic Infection
Other (allergy, sleep, improper breathing,
dehydration, smoking, caffeine, medications,
visceral disease)
MECHANICAL STRESS
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Structural- body asymmetry and
disproportion e.g. leg length discrepancy, long
second metatarsal and short first metatarsal
Postural e.g. poor posture, poorly fitting
furniture, poorly adjusted glasses, ergonomics
Constriction of muscles e.g. poor fitting
clothing
Degenerative joint disease
NUTRITIONAL FACTORS
(VITAMINS AND MINERALS)
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Nutritional inadequacies cause impairment of energy, cell
metabolism and function ,which reduces the ability of the
muscle to meet extra demands and metabolic stress
Nutrients Play a role in the synthesis of neurotransmitters,
protein, carbohydrate and fat metabolism, DNA synthesis,
collagen synthesis and proper nerve and muscle function
Low levels should be treated as they may not be adequate for
optimum health
Deficiency increases irritability of trigger points and nerves
NUTRITIONAL DEFICIENCY
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B1- important for energy and synthesis of neurotransmitters. Potentiates the
effectiveness of thyroid hormone
B6- important in lipid and protein metabolism and the synthesis of
neurotransmitters
B12- essential for energy and DNA synthesis and in fat, carbohydrate and
protein metabolism
Folic Acid- Important for synthesis of DNA, cell metabolism and for normal
brain function and development
C- important in collagen synthesis and synthesis of serotonin and
norepinephrine
Calcium, Magnesium, Potassium and Iron- Important in muscle
contraction and function
Naturopathic Approaches to
Inflammation
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Antioxidants: A, E, C, Se, Zn, CoQ10
C/Bioflavonoids- 1000mg 3x/day
Magnesium (citrate)- 300mg 2x/day
Fish Oil (18% EPA & 12%DHA)- 10g per day (at least 3g EPA)
Bromelain- 1000-2000 MCU 4x/day away from food
Quercetin- 500mg 3x/day
Boswellia- 400mg 3x/day
Glucosamine and Chondroitin Sulphate- 500mg of each 3x/day
Topical DMSO
Topical Biofreeze
Hydrotherapy
Guided imagery/systematic relaxation/hypsosis
Dietary Factors in Inflammation
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Phytonutrients- vegetables and fruits
Green/Black tea
Garlic, Ginger, Turmeric, Cinnamon etc.
Consume low glycemic load carbohydrates (insulin connection)
Eat small frequent meals to ensure glycemic regulation
Omega 6:Omega 3 should be <4:1
Decrease meat, dairy, shellfish and refined carbohydrates/fats
Decrease caffeine and alcohol
Optimize digestion and bowel habits
Identify food reactions
METABOLIC AND ENDOCRINE
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When energy metabolism of the muscle is
compromised as a result of metabolic or
endocrine imbalance it perpetuates trigger
point activity e.g.
Hypoglycemia
Hypothyroid
Menopause
Hyperuricemia
Allergy/Infection
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Can perpetuate trigger point activity, possibly
due to histamine release
PSYCHOLOGICAL FACTORS
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There is a decrease in brain serotonin which
causes increased sensitivity and low
oxygenation of the tissues e.g.
Stress
Depression
Anxiety
Insomnia
Fatigue
Tension Myositis Syndrome
The mind body connection
Conscious or Repressed Unconscious Emotions
Stress
Abnormal Autonomic Activity
Reduced Local Circulation of Blood
Mild Oxygen Deprivation
Muscle Pain
Nerve pain/Numbness/Tingling/Weakness
Tendon Pain
Practical Applications
Evaluation and Treatment
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Cervical spine
Thoracic spine
Lumbo-Pelvic-Hip complex
Upper ¼ - Shoulder, elbow, wrist, hand
Lower ¼ - knee, ankle, foot
Practical Format
Common patterns of dysfunction
Functional anatomy and biomechanics
Assessment/Examination
Treatment
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Trigger point release
Muscle release therapy
Friction massage
Joint manipulation
Stretching
Corrective exercise (inhibit, lengthen, activate,
integrate)
References
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NASM
Leon Chaitow, ND., DC
Warren Hammer, DC
Vladimir Janda, MD
Craig Liebension, DC
Paul Chek
Shirley Sarhmann
Peter Levy, DC
Stuart Taws, LMP
SLACK Hands on seminars
Chan Gunn, MD
Stuart McGill
Gray Cook, PT