Sunday 25th October, 2020

Functional rehabilitation

Overview

Optimal function for a human musculoskeletal system is were structures are in balance, stress on joints and other tissues is minimised, and biomechanics is optimised. Dysfunction is where this is changed, which creates abnormal stress and loads on various tissues and structures. This can lead to pain, injury and degeneration. In this article we discuss what causes dysfunction and how it can be corrected.

Technician performing a wheel alignment
Consider function like a wheel alignment: correct alignment drives well and lasts optimally, while out of alignment causes poor handling and rapid wear

Dysfunction basics

To correct function we first need to look at how function is controlled and what causes it to become abnormal.

Normal functional control
Normal neurological control of function

Normal functional control

This diagram shows how neurological control works using the simple example of walking.

  • You consciously decides to walk. You do not need to think about things like when to contract your hamstring muscles or what angle your ankle joint needs to be. Your Central Nervous System (CNS) takes care of all of this.
  • Your CNS has access to memorised instructions on how to walk. It uses these, while constantly monitoring feedback from various sensors around your body.
  • Based upon the memorised instructions and feedback the CNS sends out coordinated instructions to the many muscles needed.
Dysfunctional neurological control

How dysfunction occurs

When sensory input is altered the CNS will alter instructions to compensate. A noticable example would be the case of an injured ankle. The CNS would re-organise the control of muscles to produce a limp, transferring much of the load to the other side. However, any alteration of sensory input or imparement of a functional element element will cause the CNS to alter it's output causing dysfunction. Examples include:

  • injuries
  • muscular issues (eg. shortening, trigger points)
  • joint issues (eg. restrictions, abnormal sensory feedback)

Example

Later in this article we describe research showing how the presence of trigger points dramatically altered the control and coordination of shoulder muscles.

How to correct dysfunction

Woman doing physiotherapy exercises
If the CNS (Central Nervous System) receives abnormal sensory information or that a functional element is not working it will perform exercises in a compensatory manner

What will not work

Before we discuss how to correct dysfunction, lets look at two commonly used ways that wont.

Rest and medication

Injuries and pain syndromes typically involve dysfunction. Rest and medication may help heal an injury and relieve pain, however they rarely address the issues that cause dysfunction.

"Corrective" exercises

It is important to realise that control of activation of muscles is predominately under the control of the CNS. Conscious efforts can do little to change this. Put simply, if sources of abnormal sensory input remain the CNS will find away to alter the control of muscle to compensate.

What will work

Put simply, if the source of abnormal sensory input is removed or normalised the CNS will re-program and may even return to normal function without any further intervention. If the condition is chronic further assistance such as exercises may be needed to help "reprogram", or rehabilitate functional elements that may have deteriorated. Lets look at three examples.

Example One: functional restoration following the treatment of trigger points

Abduction of one's shoulder requires the coordinated effort of many muscles. (myofascial) trigger points are known to inhibit the normal function of muscles. A trial found that when trigger points were present they substantially altered the activity of the muscles resulting in un-coordinated joint movement. When the trigger points were treated the neurological control reverted back to normal (4). There has been a huge amount of research showing that these trigger points are both highly prevalent (even in asymptomatic people) and cause considerable functional abnormalities (5-17).

National Academy of Sports Medicine: Essentials of corrective exercise training
National Academy of Sports Medicine advises to restore functional elements as part of any corrective exercise program

Example two: USA's National Academy of Sports Medicine (NASM) guidelines

The USA’s National Academy of Sports Medicine in their publication NASM’s Essentials of Corrective Exercise Training (1)⁠ advise that to remove impediments for normal function the following procedures be included into correction exercise plans. We consider these a big improvement on the common practice of prescribing "corrective exercises" without any considerations, but it neglects to mention the very important articular considerations discussed in the next example.

  1. Inhibitory techniques to relax hypertonic muscles
  2. Lengthening techniques for contracted muscles
  3. Activation and integration techniques

Example three: Clinical trial

In clinical trials comparing the use of exercise alone and exerises plus manual therapies that help address muscular and articular function abnormalities, the results were far superior when the manual therapies were included (2,3). This shows the extreme importance of addressing articular functional issues. The evaluation and correction of these requires specialised knowledge and training, such as that posessed by a Chiropractor, Osteopath or a specialist Physiotheapist.

References

  1. Clark MA, Lucett SC. NASM Essentials of Corrective Exercise Training. Lippincott Williams & Wilkins; 2011.
  2. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;
  3. Yemul SR. Sunita R Yemul COMPARISON OF SUPERVISED EXERCISE WITH AND WITHOUT MANUAL PHYSICAL THERAPY FOR PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME. J Cur Res Rev [Internet]. 2013;05(05):5. Available from: https://pdfs.semanticscholar.org/58be/5f3ab071d954be4023e27183421c71ecb83f.pdf
  4. Lucas KR, Rich PA, Polus BI. the Effects of Latent Myofascial Trigger Points on Muscle Activation Patterns During Scapular Plane Elevation. Jclb [Internet]. 2007;25(8):765–70. Available from: http://dx.doi.org/10.1016/j.clinbiomech.2010.05.006
  5. Zuil-Escobar JC, Martínez-Cepa CB, Martín-Urrialde JA, Gómez-Conesa A, Shin C, Oh H, et al. Muscles Recruitment Pattern in People with and Without Active Upper Trapezius Myofascial Trigger Points in the Standing Posture. J Phys Ther Sci [Internet]. 2018;13(1):1–9. Available from: http://dx.doi.org/10.1016/j.pmrj.2016.03.004
  6. Florencio LL, Ferracini GN, Chaves TC, Palacios-Ceña M, Ordás-Bandera C, Speciali JG, et al. Active Trigger Points in the Cervical Musculature Determine the Altered Activation of Superficial Neck and Extensor Muscles in Women with Migraine. Clin J Pain. 2017;33(3):238–45.
  7. Bohlooli N, Ahmadi A, Maroufi N, Sarrafzadeh J, Jaberzadeh S. Differential activation of scapular muscles, during arm elevation, with and without trigger points. J Bodyw Mov Ther [Internet]. 2016;20(1):26–34. Available from: http://dx.doi.org/10.1016/j.jbmt.2015.02.004
  8. Chiarotto A, Clijsen R, Fernandez-de-las-Penas C, Barbero M. The prevalence of myofascial trigger points in spinal disorders: a systematic review and meta-analysis. Physiotherapy. 2015;
  9. Kaya Mutlu E, Birinci T, Dizdar G, Ozdincler AR. Latent Trigger Points: What Are the Underlying Predictors? Arch Phys Med Rehabil. 2016;
  10. Zuil-Escobar JC, Martínez-Cepa CB, Martín-Urrialde JA, Gómez-Conesa A. The Prevalence of Latent Trigger Points in Lower Limb Muscles in Asymptomatic Subjects. PM R. 2016;8(11):1055–64.
  11. Celik D, Mutlu EK. Clinical implication of latent myofascial trigger point topical collection on myofascial pain. Curr Pain Headache Rep. 2013;17(8).
  12. Fernández-De-Las-Peñas C, Gröbli C, Ortega-Santiago R, Fischer CS, Boesch D, Froidevaux P, et al. Referred pain from myofascial trigger points in head, neck, shoulder, and arm muscles reproduces pain symptoms in blue-collar (Manual) and white-collar (Office) workers. Clin J Pain. 2012;28(6):511–8.
  13. Fuentes-Márquez P, Carmen Valenza M, Cabrera-Martos I, Ríos-Sanchez A, Ocon-Hernández O. Trigger points, pressure pain hyperalgesia, and mechanosensitivity of neural tissue in women with chronic pelvic pain. Pain Med (United States). 2019;20(1):5–13.
  14. Roach S, Sorenson E, Headley B, Juan JGS. Prevalence of Myofascial Trigger Points in the Hip in Patellofemoral Pain. Arch Phys Med Rehabil [Internet]. 2013;94(3):522–6. Available from: http://dx.doi.org/10.1016/j.apmr.2012.10.022
  15. Castaldo M, Ge HY, Chiarotto A, Villafane JH, Arendt-Nielsen L. Myofascial trigger points in patients with whiplash-associated disorders and mechanical neck pain. Pain Med (United States). 2014;15(5):842–9.
  16. Celik D, Yeldan P. The relationship between latent trigger point and muscle strength in healthy subjects: A double-blind study. J Back Musculoskelet Rehabil. 2011;24(4):251–6.

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Dr Graeme

About Dr Graeme

Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more



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