Adjunctive_Therapy

[pic] ELECTIVE TITLE: Adjunctive Therapies COURSE CODE: FC0025 ASSIGNMENT CODE: M4b REFLECTIVE ESSAY STUDENT NAME: Jure Tusek (211193) WORDCOUNT: 2492 words TABLE OF CONTENTS |1. INTRODUCTION |1 | |2. ASIGNMENT |3 | |3. REFLECTIONS |4 | |3. CONCLUSION |8 | |REFERENCES and BIBLIOGRAPHY |10 | 1. INTRODUCTION When we were asked to choose a specific subject that we would like to make a further research and incorporate it with new informations given on the course, I was undecided weather to speak about exercise rehabilitation for lumbar or cervical facet irritation. I began my research on this topic and I found dozens of books and articles that prescribe exercises with emphasis on the restoration or enhancement of spine range of motion. From osteopathic view though, I couldn’t be satisfied with all these material so I made some further research to see what validity do these exercises have, and surprisingly I discovered that not only poor evidence, but as McGill (1998) stated: “a weak link or sometimes even negative outcomes,” result from reviewing these articles. It seems natural to ask myself why is that so' Thinking over and over I came to a conclusion that maybe the negative or poor outcomes are not a result of inappropriate exercises but more likely because they were not designed for the specific cause of the problem – in fact, looking through the material once again, I noticed that exercises were prescribed mostly for the symptoms (eg. cervical pain or low back pain) and not for the cause of these manifestations. Moreover, knowing the mechanisms of pain it came upon my mind a doubt of how someone can activate the muscle during the exercise if a muscle is not responding in a proper way. These are the reasons that made me reflect on the effectiveness of these exercises and made me look to the problem from other point of view – it is impossible to make exercise protocols for the symptoms and excluding the causes, it is difficult (or even impossible) to carry-out particular exercises if the muscle we are activating is painful or not responding, and finally it is possible that some exercises create other dysfunctions. At this point I came to conclusion that the most appropriate argument that satisfies my osteopathic vision and might give me appropriate answers is “breathing mechanics and spinal stabilisation”, and as soon as we were introduced to the Adjunctive Therapies course I found it challenging to integrate my knowledge with new informations about core stabilisation, muscle imbalance and spinal stability. 2. ASIGNMENT Before I began preparing power-point presentation I put down a small chart with three points to follow: breathing exercises in function of spinal stabilisation; breathing can improve spinal stabilization exercises; spinal stability can improve respiration and reduce breathing disorders. I searched for scientific papers in two of the most popular and valid internet databases (Scientific Direct, Pubmed) typing in various occasions and with different combinations: spine, stability, diaphragm, breathing pattern. I found some very interesting articles on correlation of respiratory mechanics and posture, breathing and spinal stiffness, and finally breathing disorders and their effect on muscle physiology. I began my class presentation talking about primary and accessory respiratory muscles and introducing some concepts on motor control errors and spinal stability. Basing on these informations we started to discuss about the influence of intra-abdominal pressure on spinal stability and its importance on trunk stability in response to movement and posture. Since we treat the diaphragm of most of our paediatrics’ patients, I pointed out that it would be interesting to reflect on importance of breathing mechanics during a child growth and than we took a look of signs of faulty breathing patterns, which resulted to be the missing part of our osteopathic physical exam. Examining breathing pattern of my in front of the class we could notice that during inhalation he lifted and expanded the chest and no degree of lower lib motion was noted, contrarily during exhalation his abdomen protruded and clavicles remained slightly lifted by SCM and trapezius muscles. We shortly analysed why this occurs and finally we tested passive and active motion of cervical and lumbar spine and found a positive link between his faulty breathing, lumbar and cervical spine stiffness and symptoms he was accusing. On the very end of discussion we came to conclusion that besides the use of respiration in muscle energy techniques, we could integrate our knowledge of breathing mechanics, intra-abdominal pressure and the effects on muscle tone, when mobilising spinal segments, during visceral manipulation and also to help to relax the patient as a part of preparatory phase before HVLA techniques. In addition we all agreed that a good breathing control should make a part of all instructions given to our patients regardless of what exercise we have chosen for them. To do that we have to understand breathing pattern first and than integrate it into our osteopathic exam. We did not forget to mention the role of environment and stress on breathing dysfunctions, since we are all aware of influences of these on all of our body systems and especially on central nervous system that is in charge of controlling the others. 3. REFLECTIONS Osteopaths have always recognised the importance of breathing mechanics on structure and function of the whole body and often they argued that faulty breathing is frequently overlooked and untreated, bringing to poor results (Lum L.C., 1975; Nixon P.G., 1993). Still, looking through various research work the understanding of spinal mechanics, breathing mechanics and alteration of these two systems permit the logic outcomes for both osteopathic practitioners and for patients. The concept of stability can be understood by using Bergmark’s model (McGill S., 2001) which begins with introducing the term of potential energy – “if a ball is placed in a bowl it is considered stable, because any force applied to the ball would move it up the sides of a bowl and then return in the position of least potential energy at the bottom of the bowl”. Since the objects have potential energy in virtue of their height (Jain M., 2009), it is comprehensible that the system becomes more stable by deepening the sides of the. Taking in consideration our musculoskeletal system though, it is necessary to take note of another characteristic, that is elastic potential energy calculated by multiplying stiffness and deformation within the elastic element (Jain M., 2009). Bringing together two equations it is possible to conclude that stiffness creates the stability, since the greater the stiffness the greater the depth of the bowl, and therefore more stable the structure. Joint stiffness originates from capsules and ligaments that provide passive role and the stiffness increases as soon as active contribution of muscle activation occurs. The role of muscles is to control the range of motion and to keep the joint in position where passive stiffness is optimal, but the motor control system that coordinate muscle co-activation can sometimes work inappropriately by producing non-linear muscle force, thus causing instability and facilitated motion – joint buckling. When analysing muscles it becomes necessary to divide them regarding their function, whereas two major groups are represented by local and global system. Global system consist of muscles that have broad attachments (so they change length and create force) and are mainly responsible of producing movement and controlling joints throughout a movement. According to their predominant fibre type functions these can be divided in stabilisers (Type I – slow twitch) that assist postural holding and work against gravity, and mobilisers (Type II – fast twitch) that produce motion (Elphinston, 2008). Local system consists of local stabilisers, or joint controllers, that provide the joint support and they should activate automatically just before a movement occurs – working for long periods and low effort levels. Unlike global stabilisers local stabilisers have short lines of pull, which permit a specific control of joints that lasts in time, but produce insufficient force to create and control movement. It is a logic conclusion that in case of spine buckling local system failed and excessive joint motion can occur. It is widely accepted that low back pain derives from local tissue damage (Cholewicki J., 1996) as a consequence of unstable behaviour of spinal segment. Cholewicki (2000) has demonstrated that sufficient stability of the lumbar spine is not compromised by insufficient strength but rather insufficient endurance of the paraspinal and abdominal wall muscles. The local stabilisers muscles of lumbar area are transversus abdominis and multifidus muscle, and these work in synergy with the internal abdominal obliques muscle, the diaphragm and pelvic floor muscles. All together form a cylinder with either direct stabilising effect via their musculoskeletal attachments, or in more indirect way by intra-abdominal pressure created inside the cylinder which contributes to the trunk stability mechanism in response to movement (Hodges P., 2003). The stability of the spine is therefore a result of passive joint capsule and ligaments, active muscle contraction and intra-abdominal pressure. Since the last vary with breathing, spinal stability changes throughout the respiratory cycle. Respiratory cycle is generated by muscles that can be divided in primary and accessory group. The primary driver of the respiration is the diaphragm, a thin and wide muscle with broad attachments to ribs and lumbar vertebrae, and therefore in direct relation with spine stabilisers. If the diaphragm is dysfunctional then the other respiratory muscles will change their function, often becoming overloaded (Fitting J.W., 1987; De Troyer A., 1988). The results of Janssens (2010) prove that inspiratory muscle fatigue decrease postural control and suggest that this might be a factor in the high recurrence rate of low back pain, likely because the input from the low back becomes less reliable, therefore resulting in an improper proprioceptive postural control strategy. Another evidence is brought by Hodges (2000) who demonstrated that postural activity of the diaphragm reduces in response on increased respiratory demands and observed the reduction of diaphragm and transversus abdominis muscle functions. The results given by last two authors have a huge importance in clinical practice, since the most patients present either postural control disorders or poor breathing patterns. Besides, the concepts of muscle fatigue due to exaggerated muscle work and the consequent burdening of motor control system has to be applied within all manual disciplines. Lost of co-ordinated action of respiratory muscles can also occur in various diseases such as kyphoscoliosis, neuromuscolar diseases, obesity, emphysema and asthma (DeTroyer A., 1988). Lee (2010) found that even slight changes in spinal alignment affect chest wall shape and distribution of volume between abdominal and thoracic cavity. Furthermore, the results of the study support the idea that postures predicted to reduce the motion of one part, necessarily increase the motion elsewhere which confirms the work of other studies (Dallweg D., 2008, West J., 1959) on faulty breathing mechanics and muscle involvement in patients with respiratory problems. It is important to mention though that changes in posture have only small effect on the distribution of blood flow and ventilation within pulmonary parenchyma. In a study (Petersson J., 2007) where imaging was used to observe the distribution of radiotracer in prone and supine position of healthy persons, the results suggest that posture has a profound effect on the distribution of lung tissue, but no statistically significant effect of posture on ventilation and distribution of blood flow if the effect of tissue distribution is excluded. On the other hand some other causes such as anxiety and apprehension (Klein D.F., 1993) are closely associated with altered breathing patterns and pulmonary perfusion – an increased rate of ventilation in stress related breathing patterns, produces respiratory alkalosis, characterised by the decrease in CO2 (hypocapnoea) and an increase in pH (alkalosis). The loss of homeostasis induces vascular constriction, thus decreasing blood flow, and due to Bohr effect reducing the transfer of oxygen to tissue cells (Chaitow L., 2004). The kidneys trying to correct the alkalosis begin to eliminate K+, Ca+ and Mg+, with consequences on the whole musculoskeletal system: muscles become prone to fatigue, cramp, and trigger point evolution. If a chronic breathing disorder persists it can lead to hypocapnoea characterised by respiratory, cardiac, neurological and gastrointestinal symptoms. Since the osteopaths consider the whole body as a unit, these findings are of extreme importance when connecting different body systems with posture and pain. It is therefore clear that comprehension of the patient from all of his aspects and an accurate physical exam need to be done before any treatment takes place. Some evidence is found on validity of MARM – manual assessment of respiratory motion (Courtney R., 2009), in determining faulty breathing patterns and even though other research is needed to apply this assessment within research on spinal stability and low back pain, MARM remains acceptable method of evaluation. The paper review show a clear interest of osteopathic consideration on faulty breathing patterns present in a high percentage of patients they meet during their clinical experience and even if various research work demonstrate a clear link between breathing dysfunctions and alteration of most of body systems, still more practical approach is missing in general osteopathic examination. 4. CONCLUSION I would like to begin to analyse my work by asking me if I satisfied my previously mentioned points at the beginning of the assignment, that were: A) breathing exercises in function of spinal stabilisation; B) breathing can improve spinal stabilisation exercises and C) spinal stability can improve respiration and reduce breathing disorders. If I begin with the first point I can say that it is now clear to me how breathing influences and in frequent occasions also affects spinal stability, not just because of the attachments of some respiratory muscles, but also because of the role that respiration plays in enabling intra-abdominal pressure, which has a direct effect on spinal stability. This is very useful when we have to teach our patients the exercises to improve spinal stability, where we have to consider breathing as possible causes or even the victim of muscle imbalance. We must never forget the connections that different muscles have from neural point of view and that if overloading or weakening of specific muscle occurs, soon or later this affects also the other muscles either of abdominal wall, chest wall or pelvic floor. Our goal is there so to re-establish optimal functioning of these elements in order to permit better motor control and possibly reduce any joint facilitation. On the other hand, facilitation can be take in cause of creating informational mismatch resulting again in loss of control, which affects both motion and endurance. As it is possible to deduce the two systems – spinal stability and breathing mechanics, work intimately one with other and it results difficult if not even harmful for the patient to dissociate these two mechanisms that not only they permit us a standing posture, but also offer us protection for entire abdominal content and at the same time satisfy the demands of our body to move continuously. I can say that I remained positively surprised when I saw how much interest and importance is given to this argument, not only by my colleagues but especially from researchers that present the future of our continuing education and I just hope that my actual impression that a lack of communication between different research groups will soon prove to be wrong. REFERENCES and BIBLIOGRAPHY Chaitow, Leon (2004) Breathing pattern disorders, motor control, and low back pain. Journal of Osteopathic Medicine, 7 (1), pp.34-41. Cholewicki, Jacek and McGill, Stuart (1996) Mechanical stability of the vivo lumbar spine: implications for injury and chronic low back pain. Clin. Biomech., 11 (1), pp.1-15. Cholewicki, Jacek et al. (2000) Effects of external trunk loads on lumbar spine stability. J. Biomech., 33 (11), pp.1377-1385. Courtney, Rosalba et al. (2009) Comparison of the manual assessment of respiratory motion (MARM) and the Hi Lo breathing assessment in determining a simulated breathing pattern. International Journal of Osteopathic Medicine, 12, pp.86-91. Dallweg, Dominic et al. (2008) Impact of breathing pattern on work of breathing in healthy subjects and patients with COPD. Respiratory Physiology & Neurobiology, 161 (2), pp.197-200. De Troyer, A. and Estenne M. (1988) Functional anatomy of the respiratory muscles. Clin. Chest. 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(2010) Changes in sitting posture induce multiplanar changes in chest wall shape and motion with breathing. Resp. Phys. & Neurobiolog., 170, pp.236-245. Lum, L.C. (1975) Hyperventilation: the tip and the iceberg. Journal of Psychomotoric Research, 19, pp.375-83. McGill, S. (1998) Low back exercises: ecidence for improving exercises regimens. Physical Therapy, 78, pp.754-765. McGill, S. (2001) Achieving spine stability: blending engineering and clinical approaches. 4th Interdisciplinary world congress on low back & pelvic pain. Montreal, November, pp.203-211. Nixon, P.G.F. (1993) The grey area of effort syndrome and hyperventilation. J. R. Coll. Physicians of London, 27. Petersson, J. et al. (2007) Posture primarily affect lung tissue distribution with minor effect on blood flow and ventilation. Respiratory Physiology & Neurobiology, 156, pp.293-303. PubMed. www.ncbi.nlm.nih.gov/pubmed Scientific Direct. www.sciencedirect.com West, John and Alexander, James (1959) Studies on respiratory mechanics and the work of breathing in pulmonary fibrosis. American Journal of Medicine, 27 (4), pp.529-544.