Tuesday, December 29, 2009

The Scalene Muscle & Potential pain generating factors from scalene

The scalene muscles are a group of three pairs of muscles in the lateral neck, namely the scalenus anterior, scalenus medius, and scalenus posterior. They are innervated by the spinal nerves C3-C8.

Origin and insertion
Scalenus anterior & medius: Scalenus anterior muscle arises from anterior tubercles of transverse processes of C3-6 vertebrae. It gets inserted into scalene tubercle on the first rib. Scalenus medius arises from posterior tubercles of transverse processes of C2-7 vertebrae. It gets inserted on the superior surface of the first rib behind the groove for subclavian artery. (J.Anat.Soc. India 55 (2) 52-55 2006 52)

On neck: All 3 scalene muscles produce rotation of the cervical spine to the same side. Maximum stretching of the scalenes should include rotation to the opposite side. (J Orthop Sports Phys Ther. 2002 Oct;32(10):488-96.)

On ribcage & respiration: The action of the anterior and middle scalene muscles is to elevate the first rib and rotate the neck to the same side; the action of the posterior scalene is to elevate the second rib and tilt (side flexion) the neck to the same side. They also act as accessory muscles of inspiration, along with the sternocleidomastoids.

Anatomy of interscalene triangle (IST): (J.Anat.Soc. India 55 (2) 52-55 2006 52)

IST is bounded by scalenus anterior muscle anteriorly, scalenus medius posteriorly and first rib between their insertions inferiorly. Enclosed within this triangle are:
(a) In the upper part of the triangle, ventral rami of C3, 4, and 5 taking part in the formation of phrenic nerve.
(b) In the lower part are the upper, middle and lower trunks of brachial plexus along with the subclavian artery.

I dare to compare the anterior & the middle scalene to the piriformis muscle. The piriformis allows the sciatic nerve to pass through it where as the space between anterior & the middle scalene allows many more structures through it.

Summary of anatomical relationships:
The scalene muscles have an important relationship to other structures in the neck. The brachial plexus and subclavian artery pass between the anterior and middle scalenes. The subclavian vein and phrenic nerve pass anteriorly to the anterior scalene as it crosses over the first rib.
The passing of the brachial plexus and the subclavian artery through the space of the anterior and middle scalene muscles constitute the scalene hiatus (the term "scalene fissure" is also used). The region in which this lies is referred to as the scaleotracheal fossa. It is bound by the clavicle inferior anteriorly, the trachea medially, posteriorly by the trapezius, and anteriorly by the platysma muscle.
Anatomical variations: To know the anatomical variations of IST one is referred to J.Anat.Soc. India 55 (2) 52-55 2006 52

Pain from scalene muscle

1. Role of scalene muscles in TOS:

Scalene muscles cause TOS (both vascular & neural effects) in one of the following ways:
(i) Tough and unyielding tendinous insertions, against which the soft neurovascular structures may be forced during certain movements.
(ii) Aponeurotic insertion of single scalene with sharp sickle shaped margin or both the scalenes joining to form u-shaped sling cause subclavian artery to be highly arched, which might result in kinking of the artery or thrombus formation with distal embolization.
(iii) Triangle can be narrowed to form slit like inter-scalene space by approximation of insertions of the two scalenes or the insertions may overlap resulting in high arching and scissoring effect (Thomas 1983).
(iv) Either of the scalene muscles may be larger than normal thus narrowing the space.
(v) TOCS may also result from spasm of scalenus anterior resulting in ‘scalenus anticus syndrome’.

The TOS & it’s varieties in nutshell

Thoracic outlet syndromes (TOS): caused by compression of the brachial plexus or vascular structures due to anatomical anomalies of the cervico-axillary region.
Varieties of TOS: Two main types are seen i.e. the neurogenic TOS syndromes and the vascular TOS syndromes. The neurogenic TOS syndromes make up 90% of all TOS cases. Females are more affected than males in their 4th or 5th decade. Neurogenic thoracic outlet syndrome (NTOS): NTOS is attributed to compression of the brachial plexus at the scalene hiatus. There are 2 distinct clinical entities of the NTOS i.e. the true & nonspecific NTOS.
True NTOS: have typical clinical and electrophysiological changes.
Nonspecific NTOS: have predominantly sensory signs, not well-defined electrophysiological changes.

Common symptoms of neurogenic TOS:
a. A common initial symptom is pain along the medial side of the arm, which may be more diffuse and accompanied by paraesthesiae.
b. Most of these patients suffer from amyotrophy and gradually progressive weakness of the intrinsic muscles of the hand, particularly the thenar eminence.
c. The association of vascular signs and symptoms is rare.
X-ray: In almost all cases cervical ribs or elongated transverse aprophyses of C7 are found on plain X-ray.
EMG & NCV: Characteristic changes are seen on electrophysiological studies.

2. Trigger point pain scalene producing referred symptoms: Travell & Simmons have described trigger points in scalene. The referral pattern:

1. supra-clavicular area, anterolateral chest
2. antro & postero lateral area of arm
3. antro & postero lateral area of fore arm & hand

3. Mechanical abnormality produced by tight scalene: One should view the impact of the tightness on the cervical spine arthrokinematics as well as the neural mechanics. The neural mechanics must be viewed with reference to David Butler’s neural tissue mobility specifically ULTT3.


What effect of scalene on cervical spine mechanics?

Imbalance in the anterior & middle scalene length of left & right side might lead to laterally translated vertebra on the same side & rotation to the opposite side along with mild flexion. A tight scalene hinders rotation to the opposite side. Hence, forcing the movement to opposite side of the tightness might lead to lateral translation of the lower & middle cervical vertebra to wards the tight side & rotation to the opposite side.

The key assessment involves T1&2 rib palpation for mobility & symptoms & neck rotatory mobility assessment to assess tightness of anterior & middle scalene muscles.

Manual therapy prospective of Scalene

1. Scalene stretch: opposite side rotation & downward pressure to 1st rib during inhaling & attempting apical expansion.

2. MET of Scalene when the effect is on cervical spine- fixation of the 1st rib + isometric holds to same ride rotation (20% of MCV).

3. MET of Scalene when the effect is on 1st rib- fixation of the neck in full rotation + stabilization of the shoulder girdle from above- then take deep inspiration for apical expansion.


1. Molina-Martínez FJ, Thoracic outlet syndrome, Rev Neurol. 1998 Jul;27(155):103-7.
2. Colli BO, Neurogenic thoracic outlet syndromes: a comparison of true and nonspecific syndromes after surgical treatment. Surg Neurol. 2006 Mar; 65(3):262-71; discussion 271-2.
3. Mobilization of the nervous system; David butler, Churchill-Livingstone
4. J.Anat.Soc. India 55 (2) 52-55 2006 52
5. J Orthop Sports Phys Ther. 2002 Oct;32(10):488-96.

Thursday, December 17, 2009

Coupling mechanisms in cervical spine

Radiographic study: coupling of cervical motions in lateral head translations.
The clinically common posture of lateral head translation results in an S-shaped cervical spine and may occur in side impact trauma. This posture has not been studied for cervical coupling patterns or range of motion (ROM) (2).

In a radiographic experimental study (2) on 20 subjects lateral (a mean of 51 mm) translation was produced by translating the head over a fixed thorax. The major coupled motion was lateral bending (z-axis rotation). The following was found:

1. S-shape in cervical spine was created & there is change in direction at C4–C5 disc space.
2. Upper cervical (C3–C4) lateral bending was contralateral to the main motion of head translation direction. Lower cervical and upper thoracic lateral bending was ipsilateral.
3. During the translation other segmental motions averaged less than 1 mm and 1°.

This study shows in cervical spine side bending usually there in nil-minimal involvement of rotational movements. On cervical spine observations if the spine is bend to the rt side it also rotated to the rt side.

Clinical implications: manual repositioning of cervical disc is described by Cyriax method via employing lateral translations in cervical spine (4).

Review of cervical spine coupling behavior (1):
1. 100% agreement in coupling direction (side flexion and rotation to the same side) in lower cervical vertebral segments (C2-3 and lower) but
2. Variation in coupling patterns in the upper cervical segments of occiput-C1 (during side flexion initiation) and C1-2.

Upper cervical spine coupling mechanics:

3-D MRI study (3) reveals:

1. The normal atlanto-occipital axial rotation varies approximately between (2-3) degrees. Similarly, atlanto-axial axial rotation is approximately (32-40) degrees.
2. With contribution of atlanto-occipital axial rotation the contribution of atlanto-axial axial rotation reduces.
3. Coupling mechanism is as follows:
a. Lateral bending is coupled with opposite side axial rotation at both atlanto-occipital & atlanto-axial levels. The degrees of coupling at for atlanto-occipital & atlanto-axial are different. For the atlanto-occipital joint side bending opposite side rotation is between 3-6 degrees, and for atlanto-axial joint side bending opposite side rotation is between 1-7 degrees.
b. In extension atlanto-occipital joint can axially rotate 10-18 degrees and atlanto-axial joint 4-10 degrees.


1. Cook C et al; Coupling behavior of the cervical spine: a systematic review of the literature. J Manipulative Physiol Ther. 2006 Sep;29(7):570-5.

2. Deed E Harrisona et al ; Cervical coupling during lateral head translations creates an S-configuratio. Arthroscopy. Volume 15, Issue 6, Pages 436-440 (July 2000)

3. Ishii T et al; Kinematics of the upper cervical spine in rotation: in vivo three-dimensional analysis. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E139-44.

4. Criax J; Text book of orthopaedic medicine vol.II, 11th edition, AITBS publication

Wednesday, December 16, 2009

Effect of eye position on neck muscle activity

Dominant eye assessment has been an integral part of spine conditions especially to reason out the spinal asymmetry.

Activity of splenius capitis (SC) is modified with gaze shift. Further, control of the neck muscles is coordinated with the sensory organs of vision, hearing and balance.

Impact of eye movement on cervical muscles & movements are not much studied in the context of management of cervical dysfunctions. we can pick up some clues from the study below:

The following is a study of division of physiotherapy (University of Queensland, Australia) which investigates interaction between eye movement and neck muscle activity in influencing the control of neck movement.

The effect of eye position on neck muscle activity during cervical rotation was studied on 11 subjects. Muscles to rt. Side cervical rotation (in sitting) was under real-time EMG surveillance i.e. right obliquus capitis inferior (OI), multifides (MF), and splenius capitis (SC), and left sternocleidomastoid (SCM). The cervical rotation was carried out with a fixed infra-orbital position.

The results show:

1. Right SC and left SCM EMG increased with rotation to the right, contrary to anatomical texts.
2. OI EMG increased with both directions
3. MF EMG did not change from the activity recorded at rest.

This study also shows during neck rotation SCM and MF EMG was less when the eyes were maintained with a constant intra-orbit position that was opposite to the direction of rotation compared to trials in which the eyes were maintained in the same direction as the head movement.
Hence the inter-relationship between eye position and neck muscle activity may affect the control of neck posture and movement.

Bexander, Mellor & Hodges; Exp Brain Res. Effect of gaze direction on neck muscle activity during cervical rotation 2005 Dec;167(3):422-32. Epub 2005 Sep 29.

Rotator cuff tendons & Biceps target area palpation

1. Supraspinatus:

Performance cues-
1. Sitting: HBB (Hand behind back)- Adduction & medial rotation of the arm brings the tendon from frontal plane to sagittal plane.
2. Tendon emerge under the anterior edge of acromion

2. Infraspinatus:

Performance cues-
1. Pr. Lying: prop up the patients on the elbows
2. Lateral rotation of the shoulder- ask the patient to hold to sides of the couch
3. Adduct the shoulder by shifting the affecting the elbow for 2-3 inches

Locating the tendon- The insertion of Infraspinatus tendon is just below the lateral end of the spine of scapula

3. Subscapularis:

Performance cues-
1. Sitting or ½ Lying: Therapist palpates for Bacipital tendon by repeatedly IR & ER of the arm. Just medial to the proximal tendon there is lesser tuberosity & the subscapularis (tendon feels as hard as the bone). The tendon extends down to the shaft of humerus distally.
2. Put patient’s hand on her thigh & apply the massage to specific points
3. Caution: Avoid the massage to the medial edge of the deltoid fibers & over the bacipital tendon

4. Bicep’s Long head:

Performance cues-
1. Patient Sitting or ½ Lying: patients hand on thigh
2. Palpation along the tendon: Resist the elbow flexion & palpate the tendon stiffen near the medial border
3. Palpation across the tendon: Therapist palpates for Bacipital tendon by repeatedly IR & ER of the arm.


Text book of orthopedic medicine

Friday, December 11, 2009

Dr Alsears letter to me- From medicine to meditation

From medicine to meditation

This entire article is by Dr Al Sears. This letter was received by me on my E-mail address, which made a fantastic reading for me.

Al Sears, MD
11903 Southern Blvd., Ste. 208
Royal Palm Beach, FL 33411

December 11, 2009

Dear satyajit,

When I was in India I met “yogis” or meditation masters who had remarkable powers of concentration.

Simply by focusing on their breath they could change their heart rate, raise their body temperature, and even walk on burning-hot coals.

In your daily life you probably don’t have the need or opportunity to walk on hot coals, but the power to quiet your mind gives you more control over your health than any pill or prescription.

Many of these yogis practice meditation. It’s easy enough to do on your own. There are even clinical studies that back it up.

Studies show meditation:

* Lowers blood pressure
* Improves sleep
* Reduces stress and anxiety
* Improves immunity
* Helps with pain management
* Increases productivity
* Improves concentration
* Heightens learning ability and creativity

A study published by the American Heart Association (AHA) found meditation to be as effective as medications for lowering blood pressure. The study involved 111 men and women between the ages of 55 and 85 with hypertension. About a third practiced meditation for 15 to 20 minutes twice daily. A second group practiced muscle relaxation. The third group cut back on salt and calories and practiced aerobic exercise.1

The meditation group showed the greatest improvement. Their systolic pressure – the top number – dropped an average of 10 points. And their diastolic pressure – the bottom number – fell an average of 5.6 points.2 The National Institute of Health (NIH) was so impressed with the results they granted $1.4 million for a follow-up study.3

Meditation is safe and easy. The technique is exceedingly simple. The most natural object of meditation is your breath. For beginners, I recommend mastering your focus on your breath before you try any other object of meditation.

* Find a quiet, comfortable place to sit.
* Rest your hands in your lap and close your eyes.
* For the first few minutes, focus on the natural rhythm of your breath.
* At first, don’t try to change it. Just follow your breath.
* The next step is to gently make your breath, quieter, slower, deeper and more regular.
* If your attention drifts to other things redirect it to your breath.

Try to meditate at least 10 minutes once a day. Twice a day is better.

During my trip to India I had wonderful teachers, but when I got home I felt like I was on my own. After asking around, my friends at Learning Strategies offered me a couple of great programs that make meditation a snap.

Seeds of Enlightenment takes you step-by-step through 8 simple meditations. You don’t need any experience and all you have to do is listen and follow along. One of my favorite parts is the meditation on the Laws of Attraction. It sharpens your awareness and helps you get what you want out of life. The experience is self-empowering.

You can apply this to anything: breaking free from what they call the “money and emotions game,” enhancing your quality of life and your daily experiences, even for personal and business coaching options… the possibilities are limitless.

Learn more about what’s really possible when your mind is clear and focused. This is something you should explore.

References of this article ( Dr Al sears

1 Goad, M. “A powerful case for TM” Portland Press Herald: November 27, 1995. 2 Khalsa, D. S. Brain Longevity, Warner Books, 1997: 309. 3 “The Effects of the Transcendental Meditation and TM-Sidhi program on the aging process,” International Journal of Neuroscience 16 (1): 53¬58, 1982.

Satyajit speaks: Friends & folks yoga does not belong to a particular religion or community. It is a part of health & well-being to all. By a change ancient Indian seers knew the way yoga meditation works.

Sunday, December 6, 2009

Effect of verbal cues on exercise performance

Muscle timing and activation amplitude and movement can be modified with verbal cues (Lewis & Sahrmann ,2009).

Lewis & Sahrmann tested the participants under 3 conditions: no cues, cues to contract the gluteal muscles, and cues to contract the hamstrings muscles. Hip and knee angle and electromyographic data from the gluteus maximus, medial hamstrings, and lateral hamstrings was measured while participants performed prone hip extension from 30 degrees of hip flexion to neutral. (see the figure above)

This information is important for clinicians using prone hip extension as either an evaluation tool or a rehabilitation exercise.

Pregnancy changes them all- Stability, continence and breathing. The role of fascia in these changes.

(Figure 1)

Pregnancy & pelvic Girdle Pain (PGP):

Pregnancy-related pelvic girdle pain (PRPGP) has a prevalence of approximately 45% during pregnancy and 20-25% in the early postpartum period. Most women become pain free in the first 12 weeks after delivery, however, 5-7% do not.

Pregnancy & urinary incontinence (UI):

Wilson, Herbison, Glazener, McGee & MacArthur (2002): found that 45% of women experienced UI at 7 years postpartum and that 27% who were initially incontinent in the early postpartum period regained continence, while 31% who were continent became incontinent.

The abdominal canister (container) in pregnancy and delivery:

Muscles and fascia of the lumbopelvic region play a significant role in
a. musculoskeletal function
b. continence and
c. respiration
It seems that there is an existence of an interlinked trio of lumbopelvic pain, incontinence and breathing disorders.

Musculoskeletal loading & the interlinked trio: (see figure 1 above)
Synergistic function of all trunk muscles is required for loads to be transferred effectively through the lumbopelvic region during of varying load.

While transferring load, there must be a balance in controlling the movement, maintaining optimal joint axes, maintain sufficient intra-abdominal pressure without compromising the organs (preserve continence, prevent prolapse or herniation) and support efficient respiration.

Non-optimal strategies for posture, movement and/or breathing create failed load transfer which can lead to pain, incontinence and/or breathing disorders.

Individual or combined impairments in multiple systems including the articular, neural, myofascial and/or visceral can lead to non-optimal strategies during single or multiple tasks.

Which faults are encountered in pregnency
1. Trauma to the linea alba and endopelvic fascia produces a non-optimal strategies for load transfer.
2. Fascial changes also occurs secondary to altered breathing behaviour during pregnancy.


1. Wilson, Herbison, Glazener, McGee & MacArthur (2002): Obstetric practice and urinary incontinence 5-7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284-300.
2. Lee, Lee & McLaughlin: Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008 Oct;12(4):333-48. Epub 2008 Jul 1.

Tuesday, December 1, 2009

Therapy with amitriptyline or physiotherapy is equally effective in fibromyalgia!!!

You can learn about fibromyalgia from this blog site by typing “fibromyalgia” in the search box of this blog site. The search box is at top left of this page.

In an rural set up Indian study, first of it’s kind, comparing the effect of amitriptyline or physiotherapy in improving outcome in patients of fibromyalgia over a period of six months, Joshi et al found they are equally effective.

Usually fibromyalgia is treated by: antidepressants, analgesics, exercise, cognitive behavioral therapy.

1. Therapeutic Drugs used in fibromyalgia: amitryptiline and other tricyclic antidepressants, pregabalin, duloxetine and milnacipran.
2. Physiotherapy in fibromyalgia: Exercise in the form of cardiovascular training, strength training, aerobics, flexibility training, all can lead to improvement in fibromyalgia.

Joshi employed a trained physiotherapist to conduct a uniform structured physical training and aerobic session for patients in physiotherapy treatment group. The patients were advised to perform the exercises daily twice for at least 10 min. Further there was a step-up pattern of exercise regimen followed by relaxation, stretching and strengthening techniques.

In this experiment physiotherapy was compared with following dosage of amitriptyline.

Amitriptyline dose was 25 mg to 50 mg. No patient required further escalation of doses. All patients were also offered pharmacologic treatment with 50 mg tramadol in thrice daily doses and as required.

Reference: Joshi MN, Joshi R, Jain AP. Effect of amitriptyline vs. physiotherapy in management of fibromyalgia syndrome: What predicts a clinical benefit?. J Postgrad Med [serial online] 2009 [cited 2009 Nov 30];55:185-9. Available from: http://www.jpgmonline.com/text.asp?2009/55/3/185/57399

Wednesday, November 18, 2009

Iliolumbar ligament under stress of slouching and the muscles that prevent it

Most biomechanical studies link the concepts of stooped postures and buckling instability of the spine under high compressive load. However everyday situations lumbar spine is subjected to small or neglectable compressive spinal load. Snijders et tried to find a mechanical cause of acute low back pain (LBP) in everyday situations. Hence their study in 2008 described strain on the iliolumbar ligaments (ILs) when slouching from standing upright.

This study show that

1. Dynamic slouching, driven by upper body weight and rectus abdominis muscle force may produce failure load of the spinal column and the ILs.
2. There is a significant increase of IL elongation with rectus abdominis muscle force.
3. Contraction of erector spinae or multifidus muscle tension ease the ILs.
4. Sudden slouching of the upright trunk may create failure risk for the spine and ILs. This loading mode may be prevented by controlling loss of lumbar lordosis with erector spinae and multifidus muscle force.

Erector spinae and multifidus muscle forces represent a bifurcation in back muscle force: one part acting on the iliac bones and one part acting on the sacrum. The multifidus muscle action on the sacrum may produce nutation which can be counteracted by pelvic floor muscles, which would link back problems and pelvic floor problems.

Snijders CJ et al; Man Ther. 2008 Aug;13(4):325-33. Epub 2007 Jun 5.

Tuesday, November 17, 2009

The SI joint pain- Truth of provocative tests & SI joint blocks

Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain diagnosis of sacroiliac joint dysfunction is frequently overlooked, as common practice is to the link low back pain with protruding disc even when neurological signs are absent (1).

The prevalence reported of SI joint caused pain is some where between
1. International Association for the Study of Pain (IASP) criteria demonstrated the prevalence of pain of sacroiliac joint origin in 19% to 30% of the patients suspected to have sacroiliac joint pain.
2. Hansen et al: the sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks.
3. Rupert et al: prevalence of sacroiliac joint pain is estimated to range between 10% and 38%

SI joint anatomy:
The sacroiliac joint is a diarthrodial (freely moveable joint) synovial joint with abundant innervation and capability of being a source of low back pain and referred pain in the lower extremity (6).
1. The SI articulation: The joint differs with others in that it has fibrocartilage in addition to hyaline cartilage, there is discontinuity of the posterior capsule, and articular surfaces have many ridges and depressions (2).
2. The SI innervation: The sacroiliac joint is well innervated. Histological analysis of the sacroiliac joint has verified the presence of nerve fibers within the joint capsule and adjoining ligaments. It has been variously described that the sacroiliac joint receives its innervation from the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1, and S2, or that it is almost exclusively derived from the sacral dorsal rami (2).

Diagnosis of pain from SI origin
Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain (3).However, earlier authors are skeptic about pain from SI joint. Difference in opinion exists between manual medicine practitioners & main stream physicians. Manual medicine practitioners have described many dysfunctions in SI region & pain arising from it. They advocate “cluster testing” for SI joint dysfunctions. Cluster testing refers to a group of physical tests that filters out the SI joint pain from others & it also indicates the type of SI dysfunction.

However it is true that not much exploration is done about the joint. There are no definite historical, physical, or radiological features to provide definite diagnosis of sacroiliac joint pain. While many authors advocate provocational maneuvers; others suggest accurate diagnosis be made by controlled sacroiliac joint diagnostic blocks.

Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance (3).

Questioning the SI block as the diagnostic gold standard
A review by Rupert et al (5) recently in 2009 indicates that the false-positive rate of single, uncontrolled, sacroiliac joint injections is 20% to 54%. This review reveals similar evidence levels as Hansen et al’s (6) review in 2007 i.e.

1. The evidence for the specificity and validity of diagnostic sacroiliac joint injections is moderate (Level -II).
2. The evidence for accuracy of provocative maneuvers in diagnosis of sacroiliac joint pain is limited (Level-III).

The answer why SIJ block has limited value as a diagnostic criteria comes from Berthelot et al’s (3) study. Berthelot et al reported that effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots (3). These partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block.

This report by Berthelot et al also reveals that the failure of the prevocational tests or anesthetic block is partly due to that fact that extra-articular ligaments contribute to the genesis of pain believed to originate within the SIJs. For example, studies by Vleeming et al (7), Mc Grath et al (8) reveal long posterior sacroiliac ligament is responsible for pain in patients with non-specific low back pain. However Berthelot et al have reported the SIJ ligament which either lock or in allow motion of the SIJ are responsible for pain originating from SIJ. These ligaments are
1. The expansion of the iliolumbar ligaments
2. The dorsal and ventral sacroiliac ligaments
3. The sacrospinous ligaments and
4. The sacrotuberous ligaments

Predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndromes:
To prove SIJ block is better diagnostic criteria than SIJ physical provocative maneuver, Slipman et al (4) considered 3 tests. Out of these 3 the most conspicuous are
1. Patrick’s FABER test
2. Tenderness in sacral sulcus
The test battery used by Slipman et al to confirm a positive provocative SIJ test found out 50 patients in their study. When they are tested by SIJ block (patients who had more than 80% pain reduction in VAS by the block was considered a positive SIJ block) they found only 30 out of these 50 patients had positive response to SIJ block. So according to Slipman et al predictive value of SIJ provocative test is around 60%. Hence provocative SIJ maneuvers do not confirm a diagnosis of SIJS. Rather, these physical examination techniques can, at best, enter SIJS into the differential diagnosis.

U.S. Preventive Services Task Force (USPSTF) criteria for SIJ
1. For diagnostic interventions
The outcome criteria include at least 50% pain relief coupled with a patient's ability to perform previously painful maneuvers with sustained relief using placebo-controlled or comparative local anesthetic blocks.
2. For therapeutic purposes
*Outcomes include significant pain relief and improvement in function and other parameters.
**Short-term relief for therapeutic interventions was defined as 6 months or less, whereas long-term effectiveness was defined as greater than 6 months.

Conservative management includes

1. Manual medicine techniques
2. Pelvic stabilization exercises to allow dynamic postural control
3. Muscle balancing of the trunk and lower extremities

Interventional treatments include
1. Intra-articular joint injections
2. Radiofrequency neurotomy
3. Prolotherapy
4. Cryotherapy
5. Surgical treatment.

Intraarticular injections, and radiofrequency neurotomy have been described as therapeutic measures(6). The evidence for intra-articular injections and radiofrequency neurotomy has been shown to be limited in managing sacroiliac joint pain (2,6). Glucocorticoids may diffuse better than anesthetics within these ligaments hence instead of anesthetic blocks, hence Glucocorticoids should be better therapeutic agent. Furthermore, joint fusion (arthrodesis) may result in ligament unloading to reduce pain(3).

1. Weksler N et al; Arch Orthop Trauma Surg. 2007 Dec;127(10):885-8. Epub 2007 Sep 8.
2. Forst SL et al; Pain Physician. 2006 Jan;9(1):61-7.

3. Berthelot JM et al; Joint Bone Spine. 2006 Jan;73(1):17-23.
4. Slipman CW et al; Arch Phys Med Rehabil. 1998 Mar;79(3):288-92.

5. Rupert MP et al; Pain Physician. 2009 Mar-Apr;12(2):399-418.

6. Hansen HC et al; Pain Physician. 2007 Jan;10(1):165-84.
7. McGrath MC et al; Surg Radiol Anat. 2005 Nov;27(4):327-30. Epub 2005 Nov 9.

8. Vleeming A et al; Spine (Phila Pa 1976). 1996 Mar 1;21(5):556-62.

Friday, November 6, 2009

The LPSL- Lower back pain & deep gluteal pain considerations

* LPSL = long posterior sacroiliac ligament

In many patients with non-specific low back pain or peripartum pelvic pain, pain is experienced in the region in which the long dorsal sacroiliac ligament is located (3,1).

25 sides of the pelvis from 16 cadavers were studied by McGrath et al (2005) revealed that

1. LPSL is penetrated by the lateral branches of the dorsal sacral rami of predominantly S3 & and S2. Only in few cases LPSL is innervated by S4 and rarely by S1.
2. Some of the penetrating lateral branches give off nerve fibres that disappear within the LPSL ligament.

These findings provide an anatomical basis for the notion that the LPSL is a potential pain generator in the posterior sacroiliac region.

Same researcher McGrath et al in 2009 (2) reported few more interesting aspects of LPSL & it’s anatomical relationships
1. The LPSL was observed to have proximal and distal regions of osseous attachment.
2. Between these regions of attachment the middle LPSL was observed as a convergence of three layers: the erectores spinae aponeurosis, the 'deep fascial layer' and the gluteal aponeurosis.
3. Deep to the 'deep fascial layer' a layer of adipose and loose connective tissue was observed. Lateral branches of the dorsal sacral rami were identified within this layer.

This study further indicate that there is a morphological basis for the proposal that putative sacroiliac joint pain may be due to an entrapment neuropathy of the lateral branches of the dorsal sacral rami at the middle long posterior sacroiliac ligament.

Vleeming et al in 1996 reported LPSL has

1. Close anatomical relations with the erector spinae muscle, the posterior layer of the thoracolumbar fascia, and a specific part of the sacrotuberous ligament (tuberoiliac ligament).
2. Functionally, it is an important link between legs, spine, and arms.
3. The LPSL is tensed when the sacroiliac joints are counternutated and slackened when nutated (ventral rotation of the sacrum relative to the iliac bones). The reverse holds for the sacrotuberous ligament. Slackening of the long dorsal sacroiliac ligament can be counterbalanced by both the sacrotuberous ligament and the erector muscle.

Pain localized within the boundaries of the long ligament could indicate among other things a spinal condition with sustained counternutation of the sacroiliac joints. In diagnosing patients with non-specific low back pain or peripartum pelvic pain, the long dorsal sacroiliac ligament should not be neglected. Even in cases of arthrodesis of the sacroiliac joints, tension in the long ligament can still be altered by different structures.

1. McGrath MC et al; Surg Radiol Anat. 2005 Nov;27(4):327-30. Epub 2005 Nov 9.
2. McGrath C et al; Joint Bone Spine. 2009 Jan;76(1):57-62. Epub 2008 Sep 25.
3. Vleeming A et al; Spine (Phila Pa 1976). 1996 Mar 1;21(5):556-62.

Monday, November 2, 2009

Viewing lumbar spine manual therapy from Lumbar paraspinal muscle EMG perspective

Introduction to approaches to investigating strategies in musculoskeletal conditions

The approach is a comprehensive approach called physioanatomic approach that combines both anatomic approaches & physiological approach of investigation. Either the patient's pain pattern is categorized into a nonspecific pattern or into one of 4 recognizable pathway patterns i.e. radicular, dorsal ramus, polyneuropathy, and sympathetic.
The goal of anatomic component of physioanatomic (both noninvasive and invasive) evaluation is to increase specificity by differentiating pain generators from asymptomatic underlying pathologic conditions. The physiologic component deals with function, reactivity & responsiveness of the designated or speculated pathologic tissues.
There are 2 types of anatomic imaging approach i.e. invasive & noninvasive. Example of noninvasive anatomic imaging is computed tomography, single-photon emission-computed tomographic bone scan, and magnetic resonance imaging. The above said 3 tests have significant diagnostic accuracy in detecting pathologic conditions. Example of invasive anatomic approach diskography-enhanced computed tomography.
Physiologic approach also can be invasive & noninvasive, however common physiologic approach are EMG (surface & percuteneous), NCV, biothesiometry etc. In our context, we will discuss about “what EMG & NCV studies tell us on lumbar spine manual therapy”. Before-after EMG & NCV studies in connection with manual therapy of lumbar spine are rare. However we are trying to present following mini-review on this issue. Further we will try to present a case study of physioanatomic approach to see the changes in physiological & anatomical parameters by manual therapy administration.

Electro physiological studies for manual therapy applications: Braddock et al (2007); Manual medicine guidelines for musculoskeletal injuries, National guideline clearinghouse (USA)7

Electrodiagnostic studies for the application of manual therapy are indicated under following circumstances:
1. Persistent neurological symptoms necessitating differentiation of radicular vs. peripheral neuropathy
2. Conditions non-responsive to conservative care requiring determination of the severity of the deficit
Pre and post changes of electrodiagnostic studies from prognostic & therapeutic effective-ness point of view are not considered by this recommendation.

I. EMG as an indicator of Lumbar dysfunction

a. Lumbar erector spinae flexion-relaxation phenomenon (FRP):
A number of EMG studies have shown differences in the FRP between patients with chronic low back pain and healthy individuals. Presence of the FRP during trunk flexion represents myoelectric silence. This leads to increased load sharing on passive structures and is a source of low back pain1. Loss of flexion/relaxation correlates with diminished pressure pain thresholds2.

b. Thoracolumbar myoelectric asymmetry:
Paraspinal surface electromyographic (SEMG) study reveals significant myoelectric differences between thoracolubmar myoelectric activity between involved & uninvolved sides of the back pain. It also shows contralateral responsivity i.e. increased myoelectric activity opposite the side of leg pain.
Hence this technique could be used to detect muscle dysfunction related to LBP. However research of sEMG correlations with measures of the manipulability of a lesion is warranted.

II. Basis of classification of LBA on EMG8,10

Historically, paraspinal muscle impairment has been quantitatively assessed by the use of dynamometers to supplement standard clinical assessment procedures (Roy SH, 1992). But once it is known that EMG can provide data about lumbar spine dysfunction the next question arises whether on the basis of EMG can LBA be classified? Persons with LBP often have reduced muscle strength and endurance, which may compromise the functional capacity of the spine and increase the likelihood of re-injury (Andersson, 1989). Hence an existing lumbar pathology reflects in muscle physiology of lumbar paraspinals.

Specific clinical correlation between the pathology & EMG of lumbar paraspinals has been studied by many researchers. Normative data in this context is also available8. Normative data of lumbar paraspinals for comparative purposes are of great help in classifying LBA cases. Many authorities are trying to classify LBA on assessments based on surface electromyographic (EMG) techniques to overcome some of the problems inherent in the use of dynamometers for back muscle evaluation and classification (Merletti R, 1994).

Recent approach of EMG variable is derived from the frequency rather than from amplitude of the signal. This is partly due to the fact that during a sustained contraction, the EMG signal propagates at a slower velocity and undergoes an alteration in shape associated with changes to the depolarization zone of the muscle membrane (De Luca CJ, 1985). These phenomena are referred to as "myoelectric manifestations of fatigue," and are typically measured during a contraction as a decrease in the median or mean frequency (MF) of the EMG signal.

Scheme of conducting an EMG for back muscles:

The performance state of the paraspinals muscles can be described by variables obtained from an array of EMG electrodes (De Luca CJ, 1993). Here is a description of how to conduct it

1. The electrodes are strategically placed at specific anatomical locations corresponding to contralateral and ipsilateral paraspinal muscles. Differences in the variable mapped at the beginning and end of a fatigue-inducing contraction are analyzed to assess impairment.

2. The issue of muscle performance objectivity the test is limited to the performance of submaximal constant-force isometric contractions in which the duration of the contraction is predetermined.

3. Furthermore, the useful information from the EMG signals is not derived from a single muscle group or a single parameter, but rather is the result of the concurrent behavior or mapping of many co-active muscle groups. It is hypothesized that the subject is likely to be unaware of, and cannot volitionally control, parameters derived from such a measurement scheme.

Roy et al used this method of EMG-based approach to assess and classify paraspinal muscle impairment in persons with LBP. An EMG device used to implement this technique, referred to as a Back Analysis System (BAS).

According to Oddsson et al (1998) basing on EMG initial results are promising for identification of 2 kinds of LBP impairments observed during constant-force isometric tasks:

(1) Excessive fatigue due to muscle de-conditioning and
(2) Inhibition of muscle activation secondary to pain or pain-related behaviors.

Classification procedures used to identify such impairments on the basis of EMG spectral measures have relied primarily on discriminant analysis methods. Hence newer and possibly more effective techniques are described as an area for future development10.

How much reliable is the EMG measurements in lumbar paraspinals?8

Reliability of measurements obtained for EMG variables such as the frequency of EMG signals from paraspinal muscles during isometric trunk extension has been investigated by many researchers.

1. Within-day reliability for control subjects tested in the BAS (back analysis system) resulted in 2% -6% errors.
2. Between-day variability performed 5 days apart (Thompson and Biedermann) reported correlation coefficients within a range of .75 to .96 (large & positive) for frequency values recorded from the multifidus and iliocostalis muscles.
3. Thompson and Biedermann reported reliability of frequency measurements consistently higher for the iliocostalis muscle than for the multifidus muscle.

Some other researchers (Roy et al & Thompson DA et al) have identified source of measurement variability. Following two points are pointed out by them as sources of variability.
1. Electrode placement accuracy: Errors in relocating the electrodes at the same site when repeating a test.
2. Crosstalk: Crosstalk is a source of measurement variability because surface EMG techniques do not completely isolate EMG signals from a single muscle. The amount of crosstalk between adjacent erector spinae muscles has been estimated using a technique in which EMG electrodes are placed on the contralateral muscle and only one muscle is electrically stimulated.

* Crosstalk index is the ratio between the amplitudes of the EMG signals recorded from the non-stimulated and stimulated muscles. Crosstalk index is in the range of 6% to 7%.

III. EMG studies indicating effectiveness of manual therapy:
Manual therapy is one of the most popular treatments for lower back conditions. Famous task forces on low back pain such as Quebec task force have emphasized more on strengthening of back muscles than manual therapy. Being one the most popular treatment modality for such conditions, one is forced to consider that manual therapy has not been researched on objective physiological yardsticks like EMG & NCV studies. However, recently many more researches are pored into this area so that the picture is getting clearer day by day. In the following section we are trying to present a picture of studies in manual therapy with EMG variable. We have provided examples of 4 studies first two studies are exploratory studies where as later two studies are clinical studies.
Colloca CJ et al reported consistent, but relatively localized, reflex responses occurred in response to the localized, brief duration MFMA (mechanical force-manually assisted) thrusts delivered to the thoracolumbar spine and SI joints. These authors also reported, overall, 20 treatments produce systematic and significantly different sEMG responses, particularly for thrusts delivered to the lumbosacral spine4,5.
Most of the therapeutic assessment and treatment movements in spinal manual therapy are identical. SPAM, is not only used for assessment but SPAM is commonly utilized to teat lumbar pain & restriction with or without referred pain. Detection of neuromuscular reflex responses during the maneuver may serve to guide an efficient & very objective treatment delivery. Neuromuscular reflex responses also imply progression & changes in the condition by the imparted module.

Study 1: Colloca et al (2001) investigated dynamic stiffness measurements (force/velocity) and concomitant neuromuscular response to extract more information concerning mechanical properties of the low back. This is the first study that demonstrated neuromuscular reflex responses associated with manually assisted spinal manipulative therapy in patients with low back pain4,5.
Little objective evidence is available concerning variations in PA stiffness and their clinical significance. Manually assisted spinal manipulative therapy is based on commonly assessed objective data like SPAM (spine PA movement) TPAM (transverse process posterior anterior movement) to assess spinal stiffness. However SPAM has been reported to vary with spinal level, body type, and lumbar extensor muscle activity during spinal stiffness assessment. But it is easy to discriminate asymptomatic and those who have low back pain on this4,5.
Hence Colloca et al employed surface electromyographic (sEMG) recordings obtained from electrodes (8 leads) located over the L3 and L5 paraspinal musculature to monitor the bilateral neuromuscular activity of the erector spinae group during the PA thrusts. This study is the first to assess erector spinae neuromuscular reflex responses simultaneously during spinal stiffness examination4,5.
This study by Colloca et al demonstrated increased spinal stiffness index and positive neuromuscular reflex responses in subjects with frequent or constant LBP as compared with those reporting intermittent or no LBP. Some other findings include4,5
1. Thrusts applied over the transverse processes produced more positive sEMG responses in comparison with thrusts applied over the spinous processes.
2. Left side thrusts and right side thrusts over the transverse processes elicited positive contralateral sEMG responses.
3. Patients with frequent to constant low back pain symptoms tended to have a more marked sEMG response in comparison with patients with occasional to intermittent low back pain.
Hence Colloca et al concluded identification of neuromuscular characteristics, together with a comprehensive assessment of patient clinical status, may provide for clarification of the significance of spinal manipulative therapy in eliciting putative conservative therapeutic benefits in patients with pain of musculoskeletal origin4,5.
Study 2: On clinical situation most of the times the posterior spinal exercises are co-prescribed with manual therapy or as maintenance therapy of achieved therapeutic goal. Investigators studying the effects of back exercise on EMG spectral parameters found parameters to be sensitive to back muscle adaptations. However there are no studies that substantiate that manually-assisted (MFMA) spinal manipulative therapy (SMT) may help augmenting the effects of these exercises. It is also less researched what is the appropriate time to implement spinal exercises after MFMA SMT.

Keller et al investigated whether mechanical force, manually-assisted (MFMA) spinal manipulative therapy (SMT) affects paraspinal muscle strength assessed through use of surface electromyography (sEMG) on 40 subjects grouped into 3 (1 active treatment group and 2 control groups). The results of this clinical trial demonstrated that MFMA SMT results in a significant increase in sEMG erector spinae isometric MVC (maximal voluntary contraction) muscle output6. Hence these findings indicate that altered muscle function may be a potential short-term therapeutic effect of MFMA SMT.

This study goad researchers for a randomized, controlled clinical trial to further investigate acute and long-term changes in low back function6. It also creates interest in keen researchers to explore the short & long term effects of addition of isometric back muscle contractions immediately after MFMA SMT.

Study 3. A chiropractic case study by Morningstar MW et al (2006): Lumbar disc herniation is a problem frequently encountered in manual medicine. While manual therapy has shown reasonable success in symptomatic management of these cases, little information is known how manual therapy may affect the structure and function of the lumbar disc itself. In cases where lumbar disc herniation is accompanied by radicular symptoms, electrodiagnostic testing has been used to provide objective clinical information on nerve function3.

Case Presentation by Morningstar et al
An elderly male patient presenting with right-sided foot drop had all sensory, motor, and reflex findings in the right leg and foot were absent due to lumbar disc herniation. This was validated on prior electromyography and nerve conduction velocity testing. Patient was treated using spinal manipulation twice-weekly and wobble chair exercises three times daily for 90 days total. Following this treatment, the patient was referred for follow-up electrodiagnostic studies. Significant improvements were made in these studies as well as self-rated daily function3.

Hence the authors have concluded that motion-based therapies, as part of a comprehensive rehabilitation program, may contribute to the restoration of daily function and the reversal of neurological insult as detected by electrodiagnostic testing. Electrodiagnostic testing may be a useful clinical tool to evaluate the progress of patients with lumbar disc herniation and radicular pain syndromes3.

Study 4: Bertolucci LF et al 1st facsia research congress Howard medical school, Boston, 20079.

Bertolucci et al displayed their work at 1st facsia research congress Howard medical school, Boston, 2007. His work was further published in journal of body & movement therapy, 2008. His work revolves around recording of EMG signals coming from paraspinals muscles during his self styled myofascial treatments.

Working on a specific mode of myofascial release called muscle repositioning Bertolucci considers detecting EMG activity during the maneuvers, brings a high degree of objectivity to the procedure under execution. EMG recording could be used to guide & monitor appropriateness of manual touch & manual therapy procedures could be more precise, objective & reproducible.


1. Colloca CJ et al; The biomechanical and clinical significance of the lumbar erector spinae flexion-relaxation phenomenon: a review of literature; J Manipulative Physiol Ther. 2005 Oct;28(8):623-31.

2. Leach RA et al; Correlates of myoelectric asymmetry detected in low back pain patients using hand-held post-style surface electromyography; J Manipulative Physiol Ther. 1993 Mar-Apr;16(3):140-9.

3. Morningstar MW et al (2006); Improvement of lower extremity electrodiagnostic findings following a trial of spinal manipulation and motion-based therapy

4. Colloca CJ et al; J Manipulative Physiol Ther.; Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain. 2001 Oct;24(8):489-500.

5. Colloca CJ et al; Electromyographic reflex responses to mechanical force, manually assisted spinal manipulative therapy, Spine (Phila Pa 1976). 2001 May 15;26(10):1117-24.

6. Keller TS et al; J Manipulative Physiol Ther. 2000 Nov-Dec;23(9):585-95. Mechanical force spinal manipulation increases trunk muscle strength assessed by electromyography: a comparative clinical trial.

7. Manual medicine guidelines for musculoskeletal injuries (Reference: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10798&nbr=5626)
Braddock E, Greenlee J, Hammer RE, Johnson SF, Martello MJ, O'Connell MR, Rinzler R, Snider M, Swanson MR, Tain L, Walsh G. Manual medicine guidelines for musculoskeletal injuries. California: Academy for Chiropractic Education; 2007 Apr 1. 33 p.

8. Roy SH et al, Journal of Rehabilitation Research and Development Vol . 34 No . 4, October 1997 Pages 405-414. Classification of back muscle impairment based on the surface electromyographic signal.

9. Bertolucci LF et al, J Body Mov Ther. 2008 Jul;12(3):213-24. Epub 2008 Jul 7.

10. Oddsson et al; Physical Therapy; An investigation of the reliability and validity of posteroanterior spinal stiffness judgments made using a reference-based protocol, aug 1998.

*All Rights Reserved. No Parts Of This Publication Shall Be Reproduced, Stored In A Retrieval System, Or Transmitted, In Any Form Or By Any Means, Without The Prior Permission Of The Author.

Basis of classification of LBA on EMG

Persons with LBP often have reduced muscle strength and endurance, which may compromise the functional capacity of the spine and increase the likelihood of re-injury (Andersson, 1989). Historically, paraspinal muscle impairment has been quantitatively assessed by the use of dynamometers to supplement standard clinical assessment procedures (Roy SH, 1992). Assessments based on surface electromyographic (EMG) techniques have been proposed to overcome some of the problems inherent in the use of dynamometers for back muscle evaluation and classification (Merletti R, 1994).

Recent approach of EMG variable is derived from the frequency rather than from signal amplitude of the signal. This is partly due to the fact that during a sustained contraction, the EMG signal propagates at a slower velocity and undergoes an alteration in shape associated with changes to the depolarization zone of the muscle membrane (De Luca CJ, 1985). These phenomena are referred to as "myoelectric manifestations of fatigue," and are typically measured during a contraction as a decrease in the median or mean frequency (MF) of the EMG signal.

Scheme of conducting an EMG for back muscles:

The performance state of the paraspinals muscles can be described by variables obtained from an array of EMG electrodes (De Luca CJ, 1993). Here is a description of how to conduct it

1. The electrodes are strategically placed at specific anatomical locations corresponding to contralateral and ipsilateral paraspinal muscles. Differences in the variable mapped at the beginning and end of a fatigue-inducing contraction are analyzed to assess impairment.

2. The issue of muscle performance objectivity the test is limited to the performance of submaximal constant-force isometric contractions in which the duration of the contraction is predetermined.

3. Furthermore, the useful information from the EMG signals is not derived from a single muscle group or a single parameter, but rather is the result of the concurrent behavior or mapping of many co-active muscle groups. It is hypothesized that the subject is likely to be unaware of, and cannot volitionally control, parameters derived from such a measurement scheme.

Roy et al used this method of EMG-based approach to assess and classify paraspinal muscle impairment in persons with LBP. An EMG device used to implement this technique, referred to as a Back Analysis System (BAS).

Wednesday, October 14, 2009

The flexion relaxation phenomenon

I. Lumbar erector spinae flexion-relaxation phenomenon (FRP):

A number of studies have shown differences in the FRP between patients with chronic low back pain and healthy individuals. Presence of the FRP during trunk flexion represents myoelectric silence (1).

This leads to increased load sharing on passive structures and further these tissues have been found to fail under excessive loading conditions and are a source of low back pain. Persistent activation of the lumbar erector spinae musculature among patients with back pain may represent the body's attempt to stabilize injured or diseased spinal structures via reflexogenic ligamentomuscular activation thereby protecting them from further injury and avoiding pain (1). However, flexion relaxation phenomenon (FRP) is an interesting model to study the modulation of lumbar stability (2).

II. Presence of fatigue of the erector spinae (ES) muscles modifies the FRP

Descarreaux et al studied to identify the effect of erector spinae (ES) muscle fatigue and spine loading on myoelectric silence onset and cessation in healthy individuals during a flexion-extension task. Trunk and pelvis angles and surface EMG of the erector spinae (ES) L2 and L5 were recorded during flexion-extension task.

They found:

1. Onset of myoelectric silence during the flexion motion appeared earlier after the fatigue task + cessation of myoelectric silence was observed later during the extension after the fatigue task.

2. Persistence of erector spinae (ES) myoelectric activity in flexion during the load condition.

These findings indicate presence of fatigue of the erector spinae (ES) muscles modifies the FRP. This study also confirmed earlier findings that superficial back muscle fatigue seems to induce a shift in load-sharing towards passive stabilizing structures. The loss of muscle contribution together with or without laxity in the viscoelastic tissues may have a substantial impact on post fatigue stability (2).

III. FRP in seated forward flexion or slumped postures: differences in thoracic & lumbar levels

Callaghan et al did SEMG on 22 subjects (both males & females) to examine the myoelectric activity of the erector spinae muscles (thoracic and lumbar) of the back if the FRP occurs in seated forward flexion or slumped postures.

The study shows:

1. Slumped sitting posture yield FRP of the thoracic erector spinae muscles, whereas the lumbar erector spinae muscle group remained at relatively constant activation levels regardless of seated posture.

2. Thoracic erector spinae silence occurred at a smaller angle of lumbar flexion during sitting than the flexion relaxation angle observed during standing flexion relaxation.

Hence myoelectric activity of the lumbar erector spinae did not increase, in seated forward flexion or slumped postures. This indicates that the passive tissues of the vertebral column were loaded to support the moment at L4/L5. Ligaments contain a large number of free nerve endings which act as pain receptors and therefore could be a potential source of low back pain during seated work.

This study has a great relevance as examination of flexion relaxation during seated postures may provide insight into the association between low back pain and seated work.

IV. FRP in lifting

During the full flexion phase of the back lift movement the lumbar part of the erector spinae muscle exhibits a reduced activity level (flexion relaxation).

But the question is how the required extension torque in the lumbo-sacral joint (L5/S1 joint) is balanced during the period in which apparently the lumbar erector spinae ceases to take its share?

Toussaint et al reported:

1. While flexion it is true that there is flexion relaxation but this coincide with a 25% increase in lumbar length. The change in length-force relationship & passive tissue strain provide part of the required extension torque.

2. With lifting of barbell there is a significant increase in EMG level of the thoracic part of the erector spinae occurr just before the flexion relaxation at the lumbar level. Apparently, the extensor function of the lumbar part is then taken over by the thoracic part of the erector spinae muscle.

3. This suggests that an intricate coordinating mechanism operate that apportions the load to be balanced over active--(lumbar and thoracic part of the erector spinae) and passive structures (post vertebral ligaments).

V. Repeated spinal flexions modulate FRP

Repeated flexion causes muscular fatigue, creep of passive tissues and diminished protective reflexes.

Dickey et al reported:

1. Majority of people show flexion-relaxation throughout the repeated trunk flexion.

2. With flexion-relaxation and maximum flexion angles increase.

3. The flexion-relaxation angle relative to the maximum flexion angle also increases. This effect depended on the load condition; the flexion-relaxation and maximum flexion angles show a greater increase in the unloaded than loaded condition.

Dickey et al concluded that FRP change due to repeated trunk flexions because of changes to the neuromuscular control system. The deactivation of the erector muscles near full flexion angle result in a greater spinal flexion following repeated spinal flexion. This may be related to the increased risk of injury associated with repeated flexion.

VI. FRP in relation to load & speed

The relative spine motion time differ depending on the direction of movement, being longer during trunk flexion and shorter during extension. Sarti et al (6) tried to find out whether variable speed and loading during trunk flexion-extension.

They found:

1. Increase in speed of movement increase the relative lumbar flexion time and significantly reduced the relative lumbar extension time.

2. Increased speed delays the appearance of the electrical silence or the flexion relaxation.
Adding FRP in assessment of LBA

The studies that show differences in the presence of the FRP among patients and control subjects are encouraging for this type of clinical assessment and suggest that assessment of the FRP is a valuable objective clinical tool to aid in the diagnosis and treatment of patients with low back pain (1).


1. Colloca CJ et al, The biomechanical and clinical significance of the lumbar erector spinae flexion-relaxation phenomenon: a review of literature; J Manipulative Physiol Ther. 2005 Oct;28(8):623-31.
2. Descarreaux M et al, Changes in the flexion relaxation response induced by lumbar muscle fatigue; BMC Musculoskelet Disord. 2008 Jan 24;9:10.
3. Callaghan JP et al, Examination of the flexion relaxation phenomenon in erector spinae muscles during short duration slumped sitting; Clin Biomech (Bristol, Avon). 2002 Jun;17(5):353-60.
4. Toussaint HM et al, Flexion relaxation during lifting: implications for torque production by muscle activity and tissue strain at the lumbo-sacral joint; J Biomech. 1995 Feb;28(2):199-210.
5. Dickey JP et al, Repeated spinal flexion modulates the flexion-relaxation phenomenon; Clin Biomech (Bristol, Avon). 2003 Nov;18(9):783-9.
6. Sarti MA et al, Response of the flexion-relaxation phenomenon relative to the lumbar motion to load and speed; Spine (Phila Pa 1976). 2001 Sep 15;26(18):E421-6.

Tuesday, October 6, 2009

Long thoracic nerve injuries: new theories to consider

The long thoracic nerve supplies the Serratus anterior, whose root value is (C5-C7) but the root from C7 may be absent.

Anatomic path: The roots from C5 and C6 pierce the Scalenus medius, while the C7 root passes in front of the muscle. The nerve descends behind the brachial plexus and the axillary vessels, resting on the outer surface of the Serratus anterior. It extends along the side of the thorax to the lower border of that muscle, supplying filaments to each of its digitations (finger-like projections).

Long thoracic nerve injuries in sports: Due to its long, relatively superficial course, it is susceptible to injury either through direct trauma or stretch. Injury has been reported in almost all sports, typically occurring from a blow to the ribs underneath an outstretched arm.

Also injuries to the nerve can result from carrying heavy bags over the shoulder for a prolonged time. Symptoms are often minimal – if symptomatic, a posterior shoulder or scapular burning type of pain may be reported.

A lesion of the nerve paralyses the serratus anterior to produce scapula winging, which is most prominent when the arm is lifted forward or when the patient pushes the outstretched arm against a wall. However, even winging may not be evident until the trapezius stretches enough to reveal an injury several weeks prior.

Long thoracic nerve palsy from a possible dynamic fascial sling cause:

Following is an review by Hester P et al

Long thoracic nerve palsy can result from sudden or repetitive external biomechanical forces. This investigation describes a possible dynamic cause from internal forces.

Six fresh cadaveric shoulders (3 female, 3 male, 4 left, 2 right) with full range of motion were systematically dissected to evaluate the anatomic course of the long thoracic nerve. In all specimens a tight fascial band of tissue arose from the inferior aspect of the brachial plexus, extended just superior to the middle scalene muscle insertion on the first rib, and presented a digitation that extended to the proximal aspect of the serratus anterior muscle.`

With progressive manual abduction and external rotation, the long thoracic nerve was found to "bow-string" across the fascial band. Medial and upward migration of the superior most aspect of the scapula was found to further compress the long thoracic nerve. Previous investigations have reported that nerves tolerate a 10% increase in their resting length before a stretch-induced neuropraxia develops. Previous studies postulated that long thoracic nerve palsy resulted from the tethering effect of the scalenus medius muscle as it actively or passively compressed the nerve; however, similar neuromuscular relationships occur in many other anatomic sites without ill effect.

We propose that the cause of long thoracic nerve palsy may be this "bow-stringing" phenomenon of the nerve across this tight fascial band. This condition may be further exacerbated with medial and upward migration of the superior aspect of the scapula as is commonly seen with scapulothoracic dyskinesia and fatigue of the scapular stabilizers. Rehabilitation for long thoracic nerve palsy may therefore benefit from special attention to scapulothoracic muscle stabilization.

Hester P et al; J Shoulder Elbow Surg. 2000 Jan-Feb;9(1):31-5.

Monday, October 5, 2009

Scapular Dyskinesia

Abnormal scapular motion is called scapular dyskinesis. Tennis players with scapular dyskinesia present a smaller subacromial space than non-athletes. Silva RT et al reported in Br J Sports Med (2008 Apr 8) that tennis players with scapular dyskinesia present a smaller subacromial space than control subjects. Additionally, when the shoulder was analyzed dynamically, moving from neutral abduction to 60 degrees of elevation, the tennis players with scapular dyskinesia presented a greater reduction in the subacromial space compared to unaffected athletes.

Hence it seems logical that scapular dyskinesis is one causative factor in over-head athletic injuries. However the causal relationship between scapular dyskenesia & shoulder injuries has not been reported. Moreover reliable and valid clinical methods for detecting scapular dyskinesis are lacking.

Let us discuss more on this issue on this subject & understand what exactly is scapular dyskenesia & how to test it.

Following definitions are taken from Journal of Athletic Training 2009; 44(2):160–164 g by the National Athletic Trainers’ Association, Inc (Philip M et al)

Operational Definitions

The movement that is studied:

Shoulder flexion and frontal-plane abduction (5-repeatations). (see the figure above)

Normal scapulohumeral rhythm: The scapula is stable with minimal motion during the initial 30 to 60 degrees of humerothoracic elevation, then smoothly and continuously rotates upward during elevation and smoothly and continuously rotates downward during humeral lowering. No evidence of winging is present.

Scapular dyskinesis: Either or both of the following motion abnormalities may be present.

Dysrhythmia: The scapula demonstrates premature or excessive elevation or protraction, non-smooth or stuttering motion during arm elevation or lowering, or rapid downward rotation during arm lowering.

Winging: The medial border and/or inferior angle of the scapula are posteriorly displaced away from the posterior thorax.

The Rating Scale for scapular dyskinesia:

Each test movement (flexion and abduction) rated as

a) Normal motion: no evidence of abnormality

b) Subtle abnormality: mild or questionable evidence of abnormality, not consistently present

c) Obvious abnormality: striking, clearly apparent abnormality, evident on at least 3/5 trials (dysrhythmias or winging of 1 in [2.54 cm] or greater displacement of scapula from thorax)

Final rating is based on combined flexion and abduction test movements.

Normal: Both test motions are rated as normal or 1 motion is rated as normal and the other as having subtle abnormality.

Subtle abnormality: Both flexion and abduction are rated as having subtle abnormalities.

Obvious abnormality: Either flexion or abduction is rated as having obvious abnormality.

The relationship of Scapular dyskinesia to that of Shoulder injuries

Source: Journal of Athletic Training 2009;44(2):165–173 g by the National Athletic Trainers’ Association, Inc (Angela R et al)

Angela et al reported that presence of scapular dyskinesis was not related to shoulder symptoms in athletes engaged in overhead sports.

Friday, October 2, 2009

Complete frozen shoulder lookout

Classification of FSS (Frozen shoulder syndrome)

1. Primary (Idiopathic) Frozen Shoulder

2. Secondary Frozen Shoulder

1. Systemic
1. Diabetes mellitus
2. hypothyroidism
3. hyperthyroidism
4. Hypoadrenalism

2. Extrinsic
1. Cardiopulomonary disease
2. Cervical Disc
3. CVA
4. humerus fractures
5. Parkinson's

3. Intrinsic
1. RTC Tendinitis
2. RTC Tears
3. Biceps tendinitis
4. Calcific tendinitis
5. AC arthritis

*from Coumo, F. Diagnosis, Classification, and Management of the Stiff Shoulder. In: Disorders of the Shoulder: Diagnosis and Management. Iannotti, JP and Williams GR (eds). 1999

Description of pain in primary FSS (Frozen shoulder syndrome):

The onset: After a period of pain, localized mostly in the shoulder and / or upper arm, begins the onset of severe limitation of movement of the glenohumeral joint in all directions.

Cause: Movement limitation is caused by the retraction of the glenohumeral joint capsule and adhesions of the subdeltoid bursa. Due to this condition of the glenohumeral joint the arm is not able to be elevated forward, actively or passively, more than 90 degrees. This movement is made possible by rotation of the scapula and forced posterior movement of the clavicle.

Cineradiography of the primary frozen shoulder reveals:

Cineradiography of the primary frozen shoulder reveals that not only is the movement pattern of scapula and clavicle changed, but also the relationship between the coracoid process and the clavicle. Further forward elevation of the arm is made impossible due to obstruction of the coracoid process by the clavicle. This obstruction results in the compression of the tissues lying between these bones causing pain. Postmortem examination confirms this theory.

Guided by these observations it is thus illustrated that patients with a frozen shoulder suffer pain, not only from the primarily affected tissues around the shoulder, but also from the compression of the tissues between the coracoid process and the clavicle during forward elevation of the arm. (Stenvers and Overbeek 1978).

Change in the thinking of the approach to FSS:

Many researchers and clinicians believe the effectiveness of existing physical therapy interventions can be improved by targeting the provision of specific interventions at patients who respond best to that treatment. The key messages are that subgroups should be identified (Hancock et al).

Frozen shoulder is a vast entity. This syndrome is classified in to primary & secondary. Depending on acuteness & time course of presentation FSS (Frozen shoulder syndrome) has 4 distinct stages.

1. Stage 1: "Pre-adhesive Stage"
2. Stage 2: "Freezing Stage"
3. Stage 3 "Frozen Stage"
4. Stage 4: Thawing Stage

The pain resistance sequence pattern is conspicuous in different stages. Many different articles claim, there are secondary myofascial shortening & stiffness of thoracic spine in addition to capsular tightness. Hence the treatment advocacy is varied yet not streamlined. Treatment involves:

1. Shoulder mobilization
2. Shoulder mobilization + or - capsular stretching
3. Shoulder mobilization + or - capsular stretching + or -myofascial stretching +or - *
4. Shoulder mobilization + or - capsular stretching + or - myofascial stretching + or -**

* AC ± SC± ST ± joint mobilization
** AC ± SC± ST joint mobilization ±thoracic mobilization
*** All mobilization procedures are appropriately supplemented with strengthening

Research report about effectiveness of joint mobilization in FSS:

Bulgen et al (1984) performing a RCT comparing passive mobilization techniques (3 times per week for 6 weeks, intensity unknown) with intra-articular steroid injections, ice therapy followed by PNF, or no therapy, reported following-term (6 months) advantages of any of the treatment regimens over no treatment.

Yang et al (2007) compared the use of 3 mobilization techniques----in the management of 28 subjects with frozen shoulder syndrome. ERM and MWM (Mobilization with movement) were more effective than MRM in increasing mobility and functional ability.

Research report about effectiveness of multidirectional stretching in FSS:

The vast majority of patients who have phase-II idiopathic adhesive capsulitis can be successfully treated with a specific 4-direction shoulder-stretching exercise program. Patients with more severe pain and functional limitations before treatment had relatively worse outcomes. More aggressive treatment such as manipulation or capsular release was rarely necessary, and the efficacy of early use of these treatments should be further studied.

Content of the Pre-introduction class to shoulder techniques

Thursday, October 1, 2009

Be cautious while mobilizing stiff shoulder.

Current much acclaimed article of Vermeulen HM et al has changed the approach to frozen shoulder. End range mobilization is preferred over other techniques of mobilization. However, administering mobilization in shoulder is not out of danger.

Drakos MC et al (The Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA) reported “Shoulder dislocation after mobilization procedures for adhesive capsulitis”. This study is published in Orthopedics. 2008 Dec;31(12). No abstract or text available in PUBMED.

Leon Chaitow’s recommendation of manual therapy for parkinsonism

1. Antero-posterior and lateral mobilization of the thoracic and lumbar spine (patient seated).

2. Myofascial release of the thoracic spine (patient seated).

3. Atlanto-occiptal release (patient supine; not manipulation).

4. Mobilization of the cervical spine (patient supine).

5. Muscle-energy technique (MET) release of cervical muscles (patient supine).

6. General mobilization of the shoulder joints including use of MET (patient side-lying).

7. Mobilization of the forearms (patient supine).

8. Mobilization of the wrists (patient supine).

9. Mobilization of the SI joint (patient supine).

10. MET to the hip adductors (patient supine).

11. MET to psoas muscles (patient supine).

12. MET to hamstrings (patient supine).

13. Mobilization of the ankles (patient supine).

14. MET to the ankle in dorsi and plantar flexion (patient supine).

Note: This sequence has to be performed in this order in 30 minutes.

Tuesday, September 29, 2009

Cadaver study of axial distraction mobilization of the glenohumeral joint support end range mobilization

The axial distraction mobilization techniques are frequently employed for treating patients with joint hypomobility. To know the biomechanical effects 3 different positions of glenohumeral abduction on a fresh cadaveric specimen ware chosen. They are

1. resting position
2. neutral position
3. end-range position

Result indicated that displacement of the humeral head ware as follows:

1. largest in the resting position (27.38 mm)
2. followed by the neutral (22.01 mm)
3. and the end range position (9.34 mm).

Greater gain in mobility was obtained in distraction at the end range position.

During distraction mobilization, the force applied by the therapist and displacement of the humeral head depends on the joint position tested. These results also provide rationales for choosing end range distraction mobilization for improving joint mobility.


Authors: Ar-Tyan Hsuab, Jing-Fang Chiuc, Jia Hao Changd

Wednesday, September 23, 2009

Mulligan’s positional fault corrections cause pain relief & mecanical corrections for long lasting effect!!!

According to Vicenzino et al (2007) there are an increasing number of reports espousing the clinically beneficial effects of Mulligan's mobilization-with-movement (MWM) treatment techniques. The most frequent reported effect is that of an immediate and substantial pain reduction accompanied by improved function.

Manual therapy effects on pain have been explained by many authors. The mechanism involved is thought to be an effect of mechanoreceptor response that affects the pain gait. Few others claim pain relief may be due to supra-spinal mechanisms based on opiate-like substance releases. However recent findings refer the supra-spinal mechanisms may not be involved especially spinal manual therapy-induced hypoalgesia.

Naloxone antagonism and tolerance studies employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms. Paungmali et al (2004) reported that rapid initial hypoalgesia caused by Mulligan MWM was not antagonized by naloxone, suggesting a nonopioid mechanism of action in tennis elbow i.e. existence of similar non-opiate pain control mechanism seen after spinal manual therapy. Vicenzino et al described this effect as unique & characteristic hypoalgesia of Mulligan’s techniques. The selective and specific effect of this treatment technique warrants further investigations in physical modulation of musculoskeletal pain.

Ankle positional fault corrections!!!

Study that indicates Mulligan’s ankle technique first corrects mechanical errors:

Talocrural dorsiflexion is a major impairment following ankle sprain. Lack of posterior talar glide and weight-bearing ankle dorsiflexion are common physical impairments in individuals with recurrent ankle sprains. MWM of the ankle joint involves the application of a combined posterior talar glide mobilization and active dorsiflexion movement. Collins et al reported this MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains. Vicenzino et al reported both the weight-bearing and non-weight-bearing Mulligan’s MWM treatment techniques improve posterior talar glide by 55% and 50% in recurrent ankle sprain cases. Treatment of existing positional faults leads to increased chances of not getting back the ankle sprain may the plausible mechanism. However these authors indicated future research to explore the mechanism by which this occurs to better understand the role of manipulative therapy.


1. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):180-5.
2. Vicenzino B et al; Man Ther. 2001 Nov;6(4):205-12.
3. Man Ther. 2007 May;12(2):98-108. Epub 2006 Sep 7.
4. Collins N et al; Man Ther. 2004 May;9(2):77-82.
5. Vicenzino B et al; J Orthop Sports Phys Ther. 2006 Jul;36(7):464-71.

Manual therapy class (theory) : Mulligan's technique-MWM effects on peripheral joints