Jan 18, 2013

Top 5 Fridays! 5 Recent Out of the Box Ideas


I have a lot of things going through my head at once and try to be creative in the clinic. I also want some of these things studied but don't always have the means.



Here are 5 Recent Out of the Box Ideas I either had in the clinic while treating or I want to be researched.

1) Using a Mirror Box for an Essential Tremor

This case will be a case of the week eval write-up for next week. He came in for knee and groin pain, but also asked me if I could treat an essential tremor. It is unilateral in his right hand. It affects his handwriting and  is mild, but has slightly worsened in the last 10 years. I explained mirror box treatment to him and that it may possibly help because his symptoms are unilateral. I gave him some of the stroke, chronic pain, and hand arthritis references and he was definitely intrigued. I did tell him that I was not aware of anyone using mirror box therapy for an essential tremor but it was worth a try. I also gave him the links for the recognize hands program.

2) Using a Mirror Box in OMPT

Another future case of the week write-up! A 33 yo male runner who due to improper training (surprise!) ended up with a stress fracture of his navicular in the right forefoot. He was in a walking boot for 2 months and referred to me by a local running store. He does have severely restricted dorsiflexion and is apprehensive about running. It is about 1 year since he originally started running after taking a break and over-training.

T/C distraction of uninvolved

Repeated end range plantaflexion of uninvolved

passive dorsiflexion measuring, appears as if involved is going farther!

involved side gains motion!

After several visits his dorsiflexion and motor control are improving, but not as fast as either of us would like. Today, I placed his right foot inside a mirror box (involved side) while I performed joint mobs on his talocrural and subtalar joint on his left. He was sitting watching his left foot in the mirror. After about 5 minutes of various MWMs and distractions. I then passively started ranging his foot into dorsiflexion. It even appeared to me as we were both watching in the mirror that his right (involved) foot was dorsiflexing much more! After re-testing on the half kneel ankle dorsiflexion test, his knee was much closer to the wall. If you want a mirror box to try out of the box Tx like these, order one from mirrorbox-tx.com!

I would need a diagnostic US for the next few research ideas.

3) Use diagnostic US to see if there are changes in the tissues after IASTM/STM distal to the Tx area

A colleague of mine in Chile, Nelson Adrian is using diagnostic US along with the EDGE. He is about to publish research showing local "tissue" changes after 2 minutes of IASTM, but not greater than those. Up to 5 minutes still affected pain, ROM, but not tissues. I think the changes we see are improvements of the superficial layers sliding upon one another thus promoting better movement sensation along to the brain.

I recently read some research on mechanotransduction where the researchers measured EMG and MMG at the anterior deltoid and TFL while massaging the brachioradialist and pernoeals. They found that massage at the distal area caused EMG changes at the deltoid and TFL, but only MMG changes at the deltoid.

This got me thinking, would we see the same "tissue" changes distally under the same tissue patterns under diagnostic US? It's an easy enough study, Nelson, get to it! Anyone else out there with a diagnostic US? I'll donate an EDGE tool for research!

4) Use diagnostic US to see if there are changes in the contralateral tissues of the treatment area

Along the same lines of the above ideas. Since the study that showed "scraping" of bilateral achilles tendinosis helped both the treatment side AND the non-treatment side both functionally AND physiologically (tendon changes), I thought about treating the contralateral side of areas that were
  • too painful to be treated
  • motion limitation was not improving possibly due to CNS sensitivity/perceived threat
I would want the contralateral side being measured before and after
  • using IASTM on the treatment side
  • using IASTM on the treatment side while the contralateral side (measured side) is in a mirror box (possibly enhancing any changes)
  • having the ipsilateral side do AROM
  • having the ipsilateral side do PROM
5) Using Rocktape to help rapid responders reach end range during the MDT HEP

There are patients who are able to reduce their derangements in the clinic with your guidance, assurance, and overpressure, but do not remain reduced somewhere between follow up visits. Perhaps the Tx effects of the OMPT being used are not enough to help them maintain the ROM to reach end range (where the magic happens). I've seen Rocktape work some wonders on patients this week for neurodynamic mobility and motor control in single leg stance. The next step was for me to apply it patients having difficulties with a REIL or cervical retraction with extension. Except, I have not run into that since I started taping this week! I'll update you as it happens!

I encourage you to think outside the box as one of my mentors, Mariano Rocabado does. He presented in a series of slides one of the ways he thought out of the box. Thanks to him, Santiago no longer has deformities of cleft palate because he started an educational program for parents and manual therapies to help remodel the palate prior to surgery while the children at very young. He showed the typical results of the surgical repair prior to implementing his program, and after. The results were so dramatic that only a small incisional scar was noticed after his program, compared to the remaining facial deformity of the cleft just being closed. He even noted in his typical picture taking pre and post treatment for outcomes that the parents often were not in the picture with their children prior to the program, but were overjoyed and happy in the pictures after. That actually brought tears to some of the class participants.

Thinking outside the box is what elevates our profession. Anyone who is willing to help with the above studies as capstones, or just for kicks, I just want the before and after pics, contact me! Comment below if you've had any out of the box ideas that need to be shared!

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