Another Guest Article By  Christopher J. Nentarz, PT, CSTS, NASM-PES, CSTI 

Introduction

A good understanding of function will help shape our perspective as to what assessment and treatment techniques are relevant to our clients and athletes.  While the semantics of popular definitions vary, there are some common principles we find that define the foundation for functional rehabilitation and performance.

Figure 1

3-Planes of Motion- The National Academy of Sports Medicine states function as an, “Integrated, multi-dimensional movement that requires acceleration, deceleration and stabilization in all three planes of motion. Functional training is training that enhances one’s ability to move in all three planes of motion more efficiently, whether you’re an athlete playing in a sport or simply performing activities of daily living.”

We operate in the sagittal, frontal and transverse planes.  (Fig 1) While traditional and machine based exercises are uniplanar, our strategies should focus on utilizing all three planes.

Figure 2

Feet on the Ground- According to Strength and conditioning expert Mike Boyle, functional training is, “An exercise continuum involving balance and proprioception, performed with the feet on the ground and without machine assistance, such that strength is displayed in unstable conditions and body weight is managed in all movement planes.”

Arguing over “closed chained vs open chained” is over-simplified and can a waste of time.  As a general rule, our feet are on the ground for function.  (Fig 2) But some functional movements are open chained, so we must be careful to observe the movement or exercise before passing judgement.

Sustainability- When asked about function, renowned Sports Chiropractor Kevin Jardine states, function is “Being able to successful do the task you set out to while minimizing the stresses imposed on and within the body.”

Function should be performed in a way that minimizes strain on our tissues and nervous system, so it may be repeated over and over again.  Our system should perform and be productive over a life span.  At 81 years of age, Lew Hollander, set out and completed his 21st Ironman. (Fig 3)

Figure 3

Movement Quality- Gray Cook, well-known Physical Therapist states, “Function involves possessing the correct amount of mobility and stability, allowing for controlled and coordinated movement.”

Function involves movement, and movement should be executed with competence.  Quality movements reduce injury, and allow for freedom of expression within ones functional repertoire.

Summary-

Defining global function will help us avoid “losing the sight of the forest for the trees.”  Your personal definition of function will act as a compass to point you in the direction of proper assessment and treatment techniques.

While I do see my fair share of lumbar patients, I don't see too many lateral shifts. I always tell my students that sometimes a colleague and myself would take turns doing shift corrections as the patient swore and pounded on the wall for over 45 minutes (after a brief history). I had just finished telling one of my students this story when a former fellow in training of mine called me and said a friend of his had a lateral shift of between 2-3 weeks in duration.

History: Four weeks prior to evaluation, he helped a friend move for several hours. This resulted in acute LBP which resolved in a few days. Two weeks later, while golfing, had onset of severe left LBP, and was unable to stand upright and found himself shifted to the left. He had been seeing a chiropractor who was using an activator on him in prone and gave him no home exercises. He was no better. He rated his complaints as 7/10 and constant with intermittent pain radiating to his right thigh, but not below the knee. MRI was positive according to patient, but I didn't end up looking at it, trusting the MDT classification and my hunches.

Objective: moderate lumbar lateral shirt to the left in standing, severe loss of sidegliding in standing to the right. Lumbar forward bending and backward bending not tested.
As McKenzie states you have approximately six weeks to correct a true lumbar lateral shift before various changes like adaptive shortening make it very difficult to treat; you are supposed to take a brief history then start shift correction immediately.

Assessment: Signs and Sx consistent with subacute lumbar lateral derangement with lateral shift to the right

Plan: Correct the shift, hope it stays!

Treatment: Started with shift correction in standing, performed this from mid to end range slowly, but progressively. Both he and I were surprised it wasn't extremely painful. I kept this up for about 10-15 minutes, taking a break as needed. He was sweating and my arms were getting quite a workout! He was about 75% corrected, but could not maintain the shift correction upon walking more than 10 feet. I performed  another series of corrections for about another 10 minutes and ended with some slight extensions. This peripheralized and worsened his LE complaints, so I discontinued the extension. I held the next set of shift corrections at end range sideglide, took him to the table in overcorrected position and got him in supine eventually. He had very little pain at this point, going from a 7/10 to 2/10. I proceeded with flexion in rotation closing (LEs to right, trunk relatively to left) and took him to end range. He was again surprised that it didn't hurt more. I really worked on progressing his end range and adding some sidebending to take him further.

He ended up maintaining at least 75% shift correction. He returned the next day, with only some shift correction intact, but his pain was reduced to 5/10. LE pain was abolished. My colleague followed up, as I was off in the morning. He performed more shift correction and did some STM on his lumbar spine. The patient then had a long weekend and had to be part of a wedding party. We were worried about his long drive. We reviewed his HEP from the first day, which consisted of use of a lumbar roll and shift corrections hourly against the wall.

Patient returned for the third visit and he was happy to report feeling better. He was slightly shifted. Lumbar sidegliding in standing still moderately blocked to the right. We started him in prone with hips offset. I released his right quadratus lumborum and performed some TASTM to his erectors which were moderately restricted right greater than left.  I Followed this with some lumbar rotation in flexion in closing. He was pain free, and only minimally shifted, but could walk and maintain the correction. HEP was unchanged.

On the fourth visit, the patient reported only having "stiffness" in the morning, but was Sx free the entire day for the past two days. He was very compliant. Treatment remained the same as last visit. The next follow up, was completely pain free and tested recovery of function. He had full sidegliding to the right, lumbar extension also pain free and WNL repeatedly. Repeated flexion was WNL and pain free. Repeated extension was not blocked by extension, indicating stable lumbar derangement. He left with repeated extension for prophylaxis, but was worried about bowling the next night. I told him to be careful and to extend before and after every turn and to avoid prolonged sitting. He was still just minimally shifted. We concluded that he always had a slight shift as all his repeated motions were free and painless.

Fifth visit, the patient was sore, rated 5/10, but not shifted. His lumbar sidegliding was WNL, but extension was moderately blocked. Sx were intermittent. If you see my previous post, I feel liberal interpretation of the CPR is warranted. He was acute again after having an abolished derangement. After some TASTM to his lumbar paraspinals right > left, I performed one lumbar thrust manipulation to each side. He was immediately pain free and repeated extension was now full and pain free. He left with repeated extension in standing against a table to isolate his hips for more isolated end range loading.

Discussion/Summary: Subacute lumbar lateral derangement with deformity of lateral shift. Responded well to end range loading to reduce the derangement. STM and functional release to right lumbar paraspinals and QL helped free up his movement and helped unblock his sidegliding in standing. After reducing and maintaining reduction of the derangement, the patient rederanged

Dr. Black has been updating me via FB after patient follow up. Updated the case page at the end.

via Body in Mind. Not for everyone, but as I am seeing more chronic patients of late than acute, I have started using more discussions and education to desensitize the CNS- very difficult! So I've been reading up on Lorimer's blog. Good research he posted recently.

via Allan Besselink's Blog. He is a DipMDT, the highest you can go in the MDT system, other than pursuing MDT OMPT Fellowship which is optional (and very out of the box) for them. I couldn't have put it better than he did, but have been meaning to write about MDT and McKenzie's contributions to health care. While I don't agree with their treatment of dysfunction, MDT, is a very powerful method of classification, and the literature has told us repeatedly patient classification leads to better outcomes for treatment. Abandon the pathoanatomical model!

via Charlie Weingroff's Blog Great Business Model, and one more of us should adopt. While I don't train everyone like he does, more taking the MDT + Manual Therapy Route, I do agree we should think out of the box for our practices. Mariano Rocabado said it best, it's not "No pain, no patient."

Via body in mind
http://bodyinmind.org/whiplash-anxiety-depression/

Via gpaccess on YouTube. A well explained quick video on chronic or persistent pain. I'll also be sure to email this to my patients who fall into this category. Goes along well with the Explain Pain text. Enjoy!