My Take on Reverse Hypers - Eric Cressey
My Take on Reverse Hypers
Q: What’s your take on reverse hypers
lordosis) Minimal symptoms Low risk progression - isthmic - mild slip (Meyerding I / II, slip angle o) Observation until mature - review annually to ensure no progression of slip Consists of - activity modification - cease aggravating symptoms - NSAIDS - hamstring stretches - brace Indication - spondylosis / grade 1 spondylolithesis - acute / hot on bone scan Theory - attempt to heal pars fracture - healing is not required for symptoms to settle Type - anti-lordotic - 3/12 full time, no sport - 3/12 full time with sport Results Debnath et al Spine 2007 - 42 patients with unilateral spondylysis hot on SPECT - 6/12 non operative treatment including bracing - 81% avoided surgery / complete resolution of symptoms - remainder had CT confirmed non union and underwent unilateral pars fixation 1. High risk slip - slip degree > 50% - slip angle > 30o - dysplastic - skeletally immature 2.
Debilitating pain - spondylysis - spondylolithesis 1. Pars fusion - painful spondylysis - minimal spondylolithesis 2. Fusion A. In situ v reduction - not required for grade 1 - 2 - consider if sagittal malalignment - associated with risk neurology especially L5 - controversial if should be performed in high grade slips B. Instrumented / non instrumented C. Levels - L5/S1 if grade I or II / 50% or less - L4/S1 if 50% for more D. Interbody cages - useful in long standing spondylolithesis presenting in adulthood - degenerative disc disease - nerve root pain from interforaminal compression - improves nerve root space - improves healing rate E. Posterior v circumferential - circumferential approaches may improve fusion rates and outcome in high grade slips Indication - normal discs and facets - pain relieved by pars injection - failure brace / non operative treatment - minimal slip Technique - lesion identified / debrided / iliac crest bone graft Options ORIF 1. Screw across lytic defect - unilateral defect 2. Pedicle screw + laminar hook - bilateral defect 3. TBW spinous process and transverse process Results Kakluchi et al JBJS Am 1997 - 16 patients with failure non operative treatment bilateral pars defect - pain relieved by pars injection with LA - pedicle screw + lamina hook - nerve root decompression where required - union in all 16 - 3 patients only had occasional back pain A. Wiltse Lateral Mass Fusion in situ Concept - in situ fusion via a paraspinal muscle splitting approach - no reduction or instrumentation Indication - for L5/S1 with minor slip in young patient - rarely done these days - most surgeons perform instrumented fusion Technique - midline incision - two paramedian incisions in lumbodorsal fascia 4.5cm lateral to midline - paraspinous muscle splitting approach 2 fingerbreadths lateral to midline - split sacrospinalis using finger to dissect through muscle - don't go anterior to TP or risk damage to nerve root - decorticate TP / Sacral ala / facet / famina and add crest graft / allograft / BMP Post-op - spica 3/12 with 1 leg incorporated - activity modification for 6/12 Instrumented fusion in situ without reduction Indications - slip grade 1 or II - grade III or IV with no sagittal malalignment Levels instrumentation - L5 / S1 grade I or II - L4 / S1 grade III or IV Options 1. Pedicle screw instrumentation 2. PLIF / interbody cage 3. Bohlman procedure - interbody fusion with fibula strut - augmented with decompression and PLF 4.
Reverse Hypers | Eric Cressey | High Performance …
The is frequently regarded as a key player in the compromise of hip extension, lumbar spine lateral flexion, flexion and/or extension. Although clinically, MET's to the iliopsoas can be very useful for restoring lumbar range of movement, there is little evidence to suggest that the iliosoas is tight, too strong or too weak. Similarly, in the abscence of an 'upslip' there is little evidence to suggest it's involvement in anterior pelvic tilt, rather it is more likely to be a posterior pelvic tilter. When separating the two muscles, the iliacus has an anterior rotation affect on the ilium (counternutation), whereas the psoas major has a posterior rotating affect on the ilium. Additionally, the iliacus muscle and posterio-medial aspect of the psoas major are more linkley to have stabilising functions as they are close to the joint and hence axis of rotation, whereas the antero-lateral psoas major may have a largely mobilising-power generating function. If this is the case, then the iliopsoas may be involved with functional synergies which involve the superficial abdominal muscles in maintaining the pelvic neutral position. When a forward/backward rocking motion is performed in standing, the erector spinae and superficial abdominal muscles exhibit reciprocal timing suggesting that the duration of the considerable compressive force generated by the erector spinae can be reduced in the lumbar spine through enhanced superficial abdominal muscle timing. Similarly, reduced erector spinae and enhanced superficial abdominal activity may reduce the amount of compressive forces generated on the lumber intervertebral discs. However, more ideally, it is the non-torque producing muscles of the abdominal cavity such as the horizontal fibres of interanl oblique and transverse abdominis as well as the deep fibres of multifidus which maintain lumbar spine neutral posture. By reducing the activation of both superficial abdominals and erector spinae it may be possible for the low threshold muscles to function during postural and endurance activities. During high threshold dynamic exercise such as running, transverse excursion of the diaphragm becomes essential to efficient movement as abdominal expansion may lead to loss of pelvic control. Since the oblique abdominal muscles arise from the lower 6 ribs, the oblique abdominal muscles require adequate length for inferior lateral chest expansion to take place. Notably, the low thoracic spine is covered by the pars thoracic aspect of the erector spinae and hence these muscles require sufficient relaxation for rib excursion to take place. Therefore, it makes sense for the iliopsoas to provide powerful hip/lumbopelvic stability, in a functional synergy with the gluteal muscles during activities such as sprinting and hill running. Despite these paradoxes, it is highly likely that the clinical effect of MET's on the iliopsoas is a proprioceptive one, rebalancing the stabilising synergies of the hip and lumbar spine. Importantly, by including inferior lateral breathing in an iliopsoas release, the therapist will be able to glean the importance of incorrect breathing to the dysfunction. Realistically, the clinical reasoning process allows for such areas of uncertainty by using the correlation between the impairment and disability measures to assess the validity of involving the iliopsoas muscle in the treatment process.
Nathalie Roussel, Jo Nijs, Steven Truijen, Liesbet Vervecken, Sarah Mottram, and Ga谷tane Stassijns
The objective of the study was to evaluate the breathing pattern in patients with chronic non-specific low back pain (LBP) and in healthy subjects, both at rest and during motor control tests. Ten healthy subjects and ten patients with chronic LBP participated at this case・・control study. The breathing pattern was evaluated at rest (standing and supine position during both relaxed breathing and deep breathing) and while performing clinical motor control tests, i.e. bent knee fall out and active straight leg raise. A blinded observer analyzed the breathing pattern of the participants using visual inspection and manual palpation. Costo-diaphragmatic breathing was considered as optimal breathing pattern. Subjects filled in visual analog scales for the assessment of pain intensity during the tests. At rest, no significant differences were found between the breathing pattern of patients and healthy subjects (P > 0.05). In contrast, significantly more altered breathing patterns were observed in chronic LBP-patients during motor control tests (P = 0.01). Changes in breathing pattern during motor control tests were not related to pain severity (P > 0.01), but were related to motor control dysfunction (P = 0.01).
My Take on Reverse Hypers: Q: ..
Connell AT (2008) Concepts for assessment and treatment of anterior knee pain related to altered spinal and pelvic biomechnics: a case report. Manual Therapy, 13, 560-563. This author used 3 sessions of treatment to the T10/11, T11/12, T12/L1 and L5/S1 to improve the ROM and ability to squat in a patient with anterior knee pain.
includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits high tensile strength, whilst type III collagen is much more extensible and disorganised and occuring in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). These people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, where they become the ballistic 'floppies', and either highly co-ordinated or clumsy. There deosn't seem to be in my clincial exprience an in-between. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofacscial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Specific exercise regimes more atuned to co-ordination and stability than to excessive non-stabilising stretching, muscle energy techniques, mobilisatinos with movement (Mulligans), thoracic ring relocations (especially good with autonomic symtoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee. Arnica cream for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimuate the red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. Care and even avoidance of end range movement activity. My good friend Abrahao Baptisita, Brazilian Physiotherapist and researcher, recommends the use of for the prevention of shoulder dislocations - subluxations and patella (knee cap) dislocations.
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Chapter 12: THE LUMBAR AND SACRAL AREAS
The pelvic floor can be considered as the base of the cylinder which incorporates the pelvis, abdominal muscles, back muscles, the thoracolumbar fascia and diaphragm. Frequently, people presenting with low back and pelvic pain also describe weakness of the bladder. Such weakness may involve the urethra and effective force closure around the pelvis. When a person coughs, the urethra usually contracts with the abdominal muscles thereby avoiding embarrassment. However, stess urinary incontinence occurs in 8.5 - 38% of women (Ashton-Miller et al 2001, Scan J Urology & Nephrology Supp 207). It affects 28% of elite female athletes (Bo & Borgen 2001, Med Sc Sp Ex, 33, 11, 1797), one out of ten males and 4 of every 10 females (Fantl et al 1996, Managing acute and chronic urinary incontinence, clinical practice guidlelines, no2, Rockville MD, US Dep't Health & Human Services). Cyclists can also have pelvic floor dysfunction and neuropathies as a result of direct presure on the pudendal nerves with an incorrect saddle or saddle position. Urinary continence relies on the support of the sphincter closure system and the urethral support system. Essentially, the urethra sits inside a hammock of muscular and fascial and liagmentous support.
If you were told you have facet damage, S.I
The dense C.T fibroblasts don't respond to stretch due to the stiff matrix preventing the fibroblasts from receiving any strain. Scarring due to injury causes an increase in dense C.T which can be pevented by 10minutes, 2 times per day for 1 week in a suspended tail animal model. The combination of reduced movement and inflammation is a recipe for fibrosis. R-T US can be used as feedback during dry needling to observe C.T movement. In people suffering low back pain the fascial layers are less fluid and less differentiated. Additionally, people with LBP have hicker perivascular C.T. Involuntary muscle spasms may decrease the relative C.T motion during passive movement. Conversely, increased C.T thickness, stiffness and/or viscosity may affect the passive stiffness and range of movement of adjacent muscles.
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