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The Tao of Gender
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The X Factor in Clinical Research: The Patient
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AOMA Strengthens Leadership Team
AOMA Graduate School of Integrative Medicine, a leading college of acupuncture & herbal medicine, announced the appointment of Donna LaPoint Hurta, MBA as the new VP of Finance & Operations this Fall.
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Blaming the Gluteus Medius, Overlooking the Deltoid
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March, 2012, Vol. 12, Issue 03
Kinesiology: May the Force Be With You
By Whitney Lowe, LMT
There is no question about it - kinesiology is cool! That's what I think anyway, and it boggles my mind when others are not as intrigued. But, I think it is just that some simply do not realize the benefit of this fascinating field of study.In many cases, knowing kinesiological principles is not just useful, but absolutely essential. Anyone working with pain and injury complaints should have a solid working knowledge of the primary clinical sciences.
Using kinesiology to its full extent is one of the things that will set you apart from other massage therapists and other health care professionals. Surprisingly, kinesiology is one of the clinical sciences least understood by soft-tissue practitioners. Many confuse the science of kinesiology with what is called, “applied kinesiology,” which is completely unrelated. More challenging for others is not knowing how to effectively apply these principles in a clinical setting. Yet, kinesiology's real value is revealed when it fully informs your clinical work.
Sadly, for many, this captivating subject got boiled down to mind-numbing memorization of muscle attachment sites and actions in massage school. Notably, it is the passive learning style that predominates in kinesiology education in both basic and continuing education. Read - memorize - take a test. However, if you take a moment to explore the key elements of kinesiology, you might just discover a host of valuable ways to incorporate this science in your own clinical work.
What is Kinesiology?
Kinesiology is the exploration of human movement and integrates three disciplines: musculoskeletal anatomy (form), neuromuscular physiology (function) and biomechanics. Kinesiology is that area in which these three disciplines intersect (Figure 1). Having a good foundation in these clinical sciences as they relate to soft-tissue treatment is a great starting point. By default, understanding kinesiological principles returns a better understanding of human structure and function.
Your basic education started you out with a solid foundation in muscular anatomy. Soft-tissue therapists should know what the structures are under the skin to which they will be applying soft-tissue treatment. Those working with any level of pain or injuries must know these tissues to have an idea what might be playing a role in their client's dysfunction.
The clinical knowledge necessary for therapeutic treatment does not stop with muscle names or with muscle attachment sites. In fact, it should not stop with muscles at all, but should progress to ligaments, tendons, nerve and fascia - the other soft-tissues often needing to be addressed in various conditions. While muscle tissue is the most common structure soft-tissue therapists work with, it is by no means the only cause of soft-issue pain. If you are not aware of other soft-tissues that may produce pain, you will miss important characteristics of the client's condition.
While anatomy is the study of structure, physiology is the study of function. The second key element of kinesiology is the function of the locomotor tissues, specifically the neuromuscular connection. Movement occurs because of neurological impulses delivered to muscles causing them to contract. When there is a disruption or irregularity in neuromuscular activity or control, movement disorders and pain can result.
Massage treatments frequently incorporate this fundamental understanding of neuromuscular physiology even though you might not be aware of it. Consider the way in which PNF stretching takes advantage of neuromuscular control principles such as post-isometric relaxation. Other methods such as active isolated stretching rely upon specific positions so as not to initiate the neuromuscular stretch reflex. The client who has postural dysfunction and painful trigger points is treated with methods based on physiological principles of how to best deactivate and neutralize these dysfunctional trigger points.
Biomechanics is the third intersecting clinical science of kinesiology. It is the study of structure and function of biological systems through mechanical physics, basically the study of physical forces. It is sometimes confused with body mechanics, which one learns in applying massage strokes. Performing biomechanical analysis requires an understanding of both anatomy and physiology.
To determine how a structure might respond to various mechanical forces, you must be familiar with its physiological characteristics in response to mechanical stress. Evaluating a soft-tissue injury requires exploring the forces applied to the body during injury or activity: their direction, velocity and intensity. Through this mechanical analysis, the practitioner evaluates whether those forces were sufficient to cause specific tissue injuries and consequently how those tissues should be treated.
There are five types of force that can be applied to soft tissues of the body, but only two play a dominant role in most soft-tissue injuries. The five types of force are compression, tension, torsion, bending and shear. Most soft-tissue injuries result from an excess of either compression or tension forces or a combination. The ability to identify type and magnitude of different forces acting on the body is a key aspect of biomechanics that is essential for rehabilitation science.
Putting it Into Practice
As you can see not only is kinesiology a much broader science than you may have realized, but it is an integral part of becoming a highly skilled soft-tissue therapist if you are working with pain and injury complaints. An arsenal of techniques is essentially your bag of tools. However, even with a great bag of tools, if you don't understand when to use a wrench and when to use a screwdriver and how much force to use when you apply it, your work will be so much less effective. Let's take a look at a few examples to see how quality evaluation and treatment rely heavily on kinesiology.
Case 1: Phillip
Philip works in a machine shop that builds frames for construction projects. A good deal of his day is spent using various power tools. When using these tools, he is subjected to repetitive motions along with vibrations from the tools which you can observe in this video clip.
Recently he has been complaining of neurological pain in his forearm and hand. Initially, it is tempting to suspect that he has carpal tunnel syndrome because that is a nerve compression problem that many people are familiar with. However, in applying anatomical concepts, we are reminded that there are numerous potential sites of nerve compression throughout the upper extremity and not all of them affect the median nerve. The untrained therapist may simply jump in and attempt to treat the nerve pain directly in his hand and wrist. Yet, that may not be the primary site of dysfunction.
After performing the relevant palpation, range-of-motion and manual resistive test procedures, there is a suspicion that Philip's primary complaint involves the median nerve. Performance of the upper limb neurodynamic test #1 indicates a reproduction of symptoms in his median nerve. This video clip shows how to perform the upper limb neurodynamic test #1.
Philip describes to us some of the physical activities that he engages in during work including the various motions that he performs with his wrist and arm on a repetitive basis. When performing the upper limb neurodynamic test, we notice that symptoms are more easily reproduced in his forearm with movements of his elbow that stretch the median nerve compared to movements of the wrist that also stretch the nerve.
By applying our knowledge of anatomy and mechanics to how the median nerve is stretched in these different positions, you conclude that his primary nerve pathology is likely to be near the pronator teres muscle in the forearm as opposed to a compression pathology at the carpal tunnel in the wrist. This is because stretching the nerve around the elbow causes more symptoms than stretching it near the wrist or any other part of the upper extremity. Consequently, our treatment approaches focus increased attention on the forearm and are much more successful than if we had incorrectly focused on the wrist.
In this case, we used kinesiological analysis to identify the type of soft tissue dysfunction Philip was experiencing and also more accurately pinpoint where the pain was originating from. This information will also play a crucial role in constructing the most effective treatment. We identified the pronator teres muscle to be a key culprit in the nerve compression. Our analysis of movement noted that this muscle is exceedingly overused in the power tool work activities he is performing.
The pronator teres muscle is not easily treated and requires specific identification to address it properly. Key treatment methods are selected for Phillip using our detailed knowledge of the muscle's location, attachment sites and motions of the forearm and wrist that shorten or lengthen it. The pin and stretch technique in this video clip is highly effective for Philip's pathology and is a great way to address nerve compression by the pronator teres muscle. Using our kinesiological skills in assessment and treatment allowed us to get Phillip back to full activity much sooner and with great results.
Case 2: Robbie
Robbie is an avid snowboarder and outdoor enthusiast. Recently, he suffered an injury to his quadriceps when landing improperly from a jump. He describes what happened to him which you can see in this video clip. Because this was an acute injury, accurately analyzing the forces his knee experienced during the injury is of crucial importance to identify which tissues received the greatest degree of stress.
As he describes his injury, it's evident that his knees took a heavy compressive load from landing on the hard packed snow, especially because he landed in a slightly awkward position. However, his primary complaint centers around pain that appears to be in his distal quadriceps muscle group and not with the internal knee structures themselves. In this instance, we must use our biomechanical analysis and knowledge of form and function to understand what happened with the quadriceps muscles as he landed from this jump. In school you learned that the primary action of the quadriceps is knee extension. However, this is the action of the quadriceps when they are in concentric contraction and the muscles are shortening.
It is imperative to remember that muscles are also engaged as they are increasing in length, which occurs during an eccentric muscle contraction. This distinction is very important because most serious muscle injuries occur from eccentric overload. Unfortunately, the emphasis in school on memorizing muscle actions and only focusing on their concentric contractions has led people to miss the other functional activities of a muscle which are crucial to understanding soft-tissue injuries.
Now, consider how the quadriceps are engaged as Robbie lands from the jump, especially since he said he was in a slightly awkward position making them suddenly take on a greater than normal load. It is likely that his injury was from an excessive eccentric load of the quadriceps as they resist the body's attempt to crash to the ground. The biomechanical action of decelerating motion when landing from a jump is a frequent cause of quadriceps injury.
Exploring Robbie's case further through various assessment procedures, we identify his primary location of pain and most likely site of injury to be in the quadriceps retinaculum, the connective tissue where the quadriceps muscle fibers blend into the connective tissue that eventually joins with the patellar tendon (Figure 2). Having identified the problem to involve some degree of tissue tearing and resultant muscle tightness, the focus of our treatment is on encouraging tissue elongation and reduction of muscular hypertonicity.
There are many good massage techniques that could be used to address the fiber tearing and resultant adhesions that may develop in the quadriceps retinaculum. Deep friction massage, longitudinal stripping and compressive effleurage are all highly valuable. Yet, because Robbie is such an active individual and wants to get back to his activity as soon as possible, a more aggressive treatment approach may be called for with him. Active engagement techniques for his knee extensor group are an excellent treatment choice.
Accurately performing active engagement techniques requires knowledge of kinesiology because you must understand when the muscle is engaged in concentric contraction, eccentric contraction or passively lengthening or shortening. In this instance, the goal is increasing tissue elasticity along with reducing adhesions and encouraging the most effective muscle relaxation. Active engagement techniques that encourage tissue lengthening are the ideal choice for this goal. The active engagement technique for the knee extensors demonstrated here is an exceptional way to address his primary complaint and get him back to activity as soon as possible. Without a solid grounding in kinesiology, we would not be able to identify his knee complaint nor choose the type of active engagement technique that would be most effective in addressing his injury.
How to Learn More
Understanding kinesiology is exceptionally important when you treat clients having pain and injury complaints. Yet, it isn't easy to find formal coursework in kinesiology that is directly applicable to your massage practice. Most university courses in kinesiology are aimed at physical education professionals and not at manual therapists or health care professionals. A continuing education course specifically on kinesiology would not integrate the other sciences and clinical reasoning required for application. There are some excellent books available on kinesiology, but many people find kinesiology textbooks overwhelming and are not sure how to use the books.
The most effective way to learn kinesiology is through activities that put the information directly into practice and require creative thinking and clinical reasoning by the individual. Choosing CE courses that emphasize kinesiology in conjunction with other clinical sciences as they are applied to various situations is an efficient way to learn these principles. Courses that include problem-based learning, case study evaluations or scenarios include deeper levels of analysis and allow the individual to immediately apply kinesiology to their coursework.
You can also improve your application of kinesiology by just watching simple movements you see someone performing and analyzing them. Watch someone walking, raking the yard or working at a checkout stand and analyze what type of forces are being applied to the tissues involved in the activity. When you can apply these principles in the context of your day-to-day work activities, they are much more likely to stick and become meaningful for you.
Massage therapists are ideally positioned to use kinesiology as a valuable and indispensable tool for both assessment and treatment. Putting greater emphasis on applying kinesiology in your practice will pay off with significant rewards of increased treatment success and satisfied clients.
Click here for more information about Whitney Lowe, LMT.
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