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Thursday, February 23, 2017

A POLITE Method for Proprioception

By Jeffrey Tucker, DC

When a patient’s symptoms overwhelm me, I have a system that I developed and that I can count on. I use the acronym POLITE as a reminder of the things I may need to discuss, check or perform with my patient:

P is prevention, plan, posture, proprioception.

OL is optimal loading.

I is instrumentation, ice.

T is taping, technology.

E is education, eating, exercise, ergonomics.

 

The treatment process often begins by:

  1. discussing my plan and prevention strategies, making the patient aware of poor postures and showing or assisting him into full range of motion or correcting a dysfunctional movement pattern (proprioception)
  2. showing  the patient how to resist the planes of motion in a variety of mediums (it’s easy for me to do this with Thera-Bands) to develop more integrated skills so that we change the brain’s perception of the movement system (OL – optimal loading)
  3. recommending ice, or heat, or other instruments (body composition, goniometers, etc.)
  4. taping methods and technology (deep muscle stimulator, laser, shock wave, lymph drainage device, etc.); and
  5. improving the patient’s eating, exercise, and ergonomics, and of course all the while educating the patient.

It doesn’t matter if your practice is made up of patients with acute sports injuries or chronic pain, the POLITE acronym still works. The chronic pain patient’s history usually reveals prior injuries, excess or prolonged sitting, poor postures or repetitive movements over time that have led to movement inefficiency and dysfunction in natural movement patterns. Do these factors really relate to the current symptoms? I would say, yes. Previous injury in the same muscle does play a part in recurrent muscle injury (McCall).

My examination involves posture analysis, range of motion, orthopedic testing and movement screens, but the screen depends on the patient’s complaints. Movement analysis can inform us about the patient’s movement system. The only way I know if movement patterns are compromised (from the short term presence of pain or fatigue, or the longer term impact of muscle and joint restriction, chronic pain or the deficits left by previous injury) is to ask the patient to move. I observe if the patient can do what I request, then I ask, “Was there normal range of motion? Was there control of motion in the various planes (sagittal, frontal, transverse)?” For example, when I ask a patient to perform a squat or a lunge, it’s no different than asking the patient a verbal question. I am questioning the patient’s pattern of movement under body-weight load or with a load such as a band, free weight or kettlebell. I am looking for movement quality, synergies of muscle activation and coordination with other muscles. I am looking at proprioception (one of the P’s in POLITE). It’s about fluidity, balance, timing, symmetry or asymmetry of motion. This process of asking the patient to perform a movement analysis (functional task) may provide greater insight into why he was initially at risk.

Patients in pain, especially those with a history of an old injury, oftentimes don’t even realize they have lost normal range of motion or a normal movement pattern. Others have obvious reduced range of motion or a pain with a certain movement, and that is what motivates them to come to the office. Restoring pain-free range of movement is a starting place for functional improvement in work, home, school and recreational activities. Insurance companies are demanding we document this information.

Some of the integrated variable approaches used to fix a “broken body” include range-of-motion drills, learning to maintain “neutral” spine or proper position during motion, varying the speed of motion, changing the work done in a given amount of time (density), changing how much work is done overall (volume), working the planes of motion (sagittal, frontal, transverse), exercising or work activity, and the level of stability and load applied. A common goal of rehab is to improve intermuscular coordination (more muscle, more nervous system involvement) to progressively stress the body greater than before without creating a flare up (which is not so easy sometimes). Static holds or dynamic movement can be used with all of the above. For example, simple observation of the “dead bug” or “bird-dog” pose can help us understand if the patient holds the spine still in the sagittal plane while moving an arm or a leg. Observe by looking at the static pose (patient on all fours with opposite arm and leg raised), progress to observation of watching repeated movement of the bird dog, establish if you have a patient that chooses (unknowingly) a non-functional strategy of movement (loses neutral spine), and then address the problem by cueing. Look for dysfunctions that can arise during function.

I repeatedly educate patients that we have a concept of “neutral” (especially the pelvis) posture, we have muscle/length tension relationships (muscle balance), and we have an ability to create and turn on/off muscle stiffness. You don’t just feel "tight" because some muscles got weak and long, and others got tight (short) and strong or weak (Page, Brown). Prolonged repeated sitting causes muscle imbalance, but it also causes many of the deep core stabilizers to turn off because the body—supported by the chair--doesn't have to use them. We need to reawaken or motor train these muscles to create proper stability within the musculoskeletal system. If we can turn these deep core stabilizers back on, our body will release many of these chronically tight structures to allow us to move better. Utilization of manipulation/adjustments and exercise movement therapy will improve flexibility, range of motion, strength, soft tissue issues and ultimately gait. But it can’t just be the “if we do everything, something will work” approach.

One of the missing links in rehab treatment of movement-control dysfunctions is proprioceptive training (e.g., wobble boards, roller boards, disks, physioballs). Proprioception identifies our sense of position, location, orientation and movement of body parts in relation to each other. It feels weight and tells us if we are stationary or moving, what direction we are moving, what range we are moving through and how fast we are travelling through it. Movement outcomes are determined by sensory input from mechanoreceptors, located in joints, tendons, muscles and ligaments. These receptors provide the CNS with real-time information and constantly update the status of the body’s biomechanical and spatial properties.

Other rehab programs that include multiple stimuli involve joint stability exercises (where agonist and antagonist muscles are co-contracting), balance training, plyometric (jump and/or explosive reaction) exercises and skill-specific training. These will improve the body’s neuro-muscular control (Akuthota 2004).  Past trauma and acute injuries to the body can cause an alteration in the muscles trying to support our body's movement. Assessments of functional movements would show that the wrong structures are working, negatively affecting how well we move.

POLITE in Action

I’ll share an example of the POLITE method and how I used it with a 56-year-old male entrepreneur who plays softball every Sunday. He presented with a chief complaint of a hamstrings injury. He has a history of reoccurring low back pain and previous same-side hamstring injury. He had previous physical therapy, including lumbar spine strengthening with a selection of different modalities, and injections into the low back. On top of softball, he worked out two days a week and said, “I thought I was stretching properly.” He would continue to play with various tight areas, especially the hips and shoulders, always feeling soreness and pain.

My exam begins with posture evaluation, range-of-motion analysis and low back orthopedic tests. I also assessed his ability to demonstrate:

  1. hip flexor stretches, standing and half kneeling (both of these felt tight)
  2. isometric hamstring contraction (the hamstrings were weak)
  3. glute bridging (he felt it “more in the hamstrings than in the butt area”)
  4. dead bugs (he was unable to maintain a neutral lumbar lordosis and went into lumbar extension)
  5. bird dog (he was not able to maintain neutral lumbar spine)
  6. side plank (he demonstrated weakness in the oblique abdominals)

These assessments became the patient’s exercises (see list of exercises below). I also did manipulation and soft tissue therapy to his thoracic spine, hips and shoulders. I taught him proper breathing and posture (neutral) while sitting and standing. I educated him about the crucial need to get up and about more frequently to achieve the necessary blood flow to the muscles. I taught him how to release his tight hip flexors related to his prolonged sitting. He learned a static stretch and progressed into a dynamic stretch.

The primary hip flexors have a great deal of influence on the biomechanics of the hips, pelvis and lumbar spine. Their influence on these structures elicits responses up and down the kinetic chain (McGill). He had anterior rotation of the pelvis, increasing lumbar lordosis related to the bilateral tight hip flexors. Tight and posturally shortened hip flexors will also inhibit their antagonists--the gluteus maximus. This correlated with his reduced hip extension (reduced from the tight hip flexors), which creates a need for the lumbar spine to contribute motion toward the hip extension requirement. This occurs as the proximal attachment of the psoas on the lumbar spine "gives" to the distal attachment on the femur by moving toward it through increased lordosis (McGill).

It was important to stretch the hip flexors, reawaken the glutes, strengthen the muscle fatigue in the hamstrings, increase the range of motion noted in hip extension as well as internal and external rotation. For the hamstring, I had the patient prone lie, bringing his heel to his butt (no use of hands and maintaining neutral pelvis) performing isometric holds with the CLX bands. The relatively new CLX Theraband stands for “continuous loop” band. These are non-latex bands from Theraband that have splits in each section, allowing one to place a hand, wrist, foot, ankle, etc., inside the short loop to use in exercise. They are easy to use and come in the various colors one associates with Theraband product progressions. We progressed to eccentric hamstring work. I taught him balance/proprioception exercise to improve the ankle-knee-hip-lumbopelvic chain.

My plan of corrective exercise (optimum loading) was a six-week strategy including manipulation and deep-muscle stimulator. I spent his second office visit just giving him exercises that he would do at home. After two weeks, I moved into the next set of progressive exercises. The plan encompassed teaching him to tape the hamstring, foam rolling, flexibility, ROM, activation, strength and an anti-inflammatory diet. The following is his entire exercise template:


1. Foam roll hip flexors, adductors and thoracic spine

2. Hip flexor stretches, standing and half kneeling

3. Isometric hamstring contractions

4. Glute bridging with CLX band arm resistance. 

5. Dead bugs progressing to CLX band resistance

6. Birddog progressing to fire hydrant circles and CLX resistant bands

7. Side planks

8. Mountain climbers

9. “Groiners” ending with deep squats that simulate his third-base position stance

I frequently use this progression in rehab for Glute med:

1. Clam progression

2. Bridge progression (bridge up/down, bridge with toes raised, bridge with heels raised)

3. bridge with “march” (single leg bridge holds, single leg bridge moving up and down)

4. Side lying against wall hip abduction

5. Band loop squat (side step walk or “monster walk”)

This is a typical Glute max progression I use:

1. Bridge progression

2. Leg-lock bridge

3. Hip thrusts

4. Curtsy lunges

5. Squats (double leg)

6. Split squats

7. Single-leg modified squats

After four weeks, my patient emailed me to say, “Just FYI, I hit two home runs on Sunday. Both required a lot of running.” 

Upcoming Rehab Symposium

If you are interested in learning current rehab methods, please join the ACA Rehab Council in Orlando, Fla., March 30-April 2, 2017, for our annual symposium. Visit www.CCPTR.org for registration information. 

Dr. Tucker is the secretary-treasurer of the ACA Rehab Council.


References: 

  1. Akuthota et al. Core Strengthening Arch Phys Med Rehabilitation 2004 Mar; 85:S86-92
  2. McCall et al. Injury risk factors, screening tests and preventative strategies: a systemic review of the evidence that underpins the perceptions and practices of 44 football (soccer) teams from various premier leagues.  British Journal of Sports Medicine 2013, 49:9 583-589
  3. Worsley P et al. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults. Journal of Shoulder and Elbow Surgery 2013 Apr; 22(4):e11-19 
  4. Brown S and McGill SM. How the inherent stiffness of the in-vivo human trunk varies with changing magnitude of muscular activation. Clin Biomech 23: 15–22, 2008.
  5. McGill SM. Low Back Disorders: Evidence Based Prevention and Rehabilitation (2nd ed). Champaign, IL: Human Kinetics Publishers, 2007.
  6. McGill SM and Karpowicz A. Exercises for spine stabilization: motion/motor patterns, stability progressions and clinical technique. Arch Phys Med Rehabil 90: 118–126, 2009.McGill SM. Ultimate Back Fitness and Performance (4th ed). Waterloo, Canada: Backfitpro Inc, 2009. 
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