How to Enhance Exercise Rehab With Manipulation and Soft-Tissue Therapy

By Marc Heller, DC and Scott Thorsen, DC, CSCS

As chiropractors, we are in a unique position to use our manual therapy techniques to facilitate exercise rehabilitation. Whether we use joint manipulation, soft-tissue therapies or both, these techniques can help reduce the dysfunctional motor patterns that contribute to muscle imbalance and poor motor control.

As effective as our manual techniques can be, they are often not enough by themselves. Correcting the motor disturbances in chronic and recurring musculoskeletal problems requires the patient to move differently. Integrating rehabilitative exercise into our treatment plan is vital in correcting these imbalances.

How Does Manipulation Enhance Rehab?

Before the patient can effectively rehab his/her muscles, it helps to get the whole neuromuscular system working better. Pain is driven by nociceptive input and abnormal mechanoreceptor input from dysfunctional joints and fascia. In chronic and recurring low back pain, abnormal, neurogenically driven feedback loops are often established. Any lasting pain can cause inhibition of key lumbosacral stabilizing muscles, as well as hypertonicity of others. Manual therapies can break these dysfunctional cycles and help normalize motor control.

Research shows that manipulation can wake up the key stabilizing muscles, including the multifidi. Malik Slosberg has written a nice review article on the effects of manipulation on the multifidi.¹ He states, "[T]he papers state, perhaps for the first time in the scientific literature, that manipulation results in improved contraction of the multifidus and that this benefit may be further enhanced by incorporating other co-interventions, such as exercise training, which also targets the multifidus. Manipulation and exercise training may work synergistically with manipulation to optimize multifidus recruitment and thereby improve patient outcomes."

De-afferentation is common in these cases and occurs when there is a lack of sensory input to the spinal cord and brain. Joint motion activates the sensors in the joint receptors, which bombard the brain and spinal cord with dynamic information. This stimulates the efferent, motor side of the loop to activate the stabilizing muscles around the joint. When a joint is not moving, the sensors around that joint are not being activated in a normal way. Manipulation can normalize joint receptor input.

Manipulation is part of a spine-sparing strategy, one that keeps the painful areas from moving too much. In the joint-by-joint model, we note that the areas where pain is felt, usually the lumbar spine or SI, tend toward DJD, tend to move too much and need stability. The thoracic and thoracolumbar regions tend to get stuck. The hips often get stuck. These restrictions create compensation, causing the lumbar spine and pelvis to move excessively. Pain generators create more pain if they have to move too much and/or if the movement is not well-controlled.

How Does Releasing Myofascial Restrictions Impact Rehab?

Myofascial dysfunction impairs movement patterns. The fascia is a continuous interlinked structure. This dysfunction manifests as tight and restricted bands, focal adhesions and trigger points. These abnormalities disturb normal muscle function and joint motion. The body has to compensate for this lack of movement. Fascia is rich in proprioceptors, including mechanoreceptors and nociceptors. The muscle spindles are embedded in the fascia, within the endomyceum, the connective tissue that surrounds the individual muscle fibers.

Abnormal fascial densities directly and indirectly disturb normal movement patterns. When the fascia is short and tight, it directly affects the pull of the muscle, as a significant portion of the leverage of the muscle is through the fascia, not just through the direct muscle-to-tendon-to-bone connections. Indirectly, when the fascia is tight, it disturbs the feedback loops through the various proprioceptors, such as the muscle spindles.

When nociceptors are activated, the pain further shuts down the core stabilization muscles. The fascia is not just passive soft tissue. It has significant sensory functions and thus feeds into the whole afferent-efferent loop.

Recent research shows hyaluronic acid is a key player in mediating the sliding of different fascial layers over each other.² When the fascia is too dense, abnormal sliding occurs. Deep friction changes the state of the hyaluronic acid. This may be a huge part of the puzzle of myofascial pain, and may explain how deep-tissue therapies work by changing the state of the hyaluronic acid.

Remember that any tender point, trigger point or fascial density may be more than just a shortened or tight muscle. It can represent a neurogenically driven hypertonicity. Stretching the muscle is not enough! These points need hands-on treatment. If the points are still not releasing or continue to get tight, expand your search. After you have released the tender point, either training / strengthening and/or stretching the involved muscles will be more effective.

One of the practical take-home lessons we have learned through all of our studies of soft tissue is to search broadly. The pull of the fascia affects areas distant from the site of pain. If you want to get beyond just treating the site of pain over and over, explore the fascial connections.

Improve Motor Control With an Integrated Approach Using All Your Tools

Motor control is often altered in chronic and recurrent low back pain. Spinal manipulation and myofascial therapies can often help break these cycles and resolve the problem, but many cases require exercise rehabilitation to further correct muscle imbalance and reinforce stability.

Acute pain often responds well to chiropractic manipulation. We all have many patients who come in to see us in acute pain. We adjust them and they feel better. If their acute problem continues to recur, they may be good candidates for rehab training and/or myofascial therapies.

Chronic pain is a different animal. Manipulation and soft-tissue work are often not enough. Chronic pain states tend to be more complicated and/or problematic. The anatomy can be relatively intact or can be compromised by degenerative changes in various tissues. The patient may have lost hope and think he/she just has to live with the problem and/or take pain meds. The patient may have developed a fear mentality and become afraid to move. The pain may have become more central, less peripheral; more neuropathic, less nociceptive.

When pain receptors are being fired in an ongoing manner, the nerve fibers begin to multiply and the connections become more easily fired off. In long-standing pain situations, the ability to move efficiently and without pain has been compromised.

Motor control can be improved; patients with chronic pain will function better if they learn to move properly. There is no single magic bullet, magic pill or magic adjustment that will automatically restore normal neuromuscular function. It is going to take work, both on the part of the physician and on the part of the patient. Solving chronic pain is like peeling an onion!

Evaluate and Treat the Joints and Myofascia

Assessment requires a thorough analysis of the surrounding musculoskeletal structures to determine where to apply our treatment. It is not within the scope of this article to provide a comprehensive explanation of evaluation and treatment. What we would like to do is give you a few highlights. We will include both concepts and specific areas.

Remember that the fascia is continuous and interconnected to muscles, tendons, ligaments, bones, nerves and organs. When we mention muscles, we are also talking about the fascia around and extending from these structures. Because of the interconnectedness of fascia, it is important to expand palpation beyond the confines of the muscular anatomy. This will often reveal additional soft-tissue dysfunction.

The body will adapt and compensate. As you release fascia and muscles, previously restricted areas will immediately change. Treatment is a dynamic process. If something is not changing, re-evaluate.

5 Areas of Special Consideration

1. The quadratus lumborum (QL) is a major player and can inhibit the psoas if it is tight and fibrotic. Evaluate at origin on iliac crest, insertions on 12th rib and on the tranverse processes of the spine, and the belly of the muscle.


2. Abdomen: It is important to become comfortable and proficient at palpating the abdomen. This area is commonly overlooked because of its sensitive nature. It is important to assess beyond the local area of pain. Contents of the abdomen can be significant contributors to lower back pain. It is common to find myofascial restrictions in the psoas, the iliacus and the abdominal muscles. Visceral restrictions can occur either from dysfunction of the visceral fascia, as outlined in the visceral manipulation model,³ and/or from old scar tissue.


3. The psoas is commonly involved in chronic and recurring low back pain. It can also contribute to SI pain, pelvic pain, hip pain and groin pain. It is not enough to perform the Thomas test to assess this muscle. It must be palpated. It must be manually released. It can be hypertonic and fibrotic, whether it is short or not.


4. Thoracolumbar joint dysfunction can create irritation of the superior cluneal nerve, and contribute to lumbar flank pain, gluteal and leg pain. If you find the combination of restricted joints in the T-L, and find a (Maigne) tender point 8 cm lateral to the PSIS, just below the iliac crest, pay attention. Mobilize or adjust the T-L. If you have successfully released the joint restriction, the tender point just below the iliac crest will be much less tender and nodular.⁴
   
   The T-L is a challenge; it is hard to separate the noise from the signal. This area is tight in almost everyone with any lower back pain. Use this tender-point indicator to tell you whether you have successfully release the key joint restrictions.


5. The hip joint is often restricted and often missed. Keep the joint-by-joint model in mind. If the hip can't move, the SI or lumbosacral joints will compensate by moving too much. Assess the hip joint for normal motion, remembering to take into account the patient's gender and age; and compare one side to the other.

The muscles and ligaments that directly connect to the hip joint, into the lower pelvis and to the greater trochanter, are also important. Muscles would the external rotator group (piriformis, etc.), and the adductors. Significant ligaments include the sacrotuberous ligaments at both their origin and insertion.

The Take-Home

Chronic and recurring low back pain almost always involve a compromise of motor control. Improving this dysfunctional pattern can be accomplished, but it takes attentive and persistent efforts on the part of the practitioner. Thoroughly evaluate what is driving the problem. Create a treatment plan that is tailored to the individual needs of the patient.

A best-practice approach is not a one-size-fits-all approach. Compensatory patterns in these patients often make it necessary for us to modify therapy as we go. Manipulation and soft-tissue therapies can immediately change function and reduce pain, and in turn, improve our rehab outcomes. In our practices, we find that if we start by releasing significant joint restrictions, and assessing and releasing restricted myofascial points, exercise rehab is more effective.

References

1. Slosberg M. "Manipulation Improves Recruitment of Multifidus Muscles, Reduces Disability."Dynamic Chiropractic, Feb. 26, 2012.
2. Stecco C, et al. Hyaluron within fascia in the etiology of myofascial pain. Surg Radiolog Anat, 2011;33:891-896.
3. Heller M. "Principles of Visceral Manipulation." Dynamic Chiropractic, April 15, 2013.
4. Heller M. "Thoracolumbar Junction or Superior Cluneal Nerve Entrapment Syndrome: A Hidden Source of Low Back & Pelvic Pain." Dynamic Chiropractic, Nov. 4, 2011.