Who’s On Your Team?

By: Dr. Jenifer Reiner

Who’s on your team?

Athletes whether they are professional football players or collegiate volleyball players are surrounded by a team of medical providers, team coaches, and strength and conditioning staff all focused on providing a comprehensive program to achieve optimal health and performance.  Outside these settings, however, a coordinated effort between one’s medical doctor, personal trainer, chiropractor, or physical therapist is more of a dream rather than a reality.  Clients are becoming more aware of this “team” approach and are seeking out the one-stop-shop for their training and rehabilitation needs.

Following chiropractic school I was fortunate to experience the “team” approach to rehabilitation while working in the athletic department at the University of California San Diego.   The road to recovery is a collective effort that includes medical doctors, physical therapists, athletic trainers, acupuncturists, strength coaches, and chiropractors.  While many of our skills overlapped, the combined efforts in diagnosis, treatment, and sport specific training provided appropriate checks and balances to ensure we were on the right track for success.  Outside the university setting, however, I worked in a private practice that included two other chiropractors.  Challenging cases with atypical presentations or limitations in my own treatment skills often left me frustrated due to a lack of resources.  It was time to make a change in my personal practice and recreate the university setting I had grown to love.  Around that time, Todd Durkin was in search of a sports-based chiropractor to complete his team of rehabilitation and training staff at Fitness Quest 10.  The opportunity included a team of physical therapists (Water and Sports Physical Therapy), massage therapists, a world class group of strength and conditioning coaches, Pilates instructors, and yoga teachers.  Christmas had come early.

After 2 short years since joining the “team,” it’s safe to say I have experienced the most growth professionally, educationally, and personally, than in college and post graduate work combined.  I believe the key to this success lies in the motivation of those around you, your “teammates” dedication to mastering their craft, and pure enjoyment of learning from those constantly seeking the best information available.  No one settles for mediocrity in this establishment and failure is not an option.

I write this in hopes of encouraging other industry professionals to put aside the egos, if you haven’t already done so, and seek out your “team.”  Finding a core group of individuals with varied backgrounds, who speak the same language, and work together to improve your client’s/patient’s health and physical performance, is unprecedented.  Maybe I speak for myself, but this profession is not about us.  It’s not about how much money you make, how smart you are, how great your skills are, or how many people follow you on Twitter.  We are a profession of service and I would venture to say that 99% of us feel the most satisfied when we meet our client’s goals and exceed their expectations.  Therefore, whether you are a chiropractor, physical therapist, medical doctor, strength coach, sports coach, message therapist, etc., a team of masterminds is critical to your personal and professional success.  Research your local professionals, connect with like-minded individuals in the industry, combine services under one roof, and pick the brains of your teammates.  In the words of Martin Rooney, “Success and mediocrity are both contagious.  If you want to be great, surround yourself with great people and get infected.” Most importantly, your clients will appreciate your “team” effort in their quest for health and wellness.

Dr. Jennifer Reiner is the chiropractor for Water and Sports Physical Therapy and Fitness Quest 10 in San Diego, California.  She obtained a Bachelor’s of Science Degree in Exercise Science from the University of Florida and went on to pursue a Doctor of Chiropractic degree from Palmer College of Chiropractic West.  As a member of the Palmer West Sports Council, Dr. Reiner focused her studies on sports injuries and rehabilitation.  She is also a Certified Strength and Conditioning Specialist (CSCS) by the National Strength and Conditioning Association.

She spent five years as the official chiropractor for the University of California San Diego, providing care to a variety of sports including swimming, soccer, volleyball, track and field, tennis, and basketball.  Dr. Reiner is certified in Graston Technique as well as Active Release Technique (ART).  She also holds certifications in FMS (Functional Movement Screen), SFMA (Selective Functional Movement Assessment), TRX suspension training, and K-laser therapy.

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Mobility Matters – Identifying The Cause Rather Than The Symptom

By Dr. Jennifer Reiner

In the last ten years, the term mobility within the fitness and sports performance community has been pushed to the forefront.  Foam rollers, slant boards, rolling sticks, baseballs, and other torture devices are a mainstay in gyms to improve flexibility and mobility.  As a chiropractor that works primarily with athletes and the active population, I feel the hierarchy of movement begins here.  In school, we spend years understanding the basis of joint movement, how to assess it, and ways to improve upon it.  I hope to provide a little insight from a clinical chiropractic perspective on mobility and perhaps give you a few exercises to add to the toolbox.

A wide variety of philosophies and therefore treatment and assessment protocols exist in the chiropractic profession.  While some are deeply rooted in the older chiropractic philosophy of maintenance care and wellness, others focus on rehabilitating neuromusculoskeletal problems.  To provide a little background into my methodologies and techniques, I graduated from chiropractic school with a focus on sport related injuries.  This led me to a series of seminars, specifically Active Release Technique and Graston.  I spent a three-month internship with the University of Miami and later moved to San Diego to work with the University of California San Diego’s athletic training staff.  A few years of Active Release and manipulations on 300 pound offensive linemen and 6’9” basketball players took its toll on my 5’3,” 115 pound frame.  If I continued at this rate, I knew my career would be short-lived.  It was time to treat smarter, not harder.

I began questioning the soft tissue techniques I utilized as well as my own abilities.  Common areas, such as the IT band or hip flexors, would be resistant to repeated treatments using Graston and Active Release.  I blamed the athlete’s mechanics, the sport, or a previous injury for the recurring issue.  Bottom line, my hands and body were taking a beating only to achieve temporary improvement in the athlete’s condition.  Around this time I returned to my roots of exercise science and obtained my Certified Strength and Conditioning Specialist certification.  A plethora of information related to functional movement and corrective exercise existed opening my eyes to many physical therapists, strength coaches, researchers, and other like-minded chiropractors.  Gray Cook, Mike Boyle, Craig Liebenson, Greg Rose, Stewart McGill, and Mike Reinold are just a few whose research, articles, seminars, and philosophies I took interest in.  I believe my “aha” moment came during the FMS/SMFA (Functional Movement Screen/Selective Functional Movement Assessment) seminar when the discussion began on joint mobility and stability.  Finally, objective findings coinciding with our understanding of biomechanics, to effectively provide a rationale for repetitive soft tissue and joint tightness, pain, and/or injury.  It wasn’t so much my treatment techniques that were in question, but rather the assessment.  Evaluating movement in relation to mobility and stability would be the guiding factor as to which area was the weakest link.  As such, treatment directed towards the cause utilizing objective evidence rather than symptoms, would produce long-lasting, efficient, and effective results.

Whether the FMS/SFMA is your evaluation tool or another, mobility limitations must be considered before progressing to motor control problems.  For those unfamiliar with the joint-by-joint approach described by Gray Cook and Mike Boyle, each segment of the body is viewed by its role in providing mobility or stability.  To begin, our ankle, hip, thoracic spine, and glenohumeral joint should be mobile while the knee, lower back, cervical spine, and scapulae should be stable.

The hips can be tricky, however, as this region serves both a mobility and stability purpose.  Based on these patterns, it is no wonder that disrupting the sequence creates compensation elsewhere.  For example, clinicians (me included) can get caught up at the site of the patient’s symptoms.  Insidious onset of anterior knee pain is a great example.  If orthopedic tests fail to reveal instability, compromises in range of motion, meniscal problems, etc., we often categorize the issue as patellofemoral pain, tendonitis, and so forth.  These diagnoses are more of the symptom rather than the cause.  Typical treatment including ultrasound, myofascial release, rest, and non-steroidal anti-inflammatories may provide short-term relief, but often the same issue rears its ugly head a short time later, perhaps even worse.  Well it is time to take a step back both figuratively and literally to view the areas above and below the site of complaint.  It is time to include an assessment of the fundamental movement patterns our patients and athletes are utilizing in their every day activities.  Sure, standard orthopedic tests, isolated muscle strength, and range of motion are integral to each examination, but often these do not provide the rationale for the cause of injury.  A movement screen can provide foreshadowing of a potential problem to come.  Utilizing this information begins to tell the story of the mechanical breakdown producing the dysfunction.

After performing a movement screen or assessment and evaluating your results, addressing joint mobility limitations and/or soft tissue extensibility problems is the first step in treatment.  Let’s get back to the basics, if the range of motion at a particular joint is significantly lacking, the motor control of the muscles surrounding the joint will also be compromised.  Unfortunately, you cannot exercise yourself out of poor movement patterns.  The system must be reset at the most basic of levels.  The lack of mobility may be due to several factors including a poorly managed injury, posture, stress, or inefficient stabilization.  Over time, our body detects the lack of movement and begins to compensate by making up for it elsewhere.  This is our innate ability for survival.  Compensation, however, was designed for short-term management…. i.e. running away from a pack of wolves.  Nowadays, however, when our bodies begin to signal signs of distress by way of pain, tightness, and discomfort, we run for the nearest bottle of Ibuprofen.  Silencing the alarm system leads to ongoing distress at the joint or soft tissue priming us for that disc rupture, ACL tear, meniscal derangement, rotator cuff injury, and the list goes on.

As babies, we are born with ample mobility throughout our spine and extremities.  Personally, I think God was doing us a favor (being a woman that is) providing substantial movement to be able to twist, turn, flex, and extend during the birthing process.  Mobility provides the platform by which we build our stability.   The developmental process involves movement milestones beginning with the mobility of the hips and shoulders and progresses to rolling patterns and core stability.  Therefore, we must address mobility before expecting a new level of motor control in order to overcome movement dysfunctions.

Generally speaking, many of the mobilizations/manipulations I perform are directed towards the ankles, hips, thoracic spine, and glenohumeral joint.  As such, the videos below are examples of a few exercises commonly prescribed to patients.

Whether you are a “top down” or “bottom up” believer, I’m sure we can all agree that limited dorsiflexion of the ankle can produce a number of issues up the kinetic chain.  Many athletes I treat present with low back, hip, knee, and/or ankle issues that relate to the limited mobility of the talocrural joint.  This is a modified hinge, synovial joint, comprised of the talus and distal tibia and fibula.  While the articular geometry of the ankle limits the amount of inversion and eversion, the mobility lies primarily in the sagittal plane (plantarflexion and dorsiflexion).  Dorsiflexion in the non-weight-bearing position is 20 degrees and plantarflexion is 50 degrees.  Perhaps a more functional measurement, closed chain dorsiflexion, is standard at 43 degrees with the knee flexed and 36 degrees with the knee extended (Reischi, Noceti-DeWit).

For many individuals, especially those who have played sports, an ankle sprain is as common as a winter cold.  Left untreated, scar tissue forms around the joint and soft tissues impeding dorsiflexion, an imperative component to shock absorption in running and jumping and in fundamental movements such as squatting and lunging.  Rather than strengthening the supporting musculature and improving the proprioception of the foot and ankle, patients subscribe to heavy taping and ankle braces.  In his book, Movement, Gray Cook reports a direct connection between the stiffness of a basketball shoe and the amount of taping and bracing that correlates with the high incidence of patella-femoral syndrome in basketball players.  Therefore, improving the movement within the sagittal plane improves knee tracking creating less stress at the knee, hip and lower back.  Soft tissue extensibility and joint mobility techniques are both essential for improving ankle mobility.  The video below includes stretches directed towards the flexibility of the lower leg musculature and ankle mobilization techniques directed toward the joint.

For patients presenting with lower back pain, the hip and thoracic spine must be considered.  The lumbar spine is wedged between these two generally stiff joints and is forced to make up for the insufficiency of mobility.  Increased movement at the discs creates shearing forces and aberrant movement at the facet joints.  It comes as no surprise that some of most common spinal regions for disc pathologies and degenerative changes is in the lumbar spine. The body’s natural response to excessive movement at the joint level is to tighten down the surrounding soft tissue, particularly the musculature.  If poor trunk stability is added to the equation, low back symptoms are inevitable.  Here we begin to tap into the cause of chronic mechanical lower back pain and stiffness.  It’s no wonder repetitive manipulation or soft tissue mobilization of the lumbar spine fails to solve the root of the problem.  These treatments are simply addressing the symptoms.   The hip joint is designed for multiplanar movement, as it is a multiaxial ball-and-socket joint.  In a society of chronic desk sitters, many people lack mobility in hip extension, abduction, and external rotation.  Again, where the hips do not move, the low back will.  So, provide that foundational mobility to protect the stability of the lumbosacral spine.  Here are several hip stretches and mobility exercises to improve upon these commonly restricted movements.

According to the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), repetitive strain injuries are the nations most common and costly occupational health problem, affecting hundreds of thousands of American workers and costing more than $20 billion a year in workers compensation.  The typical workstation is not ergonomically designed, and even when it is, a conscious effort in correct sitting posture is not at the top of most people’s list.  Poor sitting habits are considered a repetitive stress injury.  Although the amount of stress is minimal (literally the weight of ones head, upper extremities, and torso), the repetition or duration, in this instance, is extreme.  Insistent flexion stress to the spine causes deformation of the supportive anatomy that holds us upright.  This phenomenon is known as creep, a condition where passive, supportive structures such as ligaments and joint structures are stretched.  As a result, the mobility of our spine becomes more limited and the supportive musculature cannot function properly.  Compromising the movement of the thoracic spine only increases the stress to the adjacent joints and tissues.  As previously mentioned with the lack of hip mobility and subsequent stress added to the lumbar spine, the cervical spine suffers a similar fate.  Clinically, in the cervical spine, the most frequent degenerative changes and disc pathologies occur at the mid to lower cervical spine as a result of increased shearing and movement.  Thoracic flexion should measure 20 – 45, extension 25 – 45 degrees, lateral flexion 20 – 40 degrees, and rotation 35 -50 degrees.  Compared to other joints, this is a wide range for accepted movement, so erring towards the higher number is to our benefit.  To quote Mike Boyle on thoracic mobility, “almost no one has enough, and it’s hard to get too much.”  From a chiropractic perspective, I feel joint manipulation is very effective here, particularly at the cervicothoracic and thoracolumbar junction.  Daily mobilization and stretching techniques are just as important and can easily be given to patients/clients for homework.  In fact, most of my patients, whether they are coming in for a shoulder, neck, or lower back problem, will receive a home exercise program including thoracic mobility.

Because shoulder mobility is closely tied to thoracic mobility, I will address the glenohumeral joint here as well.   The shoulder could easily be a whole other article so, to keep it short we’ll discuss it in relation to the thoracic spine.  Before beginning to consider the movement of the shoulder, we must look at the posture and movement of the thoracic spine.  Patients with poor thoracic extension often present with impingement (secondary) issues.  In essence, improving your thoracic spine mobility will also improve shoulder mechanics.  For example, try flexing the shoulder while sitting in a slouched posture and you will experience limited motion and possibly discomfort or pain as you raise the arm.  Conversely, forward shoulder flexion with an extended thoracic spine clears the subacromial space allowing the glenohumeral joint to move freely.  Once this is established, we can move distal to the scapula stabilizers and the glenohumeral joint when considering movement dysfunctions and other pathologies.  Below are some of my favorite thoracic mobility exercises that also benefit the shoulder.

Sometimes clients may reach a plateau in their flexibility and mobility or they complain of pain (not the typical discomfort felt during a stretch).  If this is the case, be sure to refer to a clinician who is licensed to evaluate musculoskeletal conditions.   There are a variety of pathologies, which affect bone, joint, and soft tissue that can underlie movement restrictions and/or produce pain.  There are also a variety of manual techniques to mobilize soft tissue and joints such as Active Release Technique, Instrument Assisted Soft Tissue Mobilization Techniques (IASTM), belt mobilization, and manipulation/adjustments that will go beyond self-mobility work.  These can often break through soft tissue barriers including scar tissue and capsular restrictions, which can be resistant to stretching, foam rolling, and the like.

Most importantly, and the answer to my issue of repetitive “tightness,” consider your evaluation process when clients/patients complain of persistent IT band issues or chronic lower back stiffness.  Stop blaming his/her exercise regime or work environment and look deeper into their movement patterns.  Evaluating fundamental movements may actually reveal joint mobility issues or underlying stability problems away from their site of complaint. Your hands and client will thank you when you find the cause of the tightness and offer a solution to their problem rather than continuing to treat their symptoms.

Cook, Gray. Athletic Body in Balance. Champaign: Human Kinetics. 2003.

Cook, Gray. Movement. Lee Burton, Kyle Kiesel, Dr. Greg Rose, and Milo Bryant. Santa
Cruz: On Target Publications. 2010.

Magee, David J. Orthopedic Physical Assessment. 4th Edition. Philidelphia: Saunders.
2002.

Reischl, Stephen F.  Noceti-DeWit , Lisa M., Current Concepts of Orthopaedic Physical
Therapy. The Foot and Ankle:  Physical Therapy Patient Manageemnt Utilizing Current
Evidence. Orthopaedic Section, APTA, Inc. 2006.

Sahrmann, Shirley.  Diagnosis and Treatment of Movement Impairment Syndromes. St.
Louis: Mosby. 2002.

Dr. Jennifer Reiner is the chiropractor for Water and Sports Physical Therapy and Fitness Quest 10 in San Diego, California.  She obtained a Bachelor’s of Science Degree in Exercise Science from the University of Florida and went on to pursue a Doctor of Chiropractic degree from Palmer College of Chiropractic West.  As a member of the Palmer West Sports Council, Dr. Reiner focused her studies on sports injuries and rehabilitation.  She is also a Certified Strength and Conditioning Specialist (CSCS) by the National Strength and Conditioning Association.

She spent five years as the official chiropractor for the University of California San Diego, providing care to a variety of sports including swimming, soccer, volleyball, track and field, tennis, and basketball.  Dr. Reiner is certified in Graston Technique as well as Active Release Technique (ART).  She also holds certifications in FMS (Functional Movement Screen), SFMA (Selective Functional Movement Assessment), TRX suspension training, and K-laser therapy.

Advances In Therapeutic Laser Treatments

Laser technology is a rapidly growing sector of the medical community.  Today lasers are used in vision correction, hair removal, skin treatments, pain relief, and surgery.  Therapeutic lasers utilize lower powers that can non-thermally and nondestructively alter cellular function. This phenomenon, known as laser biostimulation, is the basis for the current use of lasers to treat a variety of articular, neural and soft tissue conditions.  The FDA approved therapeutic laser use in the United States in 2002; however, this technology has been available in Europe for over 30 years.

Lasers  produce their effects by igniting a cascade of reactions in the body similar to the synthesis of Vitamin D made by our skin.  As sunlight is absorbed, the skin darkens due to the production of melanin by melanocytes.  Similarly, lasers produce their biological effects as a result of photochemical reactions (rather than thermal) that occur in various cell types of the body.  These cells possess chromophores, components of molecules which absorb light.  The stimulation of these chromophores on mitochondria membranes (energy producers of the cells), increase the production of ATP.  Research has shown the biological effects of therapeutic lasers to:  (1) stabilize cell membranes (2) increase ATP (energy) production and synthesis (3) decrease C-reactive protein and neopterin levels (4) accelerate leukocyte activity (5) enhance lymphocyte response (6) reduce interleukin 1 (7) increase prostaglandin synthesis (8) enhance levels of super oxide dismutase (9) increase angiogenesis (formation of new blood cells) (10) stimulate vasodilation (11) temperature modulation (12) decrease pain and nociception.

From over 2,500 scientific studies in the National Library of Medicine, some of the benefits from laser therapy and the effects of healing reported include: promotion of tissue repair, improved wound healing, faster recovery from nerve injury, improved reinnervation, improved quality of life in chronic pain, reduced pain in post-herpetic neuralgia, reduced pain in sprains and strains, reduced scar tissue in muscle injury, improved range of motion, and injury healing is faster and of better quality (stronger tissues).

Varying wavelengths of light determine the depth for which the laser can reach.  Currently there are four classes of lasers, each with differing depths of penetration.  Class I, II, and III lasers are made up of CD players, printers, scanners, pointers, and early therapeutic low level lasers.  Newer low level lasers and LEDs (light emitting diodes) are considered class IIIb.  Numerous therapeutic lasers on the market and in abundant physical therapy and chiropractic clinics are included in this category.  Their depth of penetration is very limited thus restricting their effectiveness for deep tissues and joints of the body.  Class IV lasers are the most powerful therapeutic lasers on the market allowing the wavelengths of light to reach structures up to 5 inches in the body.  As such, conditions involving spinal discs, hip joints, shoulder joints, knee joints, and nerves, may be reached.

Sports medicine doctors in particular are turning their attention towards therapeutic lasers due to the improved healing times of musculoskeletal injuries.  The addition of lasers in the sporting arena allows for optimal tissue regeneration and repair with less residual problems, making laser therapy an integral part of an athletes rehabilitation.  The New England Patriots implemented laser technology as part of their treatment just prior to their Super Bowl victory in 2004.  Other professional sports teams include the Chicago White Sox, Milwaukee Brewers, the Toronto Blue Jays, and the Cincinnati Bengals.  Cyclist, Lance Armstrong, has used laser therapy for years to recover from injuries.  Conditions such as tendinopathies, carpal tunnel syndrome, myofascial trigger points, lateral epicondylitis, ligament sprains, muscle strains, repetitive stress injuries, chondromalacia patellae, plantar fasciitis, rheumatoid arthritis, osteoarthritis, herpes zoster, post-traumatic injury, trigeminal neuralgia, fibromyalgia, diabetic neuropathy, burns, deep edema/congestion, sports injuries, and auto related injuries may benefit from laser therapy.

The rehabilitation team at Fitness Quest 10 utilizes the class IV K-Laser to treat many of the professional athletes and clientele for optimal healing results.  To find out if laser therapy is appropriate for your condition, or to answer additional questions, please contact Water and Sports Physical Therapy at 858-488-3597 or Dr. Jennifer Reiner at Chiro@waterandsportsPT.com.

Dr. Jennifer Reiner is the chiropractor for Water and Sports Physical Therapy and the University of California San Diego.  She obtained a Bachelor’s of Science Degree in Exercise Science from the University of Florida and went on to pursue a Doctor of Chiropractic degree from Palmer College of Chiropractic West.  As a member of the Palmer West Sports Council, Dr. Reiner focused her studies on sports injuries and rehabilitation.

Currently, she is the official chiropractor for the University of California San Diego, providing care to a variety of sports including swimming, soccer, volleyball, track and field, tennis, and basketball.  Dr. Reiner utilizes gentle chiropractic adjustments to restore aberrant movement to joints of the spine and extremities when indicated.  She is also a certified Active Release (ART) provider for upper extremity, lower extremity, and spinal conditions.  Active Release is a patented soft tissue, movement based treatment that targets adhesions found in the muscle, tendons, ligaments, fascia, and nerves.  Dr. Reiner is a certified K-Laser specialist utilizing Class IV laser therapy to accelerate tissue healing, decrease edema, and provide pain relief.

References

1.  Am J Sports Med  May 2008  vol. 36  no. 5  881-887. Effects of Low-Level Laser Therapy and Eccentric Exercises in the Treatment of Recreational Athletes With Chronic Achilles Tendinopathy.   Apostolos Stergioulas, PT, PhD*, Marianna Stergioula, PT,

Reidar Aarskog, PT, Msc, Rodrigo A. B. Lopes-Martins, MPharm, PhD, and Jan M. Bjordal, PT, PhD

2.  J Am Chiropractic Association, Jan/Feb 2010.  Class IV Laser Therapy Treatment of Multifactorial Lumbar Stenosis with Low-Back and Leg Pain.  Daniel Knapp, DC

3.  J Clin Laser Med Surg. 2000 Apr;18(2):67-73.  Wound healing of animal and human body sport and traffic accident injuries using low-level laser therapy treatment: a randomized clinical study of seventy-four patients with control group. Simunovic Z, Ivankovich AD, Depolo A.

4.  J Endourology/Endourological Society. 2008 Nov;22(11):2447-50. Endoscopic ultrasound facilitates histological diagnosis of renal cell cancer. Artifon EL, Lopes RI, Kumar A, Lucon AM, Dall’oglio M, Hawan B, Sakai P, Srougi M.)

5.   K-Laser USA Case Studies. http://www.klaserusa.com

6.  Lasers Med Sci 1998. 13:293-298.  Muscular Trauma Treated with a Ga-Al-As Diode Laser: In Vivo Experimental Study. G. Morrone, G.A. Guzzardella, L. Orienti, G. Giavaresi, M. Fini, M. Rocca, P. Torricelli, L. Martini and R. Giardino

7.  LiteCure LCT-1000 Deep Tissue Therapy Laser Treats Professional Athletes. www.litecure.com/pages/199.