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Debilitating pain in the neck and mid back is one of the most common issues among patients seeking relief at Dr. Dubin’s office. Here is a typical example of a patient’s problem, and the resulting treatment plan.

Case Study

Nancy came to the office complaining of pain on both sides of her neck and in between her shoulder blades. She could not remember a particular incident that caused her neck and mid-back pain, but stated that the pain came on gradually, became more intense, and was starting to affect her everyday life.

Nancy came to the office complaining Nancy’s job requires spending most of the day typing on a keyboard with her head bent downwards and shoulders slumped forward, while looking at a computer screen (Fig. 1A). Dr. Dubin explained to Nancy that her slumped-forward posture at work was a contributing factor of her current pain symptoms. When the muscles in the back of the neck and mid back (Fig. 2A, 2B, & 2C) contract, or shorten, they cause the head to extend and the shoulders to move backward. Nancy’s posture at work resulted in head flexion and an abnormal shoulder posture that placed a prolonged stretching strain on the muscles in the neck and mid back, leading to fatigue and eventually a repetitive strain injury to those muscles.

Dr. Dubin conducted a thorough exam on Nancy’s neck and mid back, and reassured her that her condition could be effectively treated by utilizing Active Release Technique on the muscles of the neck and mid back to free up soft tissue motion; to free up joint motion; and combotherapy to help to relax the muscles, restore normal muscle tone, and break up scar tissue.

Dr. Dubin also showed Nancy a fifteen-minute stretching and strengthening home rehabilitaion program with the Flexband® and instructed her on how to ergonomically improve her workstation (Fig. 1B).

Nancy’s neck pain and mid back pain resolved after six visits at Dr. Dubin’s office, and she is continuing her home exercise routine. Nancy is now comfortable at work, and reports that her mid back and neck are flexible and pain-free.

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Sciatica is a condition in which the pain is typically perceived as radiating from the low back to the posterior buttocks, posterior thigh, and occasionally below the knee into the posterior calf and foot (Fig. 1). A disc herniation (Fig. 2B) or degenerative changes in the lumbar spine (Fig. 2C) can lead to sciatica. A normal, unherniated disc, in comparison, is shown in Figure 2A.

Sciatica may be caused by direct pressure on the lumbar nerve roots. Each nerve root has a sensory and motor component to it, supplying a particular part of the body. The sensory part carries sensory signals to the brain and the motor part carries signals that activate the muscles. In this case, the lumbar nerve roots supply the lower extremities, so excess pressure on the lumbar nerve roots causes discomfort and/or pain in the buttocks and legs.

The sciatic nerve is the largest nerve in the body and is formed by the conjoining of the fourth lumbar, fifth lumbar, first sacral, second sacral, and third sacral nerve roots (Fig. 3A and 3B). The sciatic nerve travels from the front of the pelvis to the buttock region through an opening called the greater sciatic foramen. From there, it continues to the hamstring musculature in the posterior thigh, traveling below the knee where it divides into two nerves, the tibial nerve and peroneal nerve.

Sciatica Due to Herniated Disc

A disc herniation is a “leaking” of a portion of the jelly-like material between two vertebrae, and occurs most frequently in the third to fifth decades of life. The disc, the shock-absorbing cushioning between vertebrae, may become prone to tears because of weakening of the fibers that surround the nucleus pulposis, which is the center of the disc (Fig. 4A and 4B).

Repetitive flexion (such as bending over frequently), especially when combined with rotation (such as swinging an ax) or a high force trauma (such as a car accident) can cause radial tears in the disc. These radial tears will allow the leakage of the nucleus pulposis to herniate into the spinal canal, which can cause compression on a lumbar nerve root, resulting in sciatica. In this situation, the sufferer will complain of pain when sitting or standing with a forward flexed posture, which causes further migration of the jelly-like material into the spinal canal. Conversely, when bending backwards, pain may subside because the nucleus pulposis will travel back towards the away from the nerve root, taking pressure off the nerve root.

Sciatica Due to Degenerative Changes in the Spine

The most common cause of sciatica in people over the age of 50 is degenerative changes in the lumbar spine. These degenerative changes can lead to narrowing of the spinal canal and the intervertebral foraminal space (the space between two adjacent vertebrae), Conservative where the lumbar nerve roots exit the and become part of the sciatic nerve. This narrowing can cause direct pressure on the lumbar nerve roots, leading to radiating pain in the buttocks and back of the thigh and leg.

These symptoms may become less intense when bending forward, which opens up the intervertebral foraminal space and takes pressure off the nerve root. Bending backwards, on the other hand, will narrow the intervertebral foraminal space, increasing pressure on the exiting nerve root, causing increased pain. Note that this is in direct contrast to suffering from sciatica due to a herniated disc: patients’ descriptions of that cause pain and that bring relief are used to help determine the cause of the sciatica.

A patient reporting pain or tingling down both lower extremities as well as a recent history of a loss of bladder or bowel control would immediately be referred to a neurosurgeon or orthopaedic surgeon to rule out the possibility of cauda equina syndrome. If diagnosed with this condition, the affected disc would be removed as soon as possible in attempt to prevent irreversible paralysis.

Sciatica-Like Symptoms Caused by Muscle Strain

Repetitive strain injury of the piriformis musculature and gluteus maximus musculature can cause pain in the buttocks and hamstring region (Fig. 3A). This pain does not typically radiate below the knee, unlike true sciatica, which can reach to the calf. Driving for long periods with the foot on the accelerator and/or sitting with a heavy wallet in the back pocket can directly irritate the gluteus maximus and piriformis musculature. Taking breaks when driving and removing the wallet from the back pocket would help to alleviate strain on these muscles. Using a cold pack (20 minutes on / 1 hour off) would help to decrease inflammation of this area.

Sciatica-like Symptoms Caused by Athletic Injury

Running can cause stress on the gluteus maximus and piriformis musculature. With each heel strike, there is a normal internal rotation of the femur, whose motion is controlled by the piriformis musculature; overtraining may cause injury to the piriformis. Running uphill will cause forward flexion of the pelvis, which in turn may cause a strain of the gluteus maximus musculature (which normally posteriorly rotates the pelvis).

Running injuries leading to sciatica like symptoms can be avoided by changing sneakers every 250-400 miles, at which point the sneaker loses 40% of its shock absorption capabilities. Initiating a good flexibility and strength program for the lower extremities would help in the prevention of repetitive strain injuries such as sciatica.

Biking with the pelvis flexed too far forward while reaching for the handlebars can also strain the gluteus maximus musculature. If the handlebars are set too far below the seat level, the rider may be forced to lean too far forward. A proper bike fitting may help prevent this injury. Be sure to consider bike size, seat height, and handle-bar height/angle.

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Impingement syndrome is a shoulder disorder characterized by a dull aching on the front and outside of the upper part of the arm that sometimes radiates to the elbow. Sleeping on the injured shoulder is painful, and when raising the arm by the side, the pain can be sharp and stabbing in nature. Impingement syndrome is common in individuals participating in sports such as volleyball, swimming, basketball, tennis, and baseball, and in occupations requiring arm movements above the shoulder or head. These activities may cause a repetitive strain injury to the muscles surrounding the shoulder, leading to faulty joint motion and compression on tendons in the shoulder, resulting in impingement syndrome. An explanation of the biomechanics of the shoulder will make it easier to understand the causes of impingement syndrome and how to treat and prevent it.

The glenohumeral joint, or shoulder joint, is a ball-and-socket articulation where the round head of the humerus fits into the concave glenoid fossa of the scapula (Fig. 1).

The stability of the shoulder joint is maintained by four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, whose conjoined tendons comprise the rotator cuff (Fig. 2 & 3). The middle deltoid muscle travels from the acromium process of the scapula and is attached to the humerus, acting as a lever when the arm raises up by the side from zero to sixty degrees (the deltoid muscle also pulls the humeral head superiorly and out of the glenoid fossa). To keep this motion in check, three of the four rotator cuff muscles exert a downward pull on the humeral head, while the fourth muscle exerts an inward pull on the humeral head, pulling it toward the glenoid fossa (Fig. 4).

There is a “tunnel” in the shoulder joint, the suprahumeral space, which separates the bone at the top of the shoulder from the arm bone. (Fig. 1, green border). The supraspinatus and long head of the bicep tendons pass through this suprahumeral space, and are subject to pressure from the nearby bones: the acromium process and the humeral head.

Weakness of one or more of the rotator cuff muscles may lead to abnormal upward movement of the humeral head, decreasing the suprahumeral space and putting pressure on the tendons, causing pain (compare Fig. 5A, showing a normal suprahumeral space, to Fig. 5B, showing a decreased suprahumeral space).

Normally, when the arm raises from 60 to 140 degrees (Fig. 6), the upper trapezium, lower trapezium, and serratus anterior muscles move the scapula and the attached acromium process upwards, maintaining the suprahumeral space. improper function of the rotator muscles or the muscles surrounding the scapula can lead to a decreased supra- humeral space when moving the arm away from the side of the body, increasing the of injury to the supraspinatus and long head of the bicep tendons and eventually to the development of impingement syndrome. This syndrome, while often caused by acute or overuse injury, may also be due to degenerative changes, in which case referral to a surgeon would be recommended.

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Shin splints are an inflammatory condition of the lower leg tendons, muscles, or outer covering of the shin bone (periosteum). Exercise or athletic activities such as walking, jogging, running, or step aerobics can cause microscopic tissue damage to these areas. Normally, these small injuries heal, but when tissue damage occurs faster then tissue repair, inflammation ensues and leads to the development of shin splints. Shin splints can be separated into subcategories: anterior shin splints and posterior shin splints. Anterior shin splints would be described as pain down front and outer side of the leg, while posterior shin splints would be described as down the back and inside of the leg.

Shin splints are a very common running injury. Analysis of the biomechanics of a typical running gait may help in understanding why this injury is so common in runners. It also gives clues on how to prevent it.

A running gait cycle consists of two phases: the swing phase and the stance phase. The swing phase begins with toe off and ends with heel strike, during which time the foot does not make contact with the ground surface. The stance phase begins with heel strike and ends with toe off, and the foot is in contact with the ground surface. In this discussion on shin splints, we will focus on the stance phase of the running gait cycle, because the stance phase is more commonly associated with this condition.

The stance phase can be divided into three phases: contact phase, mid stance phase, and propulsive phase, making up approximately 25%, 40%, and 35% of the stance phase respectively (Fig. 1). The contact phase begins at heel strike and ends at full forefoot loading (FFL), when the outer part of the foot and later the inner part of the foot make contact with the ground surface. Where the heel bone, calcaneus, and talus come together is the subtalar joint (Fig. 2A & 2B). During the contact phase, this subtalar joint pronates, which involves the heel bone tilting laterally, and the foot moving outward and upward. This movement allows the foot to be mobile, adapt to the ground surface, and absorb the shock of impact (Fig. 3A).

The midstance phase begins with FFL and ends when the heel begins to lift off of the ground surface. During the midstance period and into the propulsion period, the subtalar joint supinates, making the foot a rigid lever for effective toe off. This supination, which is the opposite of pronation, involves the heel tilting medially and the foot moving downward and inward.

Causes of Shin Splints

The anterior musculature of the leg — tibialis anterior, extensor digitorum longus, and the extensor hallucis longus (Fig. 4A & 4B) — decelerate the foot as it approaches the ground surface for impact before FFL (Fig. 5). Running on too many downhills and/or increasing running distances too quickly predispose a runner to developing anterior shin splints. This is because of the increased demand on the anterior leg muscles to decelerate foot slap. Driving long distances with the foot pressing on the gas pedal can also lead to fatigue of the anterior leg musculature and the development of anterior shin splints.

In a normal-functioning foot, pronation of the subtalar joint occurs only during the contact phase and early mid stance phase, turning the foot into a mobile lever so it can adapt to the underlying terrain. The posterior muscles of the leg that decelerate pronation of the subtalar joint are the tibialis posterior, flexor hallucis longus, and the flexor digitorum longus (Fig. 6A & 6B). Overpronation of the subtalar joint (Fig. 3B) during the contact or prolonged pronation into the midstance and propulsive phase, can lead to fatigue, microtrauma, and inflammation of the posterior leg musculature. This results in the development of posterior shin splints. Runners flat feet, when weight bearing causes the inside arch of the feet to disappear, will be prone to posterior shin splints because of the above pronation disorders. A custom made semi-rigid orthotic supporting the inside arch of the foot would help to alleviate the increased trauma on the posterior leg musculature by decreasing overpronation during the stance phase. Running on uneven surfaces will cause the uphill foot to overpronate, which is the body’s way of attempting to correct for leg length discrepancy on the un even terrain. This overpronation increases the risk of developing posterior shin splints on the uphill leg. Repetitive jumping activities can also overstrain the posterior leg musculature.

Checklist for the Prevention of Shin Splints

• 

  Change sneakers every 250-400 miles (at this point the sneaker can lose up to 40% of its shock absorption capabilities).

• Limit the number of hills on the running route.
• Avoid training on uneven surfaces.
• Slowly increase running mileage (the rate of increase will depend on your goals, activity level, and body type).
• Mix heavy intensity training with light intensity training, and include at least 1-2 days of rest from running during the week. Excessive training will cause depletion of glycogen stores in the leg musculature, leading to fatigue and eventual injury. A heart rate monitor may help runners train at appropriate intensities in their training program, helping to prevent overuse injuries.
• For runners, cross-train with swimming, biking, and the elliptical machine; this will maintain aerobic capacity and help in the prevention of shin splints.
• Add a flexibility and strength-training program for the lower leg to prevent muscular imbalances that can lead to injury. For example, tight calf muscles, including the gastrocnemius and soleus musculature, can cause weakness in the anterior leg musculature, which is responsible for decelerating foot slap, predisposing a runner to anterior shin splints.
• After finishing a run, stretch and then ice the lower extremities for 20 minutes to decrease inflammation.

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Tendons are tough, fibrous tissues that attach muscles to bone. The Achilles tendon, located just above the heel of your foot, attaches the gastrocnemius muscle (Fig. 1A) and the soleus muscle (Fig. 1B) to the back of the heel. Another name for the muscle group around the Achilles tendon is “triceps surae.” The Achilles tendon transmits the muscular force of the triceps surae to the ankle and foot lever. Achilles tendonitis is a common overuse injury seen in people who do activities involving running or jumping; such repetitive motions can lead to tendon damage. Analyzing the dynamics between the triceps surae, the Achilles tendon, and the ankle/foot during movement will make it easier to understand why Achilles tendonitis occurs and how to treat and prevent it.

There are two types of muscle contractions: a concentric contraction, and an eccentric contraction. A concentric contraction of the triceps surae would shorten the length of the muscle, causing the Achilles tendon to pull on the back of the heel bone, resulting in the heel lifting up and the toes pointing downward. This particular motion is termed plantar flexion of the ankle/foot (Fig. 2). An eccentric contraction of the triceps surae would prevent injury by slowing down or limiting excess motion of that area. After the foot strikes the ground and enters the mid stance phase of gait (Fig. 3A), the combination of ground reactive forces on the foot and momentum from forward leg movement results in dorsiflexion of the foot (Fig. 3B). During the mid stance phase of gait, the triceps surae contracts, causing the Achilles tendon to resist this dorsiflexion of the foot. The mid stance phase of gait ends when the heel lifts off of the ground surface.

Repetitive use of the Achilles tendon and triceps surae occurs during the midstance phase of gait/motion, and can result in trauma to the area. Tendons have fewer blood vessels than muscles, which means that less oxygen and nutrients can get to them. Faced with this shortage of blood supply, tendons take a longer time to heal than muscles. If the trauma to the tendon is faster than the rate of healing and repair, Achilles tendonitis will result.

There are five grades of tendonitis:
Grade 1 – Pain does not occur during activity, but generalized pain will be felt in the Achilles region after the training session has ended. Tenderness in the Achilles tendon will resolve before the next training session.
Grade 2 – Minimal localized pain will be present in the Achilles tendon during the training session; the pain will disappear before the next training session.
Grade 3 – Pain in the Achilles tendon now interferes with the training session but disappears before the next training session.
Grade 4 – Pain in the Achilles tendon severely interferes with the training sessions and does not disappear before the next training session.
Grade 5 – Pain in the Achilles tendon interferes with the training sessions and activities of daily living. The Achilles tendon becomes deformed and there is a loss of function of the triceps surae.

Treatment at Dr. Dubin’s office of a grade 1 or a grade 2 tendonitis would consist of adjustments to the ankle and foot to free up joint motion, deep tissue to the musculature of the and leg to free up soft tissue motion, and ultrasound and electric muscle stimulation combotherapy to restore normal tone, help in the healing process, and decrease pain. The patient would be encouraged to ice the Achilles tendon for 20 minutes after each training session. A strength-training program for the lower extremities would be implemented, emphasizing eccentric strength training of the Achilles tendon. Stretching of the Achilles musculature and tendon could be conducted on a step (Fig. 4A & 4B), and a stretching routine for the lower extremities utilizing the Flexband® would be encouraged.

Semi-rigid orthotics with no more than 7/8″ medial arch support can be a useful tool in the prevention of Achilles tendonitis in runners who have high arches or flat feet. A temporary 1/8″ heel lift can also be added to the orthotic to limit dorsiflexion of the foot; this would take pressure off of the injured Achilles tendon. Achilles tendonitis is common in recreational runners who act as their own coaches. These runners may prematurely increase the intensity, duration and frequency of their running sessions. Proper training techniques would allow for adaptive changes of the Achilles tendon, including strengthening of the tendon and increased blood supply to the area. These changes will increase the ability of the Achilles to accept increased activity but they take time and patience. For marathon runners, initially a training base of four miles needs to be established at 65%-75% maximum heart rate. Later, a training schedule should be followed. A proper warm-up consisting of a jog will increase the blood supply to the muscles and tendons, making them more efficient in absorbing loads. Hill training should gradually be added to a training route because uphill running will increase the eccentric load on the Achilles tendon. Runners should also change their every 250-400 miles, during which their sneakers have lost approximately 40% of their shock absorption capabilities.

Early therapy and intervention is important in the prevention of a grade 3 in progressing to a grade 4 or a grade 5 tendonitis. In the early stages of a grade 3 tendonitis, one week of rest from the offending activity should occur, as well as similar treatment procedures as administered in a grade 1 or a grade 2 tendonitis. Cross training with swimming, bicycling, or an elliptical machine would be useful in maintaining aerobic capacity and in allowing the Achilles tendon and triceps surae to heel properly before resumption of training.

Treatment of a more advanced grade 3 tendonitis or grade 4 tendonitis will involve a longer rest from the offending activity and a slower progression of weight training and stretching. Understanding the 3 phases of repair of injured tissues is necessary for proper treatment of these injuries.

The 3 phases of repair are the reactive phase, regenerative phase, and the remodeling phase. The reactive phase is the initial inflammatory response to trauma, where vasodilation of the blood vessels surrounding the injured tendon or muscle occurs, causing swelling, pain, and loss of function. To limit the immobilizing effects of the reactive phase, RICE (rest, ice, compression, and elevation) should be applied to the injured region. During the regenerative phase, dead cells are cleared out; tiny blood vessels are restructured to help supply oxygen to the damaged tissue; and collagen is laid down to help repair the injured tissue. Collagen, the connective tissue that replaces the damaged tendon or muscle, is initially weak, but with time, its strength improves.

After 7-14 days, damaged muscles regain approximately 50% of their strength; tendons may take a longer time to regain their strength. During the remodeling phase, the collagen tissue matures, and with proper medical treatment and compliance with a strength training and flexibility routine, the tissue will hopefully regain 100% strength. The remodeling phase can sometimes take up to six months for muscle repair and even longer for tendon repair, depending on the severity of the injury.

One of the most common musculoskeletal injuries is to the low back. Repeated, prolonged stress to the back and shoulders can lead to a multitude of injuries down the road. Most jobs require a prolonged (sitting or standing) slumped forward position, which results in a postural overstretch and eventual low back pain. Decrease and prevent lower back pain by doing a 15 to 20 minute daily stretching routine using a FlexBand® (available for purchase at Dr. Dubin’s office).

Hamstring Stretch

Using the FlexBand® in a toe hold on the right foot, lie on your back with your knee bent, foot on floor. Hand over hand slowly bring the right leg up in the air. Keep knee straight. Hold position for 5 breaths (inhale and exhale 5 times), 3 repetitions.

IT band/Glutes/External rotator stretch

Using the FlexBand® in a toe hold on the right foot, start with right leg stright up in the air. Pivot the right lef to the left side of the body. Hold position for 5 breaths (inhale and exhale 5 times), 3 repetitions.

Groin Stretch

Use FlexBand® in a toe hold on the right foot, left knee bent, left foot on the floor. Starting with the right leg up in the air, pivot the right leg to the right side, keeping left leg at 90 degrees in the original postion. Hold position for 5 breaths (inhale and exhale 5 times), 3 repetitions.

Quad Stretch

With a toe hold on the right foot and holding FlexBand® with right hand, turn onto your stomach and swing the band over the head. Hand over hand, bring right ankle into the right buttock. Hold for 10-12 breaths.

Low Back Stretch/Erector Spinae Stretch

Sit with the FlexBand® around both feet and the legs fully extended in front. Reach down hand over hand on the band until feel tension in calves, hamstrings, and erector spinae/low back musculature; let the band pull you forward. Hold tension for 10-12 breaths.

STRENGTH AND FLEXIBILITY TRAINING

Dr. Dubin is a certified strength conditioning specialist. He can customize a strength and flexibility program for individuals to conduct at home or in a gym. A good home exercise routine might include the Flexband®, Thera-ball®, and/or ankle weights. At the gym, Dr. Dubin recommends a program plus a meeting with an experienced personal trainer to review form and technique. These programs will speed up the time of recovery and are helpful in the prevention of re-injury.

ADJUSTMENTS

Adjustments, which are high-velocity, low-force techniques, are used by chiropractors to restore motion to the joints in the spine and extremities. Back pain can be caused by trauma and postrual overstrain. This can cause entrapment of the synovial folds in the facet joints of the spine, which can lead to pain, spasm, and swelling. Adjustments can free up the synovial folds, providing pain relief.

ULTRASOUND

Ultrasound is a treatment that can be useful in speeding up the healing process of injured tissues. Ultrasound travels into the damaged tendons and muscles, causing the molecules to collide, resulting in a deep heating effect. This thermal reaction causes increased metabolic activity and vasodilation of the blood vessels, allowing for more nutrients and oxygen to reach the damaged tissues while washing away many of the pain producing chemicals. The thermal effects of ultrasound decrease pain of the damaged tissues. Ultrasound also has a mechanical effect on the tissues that possibly causes the breakdown of scar tissue. During the first 24-48 hours of a soft tissue injury (the acute stage), the acronym “PRICES” is the preferred method of treatment to control the inflammatory response (Protect-Rest-Ice-Compression-Elevation-Stabilize). Ice, not heat, should be utilized during this period of healing. Pulsed ultrasound can be utilized in the acute stages of an injury to break up scar tissue without the heating effects of continuous ultrasound.

ELECTRIC MUSCLE STIMULATION

Electric muscle stimulation is another therapy that is useful in speeding up the healing process of injured tissues. This device sends an impulse into the damaged tissues, causing the muscles in that region to contract. Ongoing contraction of these muscles will decrease reflex inhibition and help to restore normal muscle tone, and the sensory input of this modality will decrease pain and spasm.

COMBOTHERAPY

Combotherapy combines ultrasound and electric muscle stimulation as a single treatment device. Based on clinical experience, combotherapy is a more effective treatment than just using ultrasound or muscle stimulation separately. Ultrasound and electric muscle stimulation are useful treatment modalities for creating a more favorable environment for the body to heal itself.

ACTIVE RELEASE TECHNIQUE

Dr. Dubin treating Mac Martin, world class athlete, utilizing ART on his Iliotibial Band.

Tissue damage can be caused by:

• excessive postural overstrain (e.g. sitting long hours at a computer screen in an ergonomically incorrect posture)
• repetitive strain injuries (e.g. repetitive typing on a keyboard that does not allow for full range of motion of the metacarpo-phalangeal joints of the fingers)
• direct trauma (e.g. a running back being blindsided by a 300 pound linebacker)

Active Release Technique (ART) is one of the most effective deep tissue techniques for breaking down scar tissue/adhesions and restoring function and movement. Active release technique involves the doctor locating adhesions that are causing the problem, applying tension with the thumbs over these lesions in the direction of the fibers, and then having the patient elongate the musculature while the doctor continues to apply tension to the lesion. By breaking up the adhesions and restoring proper blood flow to the tissues, the patients’ condition will steadily improve. Dr. Dubin was the first doctor credentialed in Active Release Technique in Massachusetts. Active release technique protocols, combined with adjustments, strength training, flexibility training, and other modalities such as combotherapy, enable Dr. Dubin to have predictable treatment success when dealing with musculoskeletal injuries involving the spine or the extremities.

The Role of Active Release Technique in the Three Stages of Tissue Healing

The first 24-48 hours of the tissues’ initial healing response is termed the “reactive phase.” During this phase, prostaglandins are produced, causing pain and inflammation as well as activation of the body’s local and systemic healing processes. The PRICES method of self-treatment is crucial during the initial stage of the injury to limit the primitive response of inflammation and create a better environment for the body to heal itself. The second stage of healing is called the “reparative phase” and consists of three reactions. First, the body’s immune system attacks and breaks down the debris at the site of injury. Then, new blood vessels form in the tissues, supplying them with increased oxygen and nutrients. Finally, there is fibroblast proliferation, which involves the replacement of the injured tissue with new muscle fibers. However, these fibers are not aligned properly, and contracted scar tissue formation can be expected. During this phase, the patient frequently experiences pain in the trigger points, which are regions where the scar tissue/ adhesions exist. The contracted scar tissue has a decreased blood flow that not only limits oxygen and nutritional uptake, but also slows down removal of noxious chemicals. This is why these trigger points are tender to the touch. A contracted muscle is not nearly as strong as an elongated muscle; a contracted muscle will limit full rehabilitation potential. Also, a contracted muscle demands more energy then an elongated relaxed muscle, and this is further impeded by decreased blood flow. The last phase is “tissue repair,” where the goal of treatment is to regain the pre-injury strength and flexibility of the damaged tissue. During phases 2 and 3, treatment focus should be on restoring proper alignment and function of the newly laid down and disorganized muscle fibers. This will create a more favorable environment for healing to occur and will potentially allow the patient to regain 100% function to this region. Deep tissue manipulation such as ART enables the doctor to achieve this goal.

TREATING INFLAMMATION

An injury caused by a forceful trauma (such as an ankle sprain) or a repetitive strain (such as overuse of the back from lifting) will result in an inflammatory response. Inflammation isolates the injury and activates the local and systemic defense and repair processes. Inflammation is a good thing, as it is necessary for proper healing of the tissues to occur. However, inflammation is a primitive response, and may become detrimental to the healing process if it is not controlled. Too much inflammation can lead to a delay in the healing process, as well as excessive scarring, ongoing chronic pain, and improper movement patterns. The key to tissue healing is to maximize the positive effects and minimize the negative effects of inflammation, thereby creating the ideal environment for the body to heal itself. When cell membranes of tissues are damaged, prostaglandin is released into the surrounding region, causing the surrounding capillaries to swell. Prolonged inflammation will decrease nutritional flow to the injured tissues, cause scarring, and ultimately lead to dysfunctional muscle groups, improper motion patterns, prolonged dysfunction, and ongoing pain sensitivity. The acronym PRICES has been used by the medical community to describe the proper measures to take in the acute phases (first twenty-four to forty-eight hours) of an injury.

• P = protect
• R = rest
• I = ice
• C = compress
• E = elevate
• S = stabilize

Ice will cause vasoconstriction of the capillaries. Both ice and compression result in improved reabsorption of fluids and decreased pain. Elevation will help drain fluids away from the injury. These three methods will limit the primitive responses of inflammation and create the optimum environment for tissue healing. As a general rule, ice should be applied to the injured tissue over a 20-minute period with a 1-hour rest period between applications. Studies have suggested that ice therapy combined with compression is more effective then ice therapy alone, so the ice pack should be secured with an ace bandage. Individuals suffering from Raynauds phenomenon, peripheral vascular disease, or susceptibility to frostbite should be cautious when utilizing this technique.

Using a typical inverted ankle sprain as an example, here is how PRICES works:

• As soon after the injury as possible, take two ice/gel packs and place one on the outside and one on the inside of ankle.
• Wrap an ace bandage around the foot and ankle for support and compression.
• Place three pillows under the leg and rest the ankle in an elevated position.

During the first 6 days of the inflammatory process, non-steroidal anti-inflammatory drugs (such as Ibuprofin) are useful in inhibiting prostaglandin formation, thereby limiting inflammation. These medications may be purchased over the counter or prescribed by your doctor (for stronger doses) and should be taken after a meal to prevent gastric upset.

Repetitive motion strain injuries are directly related to the force acting on the muscle and indirectly related to the strength of that particular muscle. Holding a 5-pound weight in the hand with the arm flexed would eventually fatigue the bicep musculature and would lead to pain in the upper arm. A strength training routine geared towards performing this particular task would allow an individual to hold the 5-pound weight for a longer time period before fatigue and pain ensues.

A typical businessperson spends most of the day sitting at a desk with shoulders slumped. A sedentary business person who does not incorporate weight training into his or her lifestyle is more at risk for neck and upper-back pain than those who do train.

Chiropractors, dentists, and other professionals work in standing, bent-over postures, causing repetitive strain to their low-back musculature. Sitting in a chair in a slouched posture also causes prolonged stress to the lumbar region.

Dr. Dubin incorporates weight training, flexibility training, and ergonomics into his lifestyle to prevent work-related and sport-related injuries. A periodized weight-training schedule for an athlete is an effective method to gradually increase muscular endurance, strength, and power to achieve peak levels of fitness for the most important competitions and limit the risk of injury. A mesocycle consists of a hypertrophy, strength, and power phase.

For business people who are not athletes, the hypertrophy phase and the strength phase are effective means to train for the stresses of their job, and can be done in any gym. The power phase can be omitted from their periodization routine because these explosive lifting techniques increase risk of injury.

Two weeks should be set aside for you to become familiar with the gym’s equipment and to decide which exercises you want in your routine. For each exercise, figure out the appropriate weight resistance; this is the weight at which you can do the exercises no more than 10x for one set (10RM). Once this 10RM is calculated, you can plug it into the hypertrophy/endurance phase calculations to figure out what weights should be used each progressive week. In the strength phase, you can find out what you can do maximally 5x for one set (5RM) or you can extrapolate off of a periodization graph using your 10RM to figure out your 5RM.

The unloading phases are important for allowing your body to recuperate for the next phase of strength training.

Dr. Dubin uses a three-day-a-week lifting routine, combining pushing with pulling exercises: Bench and Biceps, Back and Triceps, Legs and Shoulders. Each routine takes approximately one hour to complete. After completing a mesocycle, change the exercises to make the workout more interesting and work different muscle fibers.

Before beginning each routine, a 5-10 minute warm-up on a treadmill or a stationary bike is recommended to decrease risk of injury. Stretching should be conducted after the workout when the muscles are warmed up. Also, note that some studies have shown that a post-workout carbohydrate and protein meal/supplement helps the body to replenish glycogen stores and recover faster if taken within 1 hour after the workout.

Note: Consult with an experienced trainer before starting this program! A trainer will teach you proper lifting technique and instruct on use of the available gym equipment. Always visit your doctor before starting any new exercise program.

To help clarify the above information we have included the following additional examples:

• MesoCycle- a practical example
• Dr. Dubin’s workout routine