Dr. Robert G. Silverman DC, DACBN, MS, CNS, CCN, CSCS, CIISN, CKTP, CES, DCBCN, HKC, FAKTR

www.DrRobertSilverman.com

@drrobsilverman @drrobertsilvermanDrRobertSilverman

Laser Neurology and Performance

Quote

“Let there be light”.

Objective

What’s the Problem?

THE THINKER, Auguste Rodin in 1902

• Sugar consumption – 160 lbs per year

• Wheat consumption – 146 lbs per year

• Caloric sweeteners – 142 lbs per year

• NSAIDs/medications

• Toxins/Stress

• Increased neurodegenerative disease

• Joint/back pain/OA

• Rise in diabesity

Projection

By 2020 – global gluten-freefood market projected to be valued at more than $75 billion

www.statista.com/statistics/646341/gluten-free-per-capita-spending-european-union-eu/

Excessive body fat around the middle linked to smaller brain size

Conclusion: Carrying extra fat around the middle may be linked to brain shrinkage. Researchers determined obesity by measuring BMI and weight-to-height ratio in study-participants and found those with higher ratios of both measures had the lowest brain volume

M Hamer, GD Batty. Neurology, Jan 9, 2019

Is abnormal the

“new normal?”

Injury cycle

Injuries…

• Due to error in movement

• Predictable and preventable:• Specificity is only relevant after function

has been optimized

• Happen when your body encounters a force that exceeds load-bearing capacity of the tissue

www.DrRobertSilverman.com

HEALINGIS A PROCESS

PRE-INJURYHealthy Tissue

INJUREDStrained Tissue

HEALEDScar Tissue

Scar tissue left on the muscle after healing restricts the muscle fibers, nerves and vessels causing pain and leaving the muscle less flexible

A. R. Needle et al.

Pathogenesis of the cumulative trauma disorder

RecoveryCycle

Injury Cycle

Frequency of Insult

Am

ou

nt

of

Tiss

ue

Insu

lt

SymptomaticInjury Threshold

Pathogenesis of the cumulative trauma disorder

Injury Cycle

Frequency of Insult

Am

ou

nt

of

Tiss

ue

Insu

lt

Insufficient Tissue Recovery Between Injury Cycles

Tissue Damage Accumulates

Copyright Jerome M. True, DC

The NMS Detonation SequencePain DynamicTight muscle

Inhibited muscle

Strain point

PAIN

Complaint

Sherrington’s law of reciprocal

inhibition

Head = 10 lbs 1” = 2x weight

Tight muscle Inhibited muscles1. Pecs 1. Mid-lower trap2. Suboccipitals 2. Deep neck flexors3. Erector spinae 3. Abdominals4. Psoas 4. Gluteus maximus

Suboccipitals

Medial scapula stabilizers

C7 – T1TMJ

Deep neck flexorsGH jtPec major

Abs

Psoas

Hip

T/L jct

Erector spinaeL/S jct

Gluteus maximus

Strain points Symptoms1. TMJ neck & shoulder2. C7-T1 jct stiffness & pain3. GH joint4. T/L junction SI, L/S & hip5. L/S junction stiffness & pain6. Hip

1 2 34

Kinetic Chain = Functional Anatomy

Muscles act in synergy not in

isolation” Movement, not muscles

Movement becomes habit, which becomes posture, which

becomes structure

FORM = FUNCTION =

PERFORMANCE

What Comes First?

Injury Pain

Altered Motor Control

We should diagnose this?

FUNDAMENTAL QUESTION?

Dr. Rob’s Magnificent 7• Posture/pain

Functional Movement Assessment

• Push-up

• Overhead squat

• 1-legged squat

• Trunk stability push-up

• Valgus jump test

• Upper/lower muscle firing patterns

Kinetic Web

Identify the affected

structures

Determine changes in

motion patterns

Determine affected

kinetic chains

Apply correctivetreatment, exercise,laser

and motor control protocols

1 2 3

4

Chiropractic vs. opioids

• Likelihood of filling a prescription for opioids was 55% lower among chiropractic treatment recipients compared with nonrecipients for lower back pain

Whedon JM, Toler AWJ, Goehl JM, et al. J Altern Complement Med. 2018 Jun;24(6):552-556

• Statins use increased odds of:• Spondylosis

• IVD disorder

• Herniated disc

• Spinal stenosis

JAMA Internal Medicine online. May 1, 2017

Integrating Laser into Practice

“The most versatile healthcare tool of the 21st

century”.

Dr. Rob, January 2013

“No-pill pain buster”.Dr. Oz, January 2013

5 Reasons…

1) Effective – “The speed of light”

2) Research-driven; empirically studied. FDA-cleared

3) Practice building

4) Joint health

5) Brain health

Laser Focus

• Laser: Light Amplification by Stimulated Emission of Radiation

• A focused beam of light that emits photon energy

• All photons travelling same direction at same wavelength = coherent light

Coherence…

Coherence in laser light: all the photons of laser light oscillate in perfect harmony, behaving like one great giant photon and vibrating in perfect rhythm

Well, the answer is best explained using the basic principles of photochemistry

How Does it work?

How It Works

• LLLT stimulates cell activation processes which, in turn, intensifies physiologic activity

• Healing is essentially a cellular process

• Light energy initiates a cascade of reactions

• From cell membrane – cytoplasm – nucleus – DNA

• Cellular amplification

Laser directed to affected site

Photon Enters TissueAlters Cell Permeability

Cellular Photochemical ReactionAbsorbed into Mitochondria → ATP+

Resulting EffectsRapid Cell Growth → Increased Metabolic Activity

Increased Angiogenesis → Vascular ActivitySuppression of COX-2 Pathway → Decreased Inflammation

Laser Therapy 3 components integral to beneficial outcome

LASER

1) Active ingredient

2) Dosage

3) Delivery Mechanism

Specific wavelength (color) is component responsible for influencing biochemical cascades

Intensity (power of light) determines a response. Too little limits response. Too much produces adverse effect

Manner in which light is delivered determines proper tissue response and depth of penetration. Coherent, focused light insures deep tissue stimulation and absorption

Photo biostimulation

Light enters our bodies without our knowledge

• Skin and skull –Not absolute barriers to light

• E.g. sunlight passes through the skin to influence the blood (neonatal jaundice)

N. Doidge, The Brain’s Way of Healing, chap 4:116

Low-Level Laser Therapy (LLLT)

• Controls pain

• Reduces inflammation

• Increases blood flow

• Stimulates nerve tissue growth

• Improves memory and focus

Low level laser therapy (LLLT) with CMT

Conclusion: A combination of CMT and LLLT more effective than either of the two on their own. Both therapies indicated as potentially beneficial treatments for cervical facet dysfunction.

Journal of Manipulative and Physiological Therapeutics, 34.3 (2011):153-63

Effects of LLLT in the development of exercise-induced skeletal muscle fatigue and changes in biochemical markers related to post-exercise recovery

Conclusion: pre-exercise irradiation of the biceps with an LLLT dose of 6 J per application location, applied in 2 locations, increased endurance for repeated elbow flexion against resistance and decreased post-exercise levels of blood lactate, creatine kinase, and C-reactive protein

J Orthop Sports Phys Ther, 2010 Aug;40(8):524-32

Low-level laser prolong longevity of degenerative knee joints• 70 elderly patients

• Bilateral tricompartmental knee arthritis

• One knee per patient received laser plus therapy

• Other knee received PT and sham light

• Laser group 1 in 70 needed joint replacement

• Sham light 15 in 70 needed joint replacement

Clin Interv Aging, Aug 5, 2015. 10:1255-8

Osama MA, Tarek M, Hala M, et al. Biomedicine & Pharmacotherapy. May 2018;101:58-73

Photobiomodulation therapy (PMBT) and/or cryotherapy

Conclusion: PMBT used as single treatment is best modality for enhancement of post-exercise restitution, leading to complete recovery to baseline levels from 24 hours after high-intensity eccentric contractions

de Paiva PR, Tomazoni SS, Johnson DS, et al. Lasers Med Sci. 2016 Dec;31(9):1925-33. Epub 2016 Sep 13

LLLT on hand OA

Conclusion: LLLT is a safe, non-invasive, efficient and efficacious means to reduce pain and swelling and to increase joint mobility in patients suffering from Heberden's and Bourchard's OA

Baltzer AW, Ostapczuk MS, Stosch D. Lasers Surg Med. 2016 Jul;48(5):498-504. doi: 10.1002/lsm.22480. Epub 2016 Feb 2

LLLT

• Looked at DOMS

• Patients treated with ice, laser or ice/laser after eccentric muscle contraction

• Laser was the best modality for enhancing restitution post-exercise

• Led to faster recovery 24 hours after treatment

De Paiva PR, Tomazoni SS, et al. Lasers Med Sci. 2016 Dec;31(9):1925-33. Epub 2016 Sep 13

LLLT Effectiveness

• The BMJ clinical evidence recommendations for tennis elbow 2011 now include LLLT

• American Physical Therapy Associations guidelines recommend LLT for Achillies tendonitis (2010)

• The International Association for the study of pain found “strong evidence” for LLLT on myofascial pain syndrome

LLLT – Rheumatoid arthritis

• LLLT both at early and late RA progression stages significantly improved mononuclear inflammatory cells, exudate protein, medullary hemorrhage, hyperemia, necrosis, distribution of fibrocartilage and chondroblasts and osteoblasts compared to RA group

Conclusion: LLLT is able to modulate inflammatory response both in early as well as late progression stages of RA

LLLT – Rheumatoid arthritis (cont’d)

Cold lasers

“not only increases the anti-inflammatory and analgesic effect but

also has the antioxidant properties”

Starodubtseva IA, Vasil'eva LV. [The analysis of dynamics of oxidative modification of proteinsin the blood sera of the patients presenting with secondary osteoarthrosis associated with rheumatoid arthritis and treated by laser therapy]. Vopr Kurortol FizioterLech Fiz Kult. 2015 Jan-Feb;92(1):19-22

Low-Level Laser Therapy (LLLT)

• Light – stimulates biological response on cellular level

• Cells contain chromophores (light-sensitive group of atoms) – react to photons

• Photon energy stimulates electrons and kicks off important tasks like cellular respiration and ATP production

• Triggering basic cell functioning, LLLT can help brain to reverse these processes:• Release of harmful free-radicals• Lactate build-up• Weaken of BBB• Immune response cascade

Dr. Dan Engle, The Concussion Repair Manual, p.34

Hands-OnDemo

Muscle Test – Upper Body

• C1 – Flex/extension

• C2 – Flex/extension

• C3 – lateral flexion

• C4 – rotation

• C5 – deltoid

• C6 – bicep

• C7 – tricep

• C8 – finger flexors

• T1 – finger abductors

Low Back and Pelvis

MyotomesMuscles

L1-3 Iliopsoas

L2-4 Quadriceps

L3 Sartorius

L4,5 S1-3 Hamstrings

L4 TibialisAnterior

L5 Toe Extensors

L5 Glute Medius

S1 Peroneus L. & B.

S1 Glut Max/TFL

Laser Muscles

• SCM

• Scalenes

• Levator scap

• Trapezius

• Supraspinatus

• Lat dorsi

• Psoas

• Glute max

• Piriformis

• Erector spinae

Proprioception

• An integral to motor regulation

• Involves the integration of information from mechanoreceptors

• The afferent input from these mechanoreceptors provide the basis for the CNS to regulate movement

Summary of different approaches of tendon rehabilitation, and effects on strength and motor control

AStrength

Insufficient muscle capacity to perform task

Motor control

Inability to control muscle to

perform task

Undesired outcome (pain, performance,

recalcitrance, etc

Passive intervention

(injection into tendon)

Ebonie Rio et al. Br J Sports Med 2016;50:209-15

Summary of different approaches of tendon rehabilitation, and effects on strength and motor control (cont’d)

BStrength (most common approach)

Sufficient muscle capacity to

perform task

Motor control

Inability to control muscle to

perform task

Undesired outcome (pain, performance,

recalcitrance, etc

Ebonie Rio et al. Br J Sports Med 2016;50:209-15

Summary of different approaches of tendon rehabilitation, and effects on strength and motor control (cont’d)

CStrength

Insufficient muscle capacity to perform task

Motor control

Ability to control muscle to

perform task

Inability to performtask

Just proprioception

Ebonie Rio et al. Br J Sports Med 2016;50:209-15

Summary of different approaches of tendon rehabilitation, and effects on strength and motor control (cont’d)

DStrength

Sufficient muscle capacity to

perform task

Motor control

Ability to control muscle to

perform task

Ability to performtask

Proper concept of tendon neuroplastic training

Ebonie Rio et al. Br J Sports Med 2016;50:209-15

Summary…(cont’d)

• Tendon neuroplastic training purposes a concept of strength-based loading that is an important stimulus for tendon and muscle but with strategies known to optimize neuroplasticity of the motor cortex and drive to the muscle

British Journal of Sports Medicine, 2016

“Before you heal someone, ask him if he’s willing to give up the things that made him sick.”

Hippocrates

CDC

37% of adults in the U.S. ate fast food on a given day between 2013 and 2016

Cheryl DF, Jeffery PH, et al. NCHS Data Brief No. 322, October 2018

Mediators of inflammation associated with disrupted sleep and chronic illness

Interleukin-6 [IL-6]

Endothelin-1 [ET-1]

Soluble intercellular adhesion molecule-1

[sICAM-1])

Tumor necrosis factor- (TNF- )

C-reactive protein (CRP)

Mills PJ, et al. Sleep. 2007;30(6):729-735.Irwin M, et al Arch Intern Med. 2006;166(16):1756-1762.

Low-carb diet

• Low-carb diet sped up metabolism by 250 calories a day

• Effect: 20lb weight loss over 3 years without change in food intake

• Low-carb – 20%n of calories

• Proves the carbohydrate-insulin model

BMJ, 2018;363:k4583

ASPREE

• All-cause mortality

Conclusions:

Higher all-cause mortality observed among healthy older adults who received daily aspirin than among those who received placebo and was attributed primarily to cancer-related death

JJ. McNeil, MR. Nelson, RL. Woods, et al. for the ASPREE Investigator Group. The New England J of Med, Sept. 16, 2018

ASPREE (cont’d)

• Effect of aspirin on disability-free survival in the healthy elderly

Conclusion:

Aspirin use in healthy elderly persons did not prolong disability free survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo

JJ. McNeil, MR. Nelson, RL. Woods, et al. for the ASPREE Investigator Group. The New England J of Med, Sept. 16, 2018

ASPREE (cont’d)

• Effect of aspirin on CV events and bleeding

Conclusion:

Use of low-dose aspirin as primary prevention strategy resulted in significantly higher risk of major hemorrhage and did not result in lower risk of CVD than placebo

JJ. McNeil, MR. Nelson, RL. Woods, et al. for the ASPREE Investigator Group. The New England J of Med, Sept. 16, 2018

Ibuprofen alters human testicular physiology

• 600 mg of Ibuprofen for 6 weeks decrease free testosterone/luteinizing hormone (LH) ratio by 23%

PNAS. January 23, 2018;115(4):E715-E724; published ahead of print January 8, 2018

New federal exercise recommendations

• Adults to complete at least 150 minutes of moderate-intensity exercise

• 75 mins of vigorous activity every week

• Along with strength training 2X a week

• Recommends balance training for older people

• Urge kids (3-5) to be active for at least 3 hours a day

• Exercise need not last for 10 minutes - all movement that helps you stay physically active is important

• Only 20% of Americans meet guidelines

• 1/3 don’t even workout

JAMA. The Physical Activity Guidelines for Americans. Published online November 12, 2018

Aerobic exercise lengthens telomeres

• 40 mins of aerobic exercise

• 3-5 times per week

• Significant telomere length noted

• Significant reductions in BMI

• Increase in VO2 peak

• No change in telomerase activity

Eli P, Jordan W, Jue L, et al. Aerobic exercise lengthens telomeres and reduces stress in family caregivers: A randomized controlled trial - Curt Richter Award Paper 2018, Psychoneuroendocrinology, online Aug 2, 2018

• Specific nutrients and oxygen are requiredto sustain a heavily used muscle

• Overuse soft-tissue injuries result when supply of nutrients are unable to match demands of muscle/tendon region

• Healthy nutrient supply through diet and supplementation assists the body with natural function and repair processes

Dr. Rob’s Nutritional Take

3 Phases of Care

PHASE 1

Acute Phase (first 3-5 days)

Protective Phase

PHASE 2

Sub-Acute Phase (day 4-8 weeks)

Repair & Remodeling Phase

PHASE 3

Wellness/On-going

Care

CHRONIC PHASE

Beyond 3 monthsOn-going Repair & Remodeling

Scar-tissueAdhesions

Fibrosis

INJURY

Key Laser Therapy Protocols for musculoskeletal Injuries

Rotator Cuff (Impingement Syndrome): Causes

• Tendinopathy

• Wear and tear – collagen breakdown

• Poor posture

• Scapula orientation

• Falling – overstretch arm, bracing with arm

• Repetitive stress

• Heavy lifting activities

Risk Factors• Age, being an athlete, posture, weak shoulder muscles

The shoulder dysfunction continuum

• Scapular dyskinesis

• Anterior impingement syndrome

• Rotator cuff tear

• Rotator cuff rupture

Extrinsic theory Intrinsic theory

Degenerative cuff tear

1. Degenerative-Microtrauma theory

2. Oxidative stress

Increased ROS

MMP-1 increase

ECM degradation

Apoptosis

Reduced cell function

Tendon degeneration

3. Suboptimal cuff vascularity

Extrinsic compression

Downsloping acromion

Acromion spur

Os acromiale

Acromioclavicular joint spur

Lateral extension of

acromion

Science Direct, Feb. 2015 online

Summary of extrinsic and intrinsic pathways of rotator cuff tear

Exercise and LLLT for Subacromial Impingement• Conclusion: This double-blind, randomized control trial showed that

LLT and exercise therapy is more effective than exercise therapy alone for the purposes of improving pain and active/passive ROM in patients with subacromial syndrome

Clinical Rheumatology 2011; 30: p1341-46

Frozen Shoulder: The Effectiveness of Conservative and Surgical Interventions

Conclusion: Strong evidence for the effectiveness of laser therapy

British Journal of Medicine 2011, Jan. 45(1), p.49-58

Rotator Cuff Injury Treatment Protocol

• Laser at point/points of involvement:• Muscle/joint/scapular (9,16,42,53)

• Laser during movement – 30-60 sec.

• Laser “locomotor lock-in”

• Laser “core lock-in”

• Corrective exercise

• Mobilize, manipulate joint restrictions

• Myofascial release

Exercises to Rehab

• Pendulum exercise

• Posterior shoulder stretch

• Active training of the scapula muscles

• Upper trap/levator scapular stretch

• Door-way pectoralis major stretch

• Ext/int rotation

• “Y”, “W”, “T” stability exercise on ball

• Prone external rotation

• KB packing the shoulder

• Dowel shoulder packing

• Wall “Y” exercise

• Wall angels

LLLT for

Plantar fasciitis/heel pain

Plantar Fasciitis Laser Protocol

• 2 treatments a week for 3 weeks

• Area- top of foot ( Dorsal Aspect), the myofascial junction of the heel and the plantar aspect of the heel

• All treated simultaneously. 10 minutes per area

Chronic Heel PainPlantar Fasciitis

Baseline Week 1 Week 2 Week 3 Endpoint

Test 0 -13.47 -19.65 -19.79 -29.58

Placebo 0 -5.82 -10.96 -8.68 -5.38

-30

-25

-20

-15

-10

-5

0

Mea

n c

han

ge

in V

AS

Reported heel pain on the VAS across study durgation by treatment group

(n=69)

Low-Level Laser Therapy for the Treatment of Chronic Plantar Fasciitis A Prospective Study

James R. Jastifer, MD1,Fernanda Catena, MD2,Jesse F. Doty, MD3,Faustin Stevens, MD4,Michael J. Coughlin, MD1

Abstract

Background: Plantar fasciitis affects nearly 1 million people annually in the United States. Traditional nonoperative management is successful

in about 90% of patients, usually within 10 months. Chronic plantar fasciitis develops in about 10% of patients and is a difficult clinical

problem to treat. A newly emerging technology, low-level laser therapy (LLLT), has demonstrated promising results for the treatment of acute

and chronic pain.

Methods: Thirty patients were administered LLLT and completed 12 months of follow-up. Patients were treated twice a week for 3 weeks for a

total of 6 treatments and were evaluated at baseline, 2 weeks post procedure, and 6 and 12 months post procedure. Patients completed the

Visual Analog Scale (VAS) and Foot Function Index (FFI) at study follow-up periods.

Results: Patients demonstrated a mean improvement in heel pain VAS from 67.8 out of 100 at baseline to 6.9 out of 100 at the 12-month

follow-up period. Total FFI score improved from a mean of 106.2 at baseline to 32.3 at 12 months post procedure.

Conclusion: Although further studies are warranted, this study shows that LLLT is a promising treatment of chronic plantar fasciitis.

Level of Evidence: Level 4, case series.

plantar fasciitis heel pain laser therapy

Plantar heel pain is one of the most common pathologies of the foot, accounting for up to 15% of foot-related symptoms presenting to

physicians and 1% of all visits to orthopedic surgeons.30 The clinical manifestations can be disabling, and despite its high incidence, the

specific cause of plantar fasciitis is poorly understood; it is likely multifactorial and may be associated with systemic disease, local changes to

the plantar fascia tissue, or altered foot and ankle biomechanics.8,14,20,24,32

The choice of nonoperative treatment is largely up to the physician. Numerous treatment options exist, including stretching, night splints,

orthotics, casting, steroid injections, and anti-inflammatory medications. There is limited high-level evidence to support one treatment over

another.11 The treatment of plantar fasciitis can be frustrating, yet about 90% of patients will respond favorably to nonoperative treatment,

usually within 10 months.10⇓-12

Failure of these measures occurs in about 10% of patients, resulting in chronic plantar fasciitis and a difficult clinical problem. There is also

limited high-level evidence guiding the treatment of this group of patients. A recent study showed that up to 55% of foot and ankle surgeons

would consider surgery for the treatment of plantar fasciitis refractory to 10 months of nonoperative management.11

Short of surgery, a new treatment for chronic plantar fasciitis is low-level laser therapy (LLLT), which has been used extensively in other areas

of the body. It has become increasingly popular because it is painless, is noninvasive, and has shown short-term efficacy in the treatment of

plantar fasciitis.18,21 The purpose of this clinical study was to determine the effectiveness of LLLT in the treatment of chronic plantar fasciitis.

months. Thirty of the 34 patients elected to enroll and completed 12 months of follow-up. The original 16 treatment group participants had

already received treatment and so were followed to the 12-month endpoint. The 14 from the original placebo group were converted to a

treatment group, administered treatment, and followed to the 12-month endpoint.

Chronic Heel PainPlantar Fasciitis

Publication

• ASLMS abstract

Results: Plantar fascia thickness was significantly reduced in test group subjects, but not in sham participants

Intervertebral Disc Disease

• IVD – the largest structure in the body without vascular supply

Key

Healing of disc periphery has potential to relieve discogenic pain by re-establishing a physical barrier between nucleus and nerves, and reducing inflammation.

Diagnostic Accuracy of the Slump Test for Identifying Neuropathic Pain (NP) in the Lower Limb

• Slump test displayed high sensitivity within study sample of individuals with LBP

• Conversely, adding criterion of pain distal to knee during slump test yielded very high specificity

JOSPT, Aug 2015;45(8):596-603

Intervertebral Disc Tx Protocol

• Laser at point/point of involvement

• Laser during movement: 30-60 sec.

• Laser “locomotor lock-in”

• Corrective exercise:• Bracing

• McGill big 4

• Hip flexor stretched

• KB swings

Intervertebral Disc Tx Protocol (cont’d)

• Core “lock-in”

• Nutritional protocol

• Myofascial release

• Mobilize, manipulate, flx/distraction, joint restrictions

Disc Injuries

Flexion movement

Flexing the spine

Strains layers of collagen in spinal discs

MMPS, cytokines

Inflammation

Flexion moment

Flexing moment or torque

Ab muscle stiffening

No movement

Stuart McGill website

vs.

Core Injury

• After 1st episode of back pain, the deep stabilizers change how they function

• Once injured – deep stabilizers:– Have delayed action and are only turned on after you move

– They work in short burst rather than staying on as you move

– Because deep stabilizers do not function as they should, the brain recruits global muscles to compensate

– Result: Pain in back, pelvis, glutes

The Three “Anti”s

• Sparing the spine

• Core muscles should be viewed more as brakes than accelerators and as stabilizers then movers

• Best core training is 3 antis:1) Anti-extension

2) Anti-lateral flexion

3) Anti-rotation

Training – Conditioning.com. December 2012

McGill lumbar stabilization exercises

• 34 patients split evenly into 2 groups:1) McGill stabilization exercises group

2) conventional physiotherapy group

• 6-week study

• McGill – significant improvements observed in:• Chronic non-specific LBP

• Functional disability

• Active back extension ROM

• Exercises: curl-up, side-bridge, bird-dog

Arsalan G, Mahmoud RA, Mohammad T, et al. J Phys Ther Sci. Apr 2018;30(4):481-85

Curl-Up – Beginner’s

Curl-Up –Intermediate/Advanced

Feet Elevated Side Plank

Bird Dogs

Spinal stability

• Panjabi’s theory:1) Active (muscles)

2) Passive (ligaments)

3) Neural components

• All components must be integrated together

Arsalan G, Mahmoud RA, Mohammad T, et al. J Phys Ther Sci. Apr 2018;30(4):481-85

Spinal stability (cont’d)

• Active: local and global stabilizer muscles and mobilizer muscles

• Local stabilization exercises designed to improve local muscles function for the purpose of segmental stability enhancement

• McGill designed exercises in lumbo-pelvic region, based on global muscle stabilization, to increase stability and coordination of trunk muscles without any load on lumbar spine and to improve function of anterior, posterior, and lateral lumbar muscles

Arsalan G, Mahmoud RA, Mohammad T, et al. J Phys Ther Sci. Apr 2018;30(4):481-85

The Plank

Deadbug

“Stir the Pot” – exercise spares painful discs of motion and builds abdominal athleticism

Stir the Pot

Effects of free weight on chronic low-back pain• 3 sessions per week

• Biomechanical analyses of body weight squat

• Significant reduction in fat

• Infiltration at L3/4, L4/5 levels

• Increase in lumbar extension time to exhaustion of 18%

Conclusion: Free weight resistance training is effective in rehabilitating patients with chronic LBP

BMJ SM. July 2017

“If we can appreciate that painis a protective device, not a measure of tissue damage..”

Prof. Lorimer Moseley

Australia’s World Leading Brain and Pain Research

LLLT – spinal cord injury

• LLLT allowed neurons to survive

• LLLT elevated IL-4 and IL-13

• Results show that LLLT:• Has potential for reducing inflammation

• Regulates macrophage/microglial

• Promoting neuronal survival

• LLLT may be an effective candidate for treatment of spinal cord injury

LLLT facilitates alternatively activated macrophage. Nature.com, Apr 4, 2017

Low level light therapy (LLLT) modulates inflammatory mediators secreted by human annulus fibrosus (AF) cells during intervertebral disc degeneration in vitro

Key Takeaway:

• Inflammatory microenvironment in AF cells suppressed by LLLT (IL-6 and 8 levels)

• Results indicate LLLT is potential method of IVD treatment

• 405 NM – most positively affected IL-6

Photochem Photobiol 2015, Mar-Apr;91(2):403-10

LLLT for

chronic low-back pain

Prudendal neuralgia & the clinical significance of the sacrotuberous ligament

Clunealgia

• Underdiagnosed cause of low-back pain and leg pain

• Middle cluneal nerve may be entrapped where this nerve passes under or through the long posterior sacroiliac ligament

• It can get entrapped in an osteofibrous tunnel

• Super cluneal nerves:

• Cross-over the rim of the iliac crest into 3 branches (MCN)

Anatomical study of MCN entrapment

• 64 MCN branches identified

• 10 branches (16%) penetrated the LPSL

• 4 of the 10 branches penetrating the LPSL had obvious constriction under the ligament

Conclusion: First anatomical study illustrating MCN entrapment

Konno T, Aota Y, et al. J Pain Res. 2017 Jun 13;10:1431-35

Standing toe-touch

I. Determines mobility or stability issue in hip

II. Standing assessment

III. Seated assessment

IV. If you stay the same – mobility restriction

V. If you are able to get further – stability dysfunction

Perform Toe-Touch

Test

Can Touch Your Toes

Normal

Cannot Touch Your

Toes

Test One Leg at a

Time

Note Deficient

Side

If One or Both Sides Deficient

Sit on Ground & Reach for Toes

Can Touch Your Toes

Cannot Touch Your

Toes

Stability Problem

Mobility Problem

Repeat Toe-Touch Test

Neurodynamic Test

• Neurodynamics – is a technique to access the mobility of the nerves as they wind through muscle and tissue as well as the spine and extra-spinal structures

• Neurodynamic tests – meant to deduce restrictions and resistances often described as “interfaces”

• When adhesion is present, the inhibited glide of the nerve can be revealed

Dr. Jay Kennedy, Should I Do Supine Decompression When There is a Positive Slump Test? DC Products Review, Dec. 2012, p.22

Peripheral nerves

• S. Rochkind found:• LLLT can help peripheral nerves heal

• Light improves nerve-cell metabolism

• Increases sprouting of new connections between nerves

• Enhances growth of new nerve axons and myelin

N. Doidge, The Brain’s Way of Healing, p.151

Evaluation of low level laser therapy in reducing diabetic polyneuropathy related pain and sensorimotor disorders

Laser therapy resulted in improved neuropathy outcomes in diabetic patients who received it relative to the group that received sham therapy, evaluating before and after LLLT assessments

Acta medica Iranica 2013. 51;8:543-7

Laser Nerves

• Brachial plexus – scalenes• Median – pronator teres, flexor retinaculum• Ulnar – olecranon and medial epicondyle• Radial – triangular space between T minor, LH triceps and humerous• Sciatic – piriformis muscle• Femoral – psoas• Tibial – posterior to knee• Peroneal – medial biceps femoris/head of fibula• Sural – calve region• Tarsal tunnel –at tunnel

• Median nerve

• Ulnar nerve

• Radial nerve

Neurodynamic test – Upper Extremity

Neurodynamic Test – Median Nerve

Clinical Neurodynamics, Michael Shacklock

Neurodynamic Test – Median Nerve (cont’d)

The Sensitive Nervous System, David Butler

Ulnar Nerve Quick Test

Ask patient to put hand on ear and then, keeping hand on ear, lift elbow up.

For most patients with ulnar nerve or root based problems this movement, or part of the movement, will be sensitive in the ulnar distribution.

Neurodynamic Test – Ulnar Nerve

ULNT2 – Radial Nerve

• Have patient:a) Hold their arm to side

b) Flex the wrist

c) Look at their palm

d) Internally rotate their arm so they can look at their palm over their shoulder

e) Then depress the shoulder girdle

f) Laterally flex neck away from arm

David Butler, p.327. The sensitive nervous system

Shoulder vs. neck pain

• Spurling test: cervical origin – will reproduce pain extending from neck to shoulder

• Axial distraction: will alleviate symptoms

• Arm squeeze test: 97% specificity, 95% sensitivity for diagnosing between neck and shoulder pain (RTC)

Value of physical tests in diagnosing cervical radiculopathy: A systematic review. Spine Journal, 2017

Median nerve mobility during radial ulnar compressionHighlights:

• Radial ulnar wrist compression applied to increase carpal arch space

• Wrist compression increased did not affect nerve mobility in healthy subjects

• Increased nerve mobility occurred in the proximal region of the tunnel

• Wrist compression improved nerve function (compression neuropathy)

Clinical Biomechanic, Oct 2018

Effectiveness of neural mobilization

Reveals benefits of neural mobilization for back and

neck pain

JOSPT. Jul 2017

Headaches

In patients with tension-type headache the combination of neural mobilization and soft-tissue techniques induce significant improvement of pain and function

Archives of Physical Medicine and Rehab. Issue 2;211-219

Neurodynamic test – Lower Extremity

• Sciatic: slump or add neck flexion (SLR) – piriformis

• Tibial: df/ev/SLR - posterior to the knee

• Peroneal: pf/in/SLR – head of fibula/medial to b. femoris

• Sural: df/in/SLR – bottom of calve

• Femoral: prone knee bent –inguinal ligament

The Role of Neural Tension in Stretch-Induced Strength Loss• Hamstring stretching with the spine in neutral position did not result

in a significant strength loss but shifted the length-tension relationship such that strength was decreased at short muscle lengths and increased at long muscle lengths

• Hamstring stretching with increased neural tension resulted in strength loss with no associated shift in length-tension relationship

M. P. McHugh, J. Tallent, C. Johnson. Journal of Strength and Conditioning Research. 27(5), p.1327-32

Nerve-flossing

“Symptomatic nerve roots are wider than asymptomatic nerve roots due to the presence of edema. Peripheral nerves develop edema, fibrosis, and changes distal to the affected nerve.”

Okmen BM. et al. Investigation of the Effect of Cervical Radiculopathy on Peripheral Nerves of the Upper Extremity With High-Resolution Ultrasonography. Spine, 43(14):E798–E803, July 2018

PAINLifestyle

Exercise

Pain therapy(opiods)

Personalized Nutrition/Nutraceuticals

Fighting obesity

Omega-3 FA

Microbiome Curcumin Polyphenols

J of Pain Research 2016

Laser

X

“Don’t let your learning lead to knowledge,

let your learning lead to action”.

Jim Rohn

www.DrRobertSilverman.com

QUESTIONS?