The Soft Tissue Issue
By Joe Pelino BSc DC
By Joe Pelino BSc DC
Clinical priorities for soft tissue treatment and exercise prescription.
‘The desire to know is natural to good men.’
—Leonardo da Vinci
When Leonardo da Vinci wanted to understand something, he first observed its very nature. What remains unique and almost exclusive to Leonardo is that he was both scientist and artist, engineer and inventor.
This article will consider two specific treatment inventions – Dr. Mike Leahy’s Active Release Techniques® (ART®), and Susanne Klein-Vogelbach’s Swiss ball stability patterns – both learned by this author and presented as Clinical Priorities for Soft Tissue Treatment and Exercise Prescription, the fusion of ART and Core Ball Training™.
The former is a passive, manual therapy of myofascial release, while the latter is an active therapeutic exercise genre. Leahy, who came from an aerospace engineering background, applied like principles of friction to human tissue for the resolve of symptom suffering.(1) Klein-Vogelbach was inspired when she observed Swiss beach balls, which were harder than the normal variety, being used in children’s rehabilitation programs. Colorado physical therapist Joanne Posner-Mayer and chiropractor Dr. Donald Aspergen can be credited with importing the late Ms. Klein-Vogelbach’s ideas to North America.
ART AND CBT
‘To affect the quality of the day, that is the highest of arts.’
—Henry David Thoreau
Spinal Rehabilitation, by David E. Stude,(2) published in 1999, is a core textbook for chiropractic students, and offers arguably the best description and explanation for ART, the law of repetitive motion, insult to tissue correlations, and the cumulative injury cycle. For additional insight into ART, one must refer to the teaching manuals and online curriculum provided by Dr. Leahy, and of course attend hands-on workshops.
Chapter 20 of Stude’s book helps clarify the difference between ART and all other soft tissue manual techniques.
First, ART is a technique in which contact to tissue generates its tension parallel in direction to the tissue or fibre orientation of the specific structures being worked. Secondly, with ART, the structures being worked are lengthened during the procedure. ART’s more than 300 anatomical protocols manifest profound results at the hands of the properly trained and skilled provider. But how do they work?
If the forces of pressure, friction and tension exceed the tissue tolerance, the tissue changes … the tissue breaks down and scars into fibrotic adhesions. This is due to the very nature of repetitive motion in which shortened amplitudes of length of the muscles, insufficient rest and recovery, high numbers of repetitions and excessive loads of force result in fatigue and subsequent scarring adaptation. Subsequent resulting ischemia, hypoxia, bruising and shock at the cellular level trigger the adhesion fibrosis. It seems that the tissue that gets less oxygen becomes tissue that needs less oxygen, and this adaptation, although natural, does not serve the continuation of movement patterns.
As chiropractors, we bear witness to and provide treatment for a wide variety of soft tissue injuries, cumulative trauma disorders, and repetitive strain dysfunctions, all with symptoms of pain and intolerance to normal or desired movement in performance, dance, work or play. The practitioner’s goal is thus to free adhesions, to release muscles to move and slide in an unimpeded manner. This ideally promotes better fluid flow around and within the cells. It is the patient’s or athlete’s goal to maintain this relative freedom via movement and exercise. But how are these aims best achieved?
CLINICAL PRIORITIES FOR SMART CARE™
‘Nothing is so powerful as an idea whose time has come.’
We palpate for and find the tissue lesions described as types and stages of fibrous adhesions, which include edematous tissue, ropey or stringy tissue, leather-like tissue, and adhesions between specific bundles – within specific structures and between muscles and nerves or blood vessels. These include the first lesion type, called the anatomical tissue lesion. The second type is the biomechanical tissue lesion, which may in fact precede the anatomical tissue lesion.
Like da Vinci, we too learn by observing athletic movement and by simply studying the nature of movement. Well-documented quantified methods that scientifically record normal and abnormal movement patterns for most sports help to formulate both anatomical treatment protocols and exercise prescription methods to resolve the conditional dysfunction.
The perfect example is swimmer’s shoulder. With symptoms of anterior and or superior pain, the first lesion, or anatomical tissue lesion, is assumed to be in the belly and tendon of the supraspinatus muscle. The second lesion or biomechanical tissue lesion, underlying the cause is discovered to be the subscapularis muscle, which triggered the overuse mechanism. When weakened or fatigued, subscapularis will aberrantly allow the humeral head to ride up to the underside of the acromion, resulting in the impingement of the supraspinatus between the two osseous structures. The provider must treat the first-type lesion (the scarred supraspinatus) and the second-type lesion (the biomechanically fatigued subscapularis). Repeating this process in several regions of both muscles is the only way to uncover the total solution to the first type of lesion. To maintain and to enhance the effects of ART, the provider is also encouraged to teach at least one Core Ball Training exercise that would recruit the antagonists, the stabilizers to the movers, and to stretch the structures worked on.
Exercise to keep structures lengthened and to strengthen the posture to the shoulder girdle position become the goal and responsibility of the patient, in this case the swimmer. The treatment provider must engineer an exercise program that the patient can perform on their own in the gym. It must be simple, fun and effective. It must loosen what becomes too tight, and it must strengthen what becomes too weak. In this example, it would be recommended to perform specific Core Ball Training prescription exercises.
Whereas Klein-Vogelbach used the terminology of reaktio and aktio, we refer to the beautiful and relevant motion of balance harmonics and muscular endurance that provide power for the trunk and core muscles.
Back to the shoulder complex, the rationale is that one cannot move a limb powerfully without a strong anchor or base, that being the trunk. Where contemporary thought now assumes this to be true, Klein-Vogelbach was breaking new ground 40 years ago with this knowledge.
Condition: Shoulder pain in the anterior and or superior aspect of glenohumeral region.
Action: Elite performance swimmer.
First Lesion Type – Anatomical Lesion: Supraspinatus muscle and tendon, coraco-acromio ligament, middle and anterior deltoid muscle attachment, trapezius at acromial attachment, acromioclavicular ligament.
Second Lesion Type – Biomechanical Lesion: Subscapularis muscle and tendon, latissimus dorsi, teres major, subclavius, pectoralis major.
Treatment Solution, Part 1: ART soft tissue treatment protocols to the biomechanical lesion structures listed and then to the anatomical lesion structures.
Treatment Solution Part 2: CBT exercise prescription protocols.
Plan of Management: Provide one to three treatment sessions, repeating the first treatment solution, with the goal being a minimal 50 per cent reported improvement in pain, motion and performance. Continue treatment and exercise for sessions four to eight, adding CBT protocols.
Frequency, intensity and duration of Core Ball Training are increased to maximize recovery.
Resistance cuff rotation using tubing or gravity or both can also support this goal. Resistance exercise that employs mass and weights will have a similar result. Integrating CBT between sets will avoid the otherwise repetitious nature of weightlifting.
For contemporary conditions, once the provider has completed all the ART protocols, and has explained and demonstrated the appropriate Core Ball Training protocol, the patient should actually perform the prescribed exercises, both in the clinician’s treatment room on the treatment table or in the clinic gym. To facilitate compliance, the patient is also directed to the CBT online curriculum.•
Active Release Techniques® is patented and owned by Dr. P Michael Leahy. For further information, contact 888-396-2727, www.activerelease.com.
Core Ball Training™ as well as sport-specific programs for golf,
hockey, and triathlon are taught by Dr. Joe Pelino. For further information, contact Dr. Pelino online through www.coreballsports.com.
1. Leahy PM. Active release techniques®
soft tissue management system for the upper extremity. Active release techniques, Champion Health llp; 1998; 51,56.
2. Stude DE. Spinal rehabilitation. Appleton & Lange 1999; 20:443.