Strategy

Stretch

  • This includes neural mobilization, joint stretching, and/or muscular stretching.
  • Often there is an impairment in rotation(osteokinematics) and possibly an abnormal IAR. There is a need to restore tensile length and or tolerance for tensile load (distracting forces).

Soft Tissue

  • This could include any form of soft tissue mobilization, including massage, MFR, rolfing, self massage with tennis balls or even foam rolling. This is directed at morphologically shortened muscles and/or restricted fascial mobility.
  • Often there is an impairment in rotation(osteokinematics) and possibly an abnormal IAR. Improving soft tissue mobility will improve tolerance for tensile load, help restore tensile length, and occassionally improve tissue folding.

Mobilize

  • This is a joint that is hypomobile and would benefit from manipulation between III-V. Grades I and II will fall in the inhibition strategy.
  • Often there is an impairment in translation (arthrokinematics) and possibly an abnormal IAR. Improving glide/translation may restore the normal axis and therefore assist with restoring rotation. The goal is often to get to allowing rotations and stretching to occur. The sooner mobilization can cease and stretching can begin, the sooner the patient has long term carryover of healthy restoration of movement.

Strengthen/Stabilize

  • This includes stabilization of the muscular system through exercise. The goal of this is to improve cross-sectional area and either maximum force generating capacity of that tissue and/or the endurance of that particular tissue. This tissue usually does not have a high level of intolerance and therefore the focus is on increasing the optimal loading zone and the capacity for absorbing and or creating force.
  • Addtionally, stabilization is commonly utilized during a spondylolisthesis patho-anatomic hypothesis (shear dysfunction) and may be confirmed with segmental testing and/or radiography. You may feel a large neutral zone (laxity) with facet gliding at the L4/5 segment and therefore need to stabilize this segment.

Re-train/Re-education

  • Postural re-education and movement retraining are the focus here. If you bill neuromuscular re-education, this likely falls under “retraining”. Balance and gait training also fall in this category.

Educate

  • This patient must change modify their current activities (they themselves may be preventing a healing response). Poor habits (lack of exercise, nutrition, vices such as smoking affecting intrinsic healing potential). They may need temporary or permanent changes to their lifestyle. This may include a cardiopulmonary exercise program (walking, biking, swimming program). This is NOT neuromuscular re-education, gait training, etc.

Offload

  • Bracing & taping are primary examples. This may also include self-traction at home for primary decompression issues. This patient often has poor tolerance for tissue loading, and therefore this treatment is directly aimed at increasing tolerance. This may include positioning that optimizes blood flow(abduction pillow for RTC repair).


Inhibition

  • This includes Grade I and II joint mobilization for pain dominant joints and spinal segments. The goal is generally NOT to restore joint translation (arthrokinematics) via tissue deformation of collagenous structures. This patient generally presents with excessive spasm and guarding. This may also include post-isometric relaxation which is focusing on resetting the resting tone of the muscle spindle, it may be physiologically shortened (as opposed to morphologically shortened). The patient may also need cognitive behavioral/psycho-social strategies such as relaxation to progress mobility, function, and/or pain control.


Modalities/Physical Agents (Pain, swelling, to promote healing)

  • Ultrasound
  • Electrical Stimulation
  • Acupuncture
  • Thermal Modalties (heat/ice)