Saturday, October 21, 2017

Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion.

Graded Motor Imagery

The objective of this study was to determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain. This was a single-blinded case series which took part in 3 outpatient clinics involving 69 patients with shoulder pain and limited AROM.

Patients moved their unaffected shoulder through comfortable AROM in front of a mirror so that it appeared that they were moving their affected shoulder. The authors measured pain, pain catastrophization, fear avoidance, and AROM in 69 consecutive patients with shoulder pain and limited AROM before and immediately after mirror therapy. There were significant differences in self-reported pain (P=.014), pain catastrophization (P<.001), and the Tampa Scale of Kinesiophobia (P=.012) immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase (mean, 14.5°) in affected shoulder flexion AROM immediately postmirror therapy (P<.001), which exceeded the MDC of 8°.

A brief mirror therapy intervention can result in statistically significant improvements in pain, pain catastrophization, fear avoidance, and shoulder flexion AROM in patients presenting with shoulder pain with limited AROM. The immediate changes may allow a quicker transition to multimodal treatment, including manual therapy and exercise in these patients. Further studies, including randomized controlled trials, are needed to investigate these findings and determine longer-term effects.

Friday, October 20, 2017

Top 5 Fridays! 5 Side Plank Variations

For lumbar and/or hip patients, make sure to restore sideglideing in standing to the involved side. Then check the LCAP test to check their lateral chain strength and activation.

If SGIS is symmetrical and they are pain free, and there is an assymmetry in LCAP, then time to stabilize with side planks! Thanks to Dr. Nicole Canning, DPT (follow her on instagram) for the variations video!

Side Plank Variations

Side planks are a great way to challenge your core muscles and promote trunk, pelvis, hip, and shoulder stability.
Here are 5 variations you can try:
1️⃣ Side Plank Thrusters - start in a side plank and lower your hips towards the ground then lift them right back up again
🔹 You should feel this mostly on the side that is towards the ground
🔹 Keep your shoulder strong and prevent that pinching behind your shoulder blade by continuing to push your forearm into the ground
2️⃣ Side Plank with Hip Abduction - maintaining a side plank position, lift the top leg up until your knee and ankle are in line with your hip, then slowly lower it back down again
🔹 This exercise targets the gluteus medius
🔹 To feel it even more in your glutes, slightly rotate your toes toward the ground and lead with your heel
3️⃣ Thread the Needle - from a side plank position, rotate the top arm down and between your body and the floor, then rotate it back up again
🔹 This variation is great for shoulder stability as it produces a body on arm motion
🔹 Keep your core nice and strong to control those rotations
4️⃣ Top Leg Crunch - in a side plank position with your top hand behind your head, bring your top elbow and knee towards each other and then kick back out again
🔹 If this is too difficult, try dropping your bottom knee to the ground
🔹 You can target your side a little more by externally rotating your top hip and performing more of a side bend than a crunch
5️⃣ Rotisserie Planks - start in a forearm plank position, rotate into a forearm plank, and then rotate to the other side
🔹 Maintain control over your body as you rotate, keep movements slow, keep shoulders, hips, and ankles in one straight line when you rotate to the side
🔹 Keep pushing the floor away from you throughout the entire movement
🔹 Don't let your hips pop up or your stomach to sag towards the floor as you rotate

🔹 You always want to be actively pushing the floor away from you through your forearm to avoid that pinching pain you might experience in your shoulder blade and thoracic spine
🔹 Keep your shoulders, hips, knees, and ankles in a straight line
🔹 If these are too difficult you can modify by putting your lower knee on the ground
🔹 If these are too easy or if you want to add more challenging scapular/shoulder stability then raise up into a full side plank instead of a forearm side plank
🔹 Keep your chin tucked and cervical spine in line with the rest of your spine
Happy Planking!

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

The corticospinal responses of metronome-paced, not self-paced strength training are similar to motor skill training.


The corticospinal responses to skill training may be different to strength training, depending on how the strength training is performed. It was hypothesised that the corticospinal responses would not be different following skill training and metronome-paced strength training (MPST), but would differ when compared with self-paced strength training (SPST). Corticospinal excitability, short-interval intra-cortical inhibition (SICI) and strength and tracking error were measured at baseline and 2 and 4 weeks. Participants (n = 44) were randomly allocated to visuomotor tracking, MPST, SPST or a control group.

MPST increased strength by 7 and 18%, whilst SPST increased strength by 12 and 26% following 2 and 4 weeks of strength training. There were no changes in strength following skill training. Skill training reduced tracking error by 47 and 58% at 2 and 4 weeks. There were no changes in tracking error following SPST; however, tracking error reduced by 24% following 4 weeks of MPST. Corticospinal excitability increased by 40% following MPST and by 29% following skill training. There was no change in corticospinal excitability following 4 weeks of SPST. Importantly, the magnitude of change between skill training and MPST was not different. SICI decreased by 41 and 61% following 2 and 4 weeks of MPST, whilst SICI decreased by 41 and 33% following 2 and 4 weeks of skill training. Again, SPST had no effect on SICI at 2 and 4 weeks. There was no difference in the magnitude of SICI reduction between skill training and MPST. This study adds new knowledge regarding the corticospinal responses to skill and MPST, showing they are similar but different when compared with SPST.

The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: a systematic review

Sacroiliac Joint

The aim of this study is to investigate the effectiveness of physical therapy interventions in the treatment of sacroiliac joint dysfunction (SIJD). MEDLINE, PUBMED, CINAHL, AMED, PEDro, and CIRRIE databases were searched and only relevant data from studies that matched the inclusion criteria were included. CASP tools for critical appraisal were used to assess the quality of studies included.

Nine articles met the inclusion criteria, of which, three examined the effect of exercise on SIJD, three used kinesio tape and four studies examined the effect of manipulation. Various outcomes were used including the visual analogue pain scale (VAS), Oswestry disability questionnaire (ODQ), numerical pain rating scale (NPRS) and pelvic position measurement (PALM, pelvimeter and photogrammetry). The quality of included studies ranged from low to average as the CASP tools revealed several limitations that affect the validity of the studies. The results showed that physiotherapy interventions are effective in reducing pain and disability associated with SIJD, with manipulation being the most effective approach and most commonly used within physical therapy clinics.

Manipulation, exercise and kinesio tape are effective in the treatment of pain, disability and pelvic asymmetry in SIJD.

Thursday, October 19, 2017

Physiological tremor increases when skeletal muscle is shortened: implications for fusimotor control.

Muscle Spindle under microscope

The involuntary force fluctuations associated with physiological (as distinct from pathological) tremor are an unavoidable component of human motor control. While the origins of physiological tremor are known to depend on muscle afferentation, it is possible that the mechanical properties of muscle-tendon systems also affect its generation, amplification and maintenance.

In this paper the authors investigated the dependence of physiological tremor on muscle length in healthy individuals. They measured physiological tremor during tonic, isometric plantarflexion torque at 30% of maximum at three ankle angles. The amplitude of physiological tremor increased as calf muscles shortened in contrast to the stretch reflex whose amplitude decreases as muscle shortens. They used a published closed-loop simulation model of afferented muscle to explore the mechanisms responsible for this behaviour.

The team demonstrate that changing muscle lengths does not suffice to explain our experimental findings. Rather, the model consistently required the modulation of γ-static fusimotor drive to produce increases in physiological tremor with muscle shortening-while successfully replicating the concomitant reduction in stretch reflex amplitude. This need to control γ-static fusimotor drive explicitly as a function of muscle length has important implications. First, it permits the amplitudes of physiological tremor and stretch reflex to be decoupled. Second, it postulates neuromechanical interactions that require length-dependent γ drive modulation to be independent from α drive to the parent muscle. Lastly, it suggests that physiological tremor can be used as a simple, non-invasive measure of the afferent mechanisms underlying healthy motor function, and their disruption in neurological conditions.

Anatomy 101: The Windlass Mechanism & Great Toe Extension

Last month there was a strong focus on the foot and ankle complex and it is time to come back to an old biomechanical concept - the windlass mechanism.

This blog was first found on Rayner and Smale

I fear that some key concepts have been lost in our teaching as we move to follow new trends. So, just as I loved writing about the Cloward sign and research from 1959, we are going to take another step back in time. This time it is to 1954, when J.H Hicks wrote about the plantar aponeurosis and proposed a biomechanical model explaining how diverse the function of the joints of the foot are between weight bearing and non weight bearing.

Hicks (1954) discussed four key observations that had been made about what should normally occur in the foot during weight bearing when the first metatarsalphalangeal joint (MTPJ) moves into extension:
  • The medial longitudinal arch (MLA) height increases. 
  • The calcaneus inverts. 
  • The leg (tibia and fibula) externally rotates. 
  • A tight band appears (the plantar aponeurosis). 
I think many clinicians would agree that these observations are coupled with toe extension but what he came to understand further through investigating both live subjects and cadavers, is that these observations occur in both situations, concluding therefore that the mechanism was not primarily due to muscular activity(Hicks., 1954, p.26).

The windlass mechanism refers to the function of the anatomy on the base of the foot, specifically the plantar aponeurosis, sesamoid bones, plantar pads and the attachment of these structures under the MTPJ. The term ‘windlass' actually is a verb used in sailing meaning to haul or lift something using windlass. Hicks, and other researches from this time used the word windlass to describe how the bow-string structure of the plantar aponeurosis hauls the calcaneus and first MTPJ closer together and is done so when the first ray moves into extension. The outcome of these bones moving closer together in distance is a rising of the metatarsals forming the apex of the triangle and resulting in the MLA rising.

Below is an image that outlines how the base of the great toe acts at the windlass, while the plantar aponeurosis (PA) is the bow-tie connecting the calcaneus to the MTPJs across all five toes. "The PA is a strong elastic band spanning the foot longitudinally and connecting the calcaneus to the toes. It appears as a strong and thick band from the heel to midfoot, from which point it fans out into five slips that run underneath the metatarsal heads (MHs) and attach to the plantar side of the proximal phalanx of each toe" (Caravaggio, Pataky, Goulermas, Savage & Crompton., 2009, p.2491).

Image courtesy of Google Images

When the heel strikes the ground, at the beginning of stance phase, the ankle is in dorsiflexion. From this point the tibia “rotates inwardly and the hind foot or triple joint complex (subtlar, talonavicular, and calcaneocuboid) moves into a more everted or valgus position whereas the tibiotalar or ankle joint plantar flexes" (Van Boerum & Sangeorzan., 2003). The movement of these joints creates a pre-loading effect on that plantar aponeurosis as the foot pronates towards the foot-flat phase of mid-stance (Caravaggio, et al., 2009).

When the foot reaches foot-flat or mid-stance, the tension in the plantar aponeurosis reduces and the foot is able to shock-absorp and adapt to the terrain through midfoot supination or pronation depending on the demand. Once we move to the last 30% of stance phase and prepare for push off, the great toe starts to move into extension, which again tightens the plantar aponeurosis and assists with re-supination of the foot (Caravaggio, et al., 2009; Kappel-Bargas, et al., 1998). During the normal gait cycle between 45-55 degrees of great toe extension is required (Neumann., 2013). Caravaggio and associates (2009, p. 2498) also confirmed that while the PA attaches through 5 slips to all five toes, the most load occurs under the 1st MTPJ and this load reduces with lateral movement, with the 5th toe being the lowest load.

As first MTPJ extension increases, the height of the MLA should also increase. What Kappel-Bargas et al (1998) reported however, is that some people have immediate movement of the arch when the toe first extends and others have delayed movement of the arch. Both of these behaviours were different to the normal pattern. At this time, nearly 20 years ago, these authors speculated that early onset of arch movement with first MTPJ extension would perhaps predispose the arch to higher tensile loads, while delayed onset of movement was more commonly seen in people with increased rear foot angle and more mid foot pronation. Both scenarios result in an ineffective windlass mechanism.

I love this diagram below which describes the horizontal plane kinematics of the gait cycle.

Image courtesy of Google Images 9.11.17

Great toe extension in weight bearing.

You can use the windlass test to examine the amount of toe extension in weight bearing by lifting the big toe and evaluating the impact it has on the arch (Bolga & Malone., 2004). In patients with plantar fasciitis, this test is considered to be positive if it reproduces pain in the medial calcalneal tubercle (Bolga & Malone., 2004, p. 79). Regardless of whether there is plantar fasciitis or not, this test will tell you if movement of the MLA is normal, early or delayed.

Other factors to consider:
  • Ankle dorsiflexion ROM in weight bearing
  • Tibialis posterior strength and endurance. A major active supporter of the MLA is tibialis posterior, which acts eccentrically during the shock absorption phase of gait to prevent arch collapse and eversion of the foot (Bolga & Malone., 1998; Van Boerum & Sangeorzan., 2003). Tib post is not the only muscle to consider though. "The combined effects of the flexor digitorum longus, flexor hallucis longus, peroneus longus, and Achilles tendons permit the supination needed to enhance the windlass mechanism” (Bolga & Malone., 2004, p. 79). 
  • Rearfoot/calcaneal angle. A mentioned above it is important for the rear foot to move from supination to pronation and back to supination again. Understanding the starting position of the calcaneus and movement of the calcaneus during plantar flexion with toe extension will guide our understanding of how the medial arch behaves during gait. 
  • Palpation - of the first MTPJ joint, of the PA and surrounding soft tissue structures of the foot. 
Calf tightness, achilles tendon tightness and ankle dorsiflexion stiffness are all risks for plantar fascia overload. Cheng et al (2008) were interested in further understanding the relationship between dorsiflexion angles, achilles tendon force and the impact on plantar fascia and the windlass mechanism to help direct treatment strategies that reduce plantar fascia strain in plantar fasciitis. From their study they found that 2/3 of plantar fascia strain is attributed to great toe extension and the remaining 1/3 to achilles tendon force.

They confirmed that when under load, the region of maximum stress of the plantar fascia is near the medial calcaneal tubercle (2008, p. 1942) which correlates with common clinical presentation of medial heel pain during weight bearing.

The results showed that higher loads occur on the plantar fascia under the first toe and reduced when moving out to the 5th toe which may offer an explanation as to why people weight bearing through the outer border of their feet when they have plantar fascia or toe pain. But if walking occurs without great toe extension, not enough pressure is applied to the plantar aponeurosis to effectively raise the MLA which may place the foot in a biomechanically disadvantaged position with an ineffective windlass mechanism. Therefore, retraining plantar flexion with pressure through the great toe is important for normal biomechanics.


Key points:
  • PROM and AROM is key. 
  • Tension to the plantar aponeurosis occurs through both toe extension and ankle dorsiflexion. 
  • Look at static & dynamic posture. 
  • It is a good idea to observe our patient’s foot posture during quiet stance and gait, looking at the foot from front, side and behind to understand the resting versus dynamic posture. 
  • When looking at static posture consider more than if the foot is pronated or not. Look at the foot from behind and measure the rear foot angle to understand what impact the resting position of the calcaneus has on the windlass mechanism. 
  • When looking at the foot from the side it is easy to see that if the first metatarsalphalangeal joint does not have extension ROM it will flatten the arch. 
  • Remember that posture does not equal pain. 
  • Don't forget about the muscles. 
  • Muscles that have the ability to influence height of the medial longitudinal arch include tibialis anterior, tibialis posterior, peroneals and gastrocnemius. 
  • Look above and below. 
  • Bolga & Malone (2004) made note to emphasise that foot static and dynamic posture can be influences by proximal neuromuscular control such as gluteus medius weakness, ankle dorsiflexion stiffness, achilles cord tightness, and tibialis posterior weakness. So while I encourage you to keep toe extension close to the front of your mind, be sure to see the bigger picture as well. 
The windlass mechanism aka movement of the medial longitudinal arch is essential for shock absorption and dissipation of forces through foot. It explains how the foot can act as both a rigid level and an adaptable shock absorber during the stance phase of gait. The aim of this blog was to rehash some old anatomy and biomechanical concepts and to remind you how cool the foot really is and how multifunctional the joints, ligaments and active structures are in the foot which act together to allow synchronous and effortless gait.

Sian - via Rayner and Smale

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

twitter @siansmale
instagram @siansmale_SF


Bolgla, L. A., & Malone, T. R. (2004). Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of athletic training, 39(1), 77.

Caravaggi, P., Pataky, T., Goulermas, J. Y., Savage, R., & Crompton, R. (2009). A dynamic model of the windlass mechanism of the foot: evidence for early stance phase preloading of the plantar aponeurosis. Journal of Experimental Biology, 212(15), 2491-2499.

Cheng, H. Y. K., Lin, C. L., Wang, H. W., & Chou, S. W. (2008). Finite element analysis of plantar fascia under stretch—the relative contribution of windlass mechanism and Achilles tendon force. Journal of biomechanics, 41(9), 1937-1944.

Gelber, J. R., Sinacore, D. R., Strube, M. J., Mueller, M. J., Johnson, J. E., Prior, F. W., & Hastings, M. K. (2014). Windlass mechanism in individuals with diabetes mellitus, peripheral neuropathy, and low medial longitudinal arch height. Foot & ankle international, 35(8), 816-824.

Hicks, J. H. (1954). The mechanics of the foot: II. The plantar aponeurosis and the arch. Journal of anatomy, 88(Pt 1), 25.

Kappel-Bargas, A., Woolf, R. D., Cornwall, M. W., & McPoil, T. G. (1998). The windlass mechanism during normal walking and passive first metatarsalphalangeal joint extension. Clinical Biomechanics, 13(3), 190-194.

Lucas, R., & Cornwall, M. (2017). Influence of foot posture on the functioning of the windlass mechanism. The Foot, 30, 38-42.

Maitland, G. D. (1977). Peripheral manipulation. Butterworth-Heinemann.

Neumann, D. A. (2013). Kinesiology of the Musculoskeletal System-E-Book: Foundations for Rehabilitation. Elsevier Health Sciences.

Van Boerum, D. H., & Sangeorzan, B. J. (2003). Biomechanics and pathophysiology of flat foot. Foot and ankle clinics, 8(3), 419-430.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review

Carpal Tunnel Syndrome Cartoon

The objective of this study was to review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS). The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were all searched by two independent reviewers.

A best-evidence synthesis was performed to summarize the results of the Included studies (2 reviews and 22 RCTs). For physical therapy moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active trigger points, or low-level laser therapy in the short-term. For several electrophysical modalities moderate evidence was found in the short-term (ultrasound versus placebo, ultrasound as single intervention versus other non-surgical interventions, ultrasound versus a corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia versus placebo, iontophoresis versus phonophoresis, pulsed radiofrequency added to a wrist splint, continuous versus pulsed versus placebo shortwave diathermy, and interferential current versus transcutaneous electrical nerve stimulation versus a night only wrist splint). In the mid-term moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs optimal treatment parameters could not be identified.

Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in short-term and mid-term. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.