Clinical Guide to Positional Release Therapy PDF

Clinical Guide to Positional Release Therapy The incidence of lower-quarter injury in athletic and recreational populations is staggering, as is its potential economic cost. Shibuya and colleagues (2014) reported that 280,933 foot and ankle fractures and dislocations occurred in the United States b...

Clinical Guide to Positional Release Therapy The incidence of lower-quarter injury in athletic and recreational populations is staggering, as is its potential economic cost. Shibuya and colleagues (2014) reported that 280,933 foot and ankle fractures and dislocations occurred in the United States between 2007 and 2011. Of those, 92.74% were non-work-related; 55.7% occurred at the ankle, and the greatest number occurred in the foot at the metatarsals (12.5%). Given the magnitude of fracture alone, it is not surprising that one in five middle-aged to older Americans suffers from foot pain (Thomas et al. 2011). Although extrinsic factors such as skill level, shoe type, and playing surface are important to take into account when evaluating a patient presenting with lower-quarter injury and somatic dysfunction, potentially modifiable intrinsic factors such as anatomical alignment, muscle tightness, range of motion, and strength and tissue imbalance may have the greatest potential to be influenced by PRT. The literature review by Murphy, Connolly, and Beynnon (2003) revealed little consensus among prospective studies on these factors; however, the literature suggests that these factors may play a role in the predisposition of lower-extremity (LE) injury and possibly the development of somatic dysfunction. It would stand to reason that if somatic dysfunction reduces strength, as seen in the Wong and Schauer-Alvarez hip study (2004), then it could also affect the stability and function of the lower-extremity articulations and tissues, specifically at the foot. However, the hip articulation is not the only driver of kinematic movement in the lower extremity. The role of distal kinematics and foot type or posture for the predisposition of lower-quarter injuries such as Achilles tendinopathy, patellofemoral syndrome, medial tibial stress syndrome (MTSS), and iliotibial band friction syndrome has received considerable attention (Dowling et al. 2014; Neal et al. 2014). However, most foot studies are retrospective and involve the analysis of static foot posture, which may lack clinical relevance once the patient ambulates (Dowling et al. 2014). A long-standing theoretical assumption has been that an increased navicular drop, or a “flat foot posture,” increases the risk for MTSS, and that a high arch, or pes cavus foot, increases limb stiffness. Both foot postures are thought to increase the risk of lower-extremity injury (Neal et al. 2014; Tong and Kong 2013). However, foot posture assessment methods such as the navicular drop test and foot posture index have resulted in mixed causation findings (Neal et al. 2013). It is 48 possible that these assessment methods are not sensitive enough to detect dynamic changes when the patient ambulates (Dowling et al. 2014). To date, systematic reviews of foot posture, either static or dynamic, have yielded only limited evidence to support the association between altered foot posture and the risk for lower-quarter injury. However, Neal and colleagues (2014) reported strong evidence for an increased risk of MTSS among patients with a static pronated foot posture with very limited evidence of a propensity for patellofemoral pain. As well, Dowling and colleagues (2014) found very limited evidence that dynamic foot function is a risk factor for the development of lower-extremity injury. The authors did indicate that the clinical assessment of lower-quarter kinematics was a significant challenge because most clinicians lack access to sophisticated kinematic analysis technology as well as expertise in using it and interpreting the outcomes. Kinematic research findings thus may not be clinically relevant based on the multifactorial nature of lower-quarter injury and the difficulty of assessment in the clinical environment. However, age and body composition are easily assessed in the clinical environment. As discussed in chapter 3, the older population may be more susceptible to injury as a result of the aging process. According to Hill and colleagues (2008), foot injury afflicts more than 30% of the aged population, which has been associated with falls (Spink et al. 2011). In a systematic review, losses in strength, range of motion, balance, and flexibility were assessed as potential risk factors that could be mitigated by the use of a foot and ankle (FA) exercise intervention program. Investigators, however, found only limited evidence to support the use of an FA exercise intervention program to reduce the risk of falling in this population. Significant improvements occurred only in balance and flexibility (Schwenk et al. 2013), which may improve foot function and reduce the risk of falling. Obese patients may be more susceptible to osteoarthritis from increased joint loading. Abnormal foot function has also been observed in the obese population (Butterworth et al. 2014). The authors found among the obese strong associations among decreased balance, increased dynamic pronation, and increased plantar pressure during ambulation. However, because of methodological variations in the assessment of foot structure across studies, a direct relationship between body composition (fat T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. Foot TREATMENT Common Anatomical Areas and Conditions for PRT • Fibromyalgia • Sprains and strains • Osteoarthritis Dorsal Structures • Lisfranc sprain • Morton’s neuroma • Osteoarthritis Plantar Structures • Plantar fasciitis • Metatarsalgia • Morton’s neuroma • Tendinopathy • Bursitis • Dorsal compression syndrome • Turf toe • Sesamoiditis • Bone spur mass) and foot structure was not possible. Butterworth and colleagues (2013) posited that foot pain experienced in the obese population may be the result not only of altered foot mechanics but also of “metabolic and inflammatory mediators produced by adipose tissue” (p. 7), which, if coupled, may create somatic dysfunction of the lower quarter in this population. In my clinical observation of thousands of patients who have presented with lower-quarter somatic dysfunction, the majority of lesions are the result of compensatory biomechanical loading patterns such as prolonged stance pronation, weak hip abductors, leg length discrepancy, muscle imbalance, excessive weight, and prior injury. The somatic or myofascial lesion patterns often manifest from either a functional or structural abnormality, which overloads the tissues; the tissues respond by forming osteopathic lesions in defense. However, it is imperative that therapists consider other triggers in the assessment process to identify and address any underlying disease process, visceral facilitation, or neurological derangement. Unfortunately, at this time scant literature exists examining the effect of PRT on lowerextremity intrinsic and extrinsic factors in isolation or in combination. The body of PRT literature has tended to focus on facial, spinal, pelvic, and upper-quarter painful conditions (Wong 2012). Positional release therapy research is starting to gain a footing on explaining how the therapy provides significant pain relief and correction of somatic dysfunction. However, until the gaps in the PRT literature are filled, clinical experience and feedback from patients about what they value from their clinical experience with PRT will inform the positional release therapist about how to approach lower-quarter somatic dysfunction. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 49