104 Basic Provider Treatments.pdf

Basic Provider Treatments Learning Objectives ◦ Understand physiology behind each treatment ◦ Understand when and why to use the treatment ◦ Can perform each treatment proficiently ◦ Pathways to memorize ◦ Spinocerebellar tracts (DSCT, VSCT, RSCT, CSCT) ◦ Dentatorubrothalamocortical...

Basic Provider Treatments Learning Objectives ◦ Understand physiology behind each treatment ◦ Understand when and why to use the treatment ◦ Can perform each treatment proficiently ◦ Pathways to memorize ◦ Spinocerebellar tracts (DSCT, VSCT, RSCT, CSCT) ◦ Dentatorubrothalamocortical tract ◦ Reticulospinal tracts (PRST, MRST) ◦ Vestibulospinal tracts (MVST, LVST) First Level of Treatments These are the exercises listed under “Practitioner” on the D/P templates that are commonly used with most patients 50-75% of the treatments listed on here will be used with every patient you encounter With advanced modules you will begin to understand the bigger picture, and can then review these slides to see how they fit with your patient’s care Structuring Visits The initial 20 min are used for therapies under the “Rehab” section. These cover the normal rehab visit flow ◦ Warmup/charging the system ◦ Energy/healing ◦ 1 system rehabilitation ◦ Integration of multiple systems The second 20 min are for therapies under the “Provider” section. These cover other therapies that are limited to providers ◦ Physical modalities ◦ Fine tuning systems ◦ Integration using Gyrostim/Virtualis If you are seeing a patient for the entire session, there is flexibility and you do not need to stick to this format. The patient’s visit can be more focused and tuned to what the main problem is. ◦ IE. Focusing the entire visit on defeating a nystagmus, fixing velocity storage, or a specific finding/purpose Subluxation Theory 1. Vast majority of information going into the CNS is from the muscles surrounding your spine, from constant input from gravity 2. Muscle receptors are major sources of proprioception – 1a (muscle spindles) and 1b (golgi tendon organs) 3. Subluxation, or a joint position error (JPE) leads to aberrant input into the CNS 4. We can use adjustments and manual therapies to correct the aberrant input, leading to improved neurological function 5. Be careful – often the exam findings are secondary to another problem. Altered mm tone can be due to visual/vestibular dysfunction, PMRF, frontal lobe, or dystonia. Evaluate all findings and identify the root cause 6. Do not blindly adjust without considering the all factors. 21st Century Chiropractic Manual Therapies Spinal Manipulation ◦ Indications: Cervicogenic dizziness, somatic/segmental dysfunction ◦ Arthrostim, drop table, manual adjusting Myofascial Therapy ◦ Indications: Taut/tight mm fibers, mm spasms ◦ Pin/stretch, active release, Hypervolt, rapid release Arpwave 1. Proprietary combination of 245hz direct current and secondary background stimulation at 10,000Hz, capable of penetrating deep tissues 2. This dual signal system allows healing of tissue and nervous system repair, without unwanted sensorimotor system deactivation and uncontrolled neuromotor activation 3. Can combine with functional movement and eccentric contracts for optimal motor function and coordination Indications: Cervicogenic dizziness, pain, impaired proprioception, muscle spasms Use to tolerance, stronger is preferred WITHOUT muscle contraction Photobiomodulation 1. The red wavelength of light triggers therapeutic cellular and physiological processes of the human body 2. The rate limiting enzyme of mitochondria (cytochrome C oxidase) absorbs this wavelength. Being exposed to this light increases all mitochondrial functions up to 60%. 3. Every molecule, cell, tissue and organ has an ideal resonance frequency which coordinates its activities. We can change the protocols/frequencies depending on the tissue we are trying to affect. 4. The 630-640 wavelength is the energy given off during cell proliferation and growth (Avant is 637nm). 5. Wavelength is the determining factor for penetration, 808nm is used due to increased penetration for the brain Arndt-Schulz Law aka Biphasic Dose Response Additional Benefits Avant Applications Red vs IR ◦ Red light (637nm) for superficial tissue, pain, inflammation, and healing/regeneration ◦ Near IR (808nm) for deep pain, deeper tissues, large muscles, nerve roots and brain ◦ Avant recommends doing half IR and half Red in that order Physical – Pain, inflammation, healing tissue ◦ Nerve root 30s IR and 30s Red ◦ Affected area 120s IR and 120s Red ◦ Once they can - affected area during movement/manual therapy 120s IR and 120s Red Co activation – Use the laser in the anatomical area you’re trying to stimulate while doing therapies ◦ Maximum of 30s IR and 30s Red on each brain region ◦ Can do multiple brain regions per session Triage/sensitive pts – If a patient is fatiguing use the laser in the appropriate region of the brain to improve their stability Complex Movements Complex movements are simple to perform but complex to master due to the many variations that can be performed Think of complex movements as a primary cerebellar exercise that fires into various areas of the brain Depending on the type of movement, you can fire different areas of the cerebellum and have different amounts of simulation based on the context of the patient We will dive deeper on how to understand and utilize levels of the cerebellum in another module Complex Movements Application Gentle stimulation into IP CB and CL frontal lobe ◦ Perform 5 reps between every exercise ◦ Passive is preferred for now to prevent fatigue Isometrics/uniplanar ◦ Perform an isometric on one hand with/without complex movements on the other hand ◦ This will decrease CB activity on the IP isometric side ◦ Perform long axis distractions of the fingers, toes, ankles to achieve a similar outcome ◦ Fires into the fastigial nucleus Dentatorubrothalamocortical tract How the cerebellum communicates to the contralateral frontal lobe 1. Dentate nucleus – planning, initiation of fine and complex movements. Executive function, linguistic, mood regulation 2. Red Nucleus – motor control, pain modulation, muscle tone 3. Thalamus – central processing center of all information 4. Cortex – supplemental motor, motor area, and somatosensory area Head Eye Vestibular Motion (HEVM) Integration of the somatic, vestibular and ocular systems by moving the head, eye and body together. Majority of TBI patients have cervical stability problems due to aberrant firing of different reflexes w/ vestibular deficits ◦ Vestibulocollic reflex (VCR) – fires cervical spine mm when there is vestibular input, stabilizing the head ◦ Cervicocollic reflex (CCR) – fires cervical spine mm in response to change in neck position HEVM activates the CCR and VCR together (proprioceptors), integrates it with vestibular and ocular information centrally to recalibrate the system Reticulospinal and vestibulospinal fibers play a big role with modulating gravity-dependent postural reflexes of neck and limbs ◦ HEVM can lead to changes in cervical, thoracic and lumbar musculature tone Reticulospinal Tracts Pontine reticulospinal tract and medullary reticulospinal tract ◦ Muscle tone, balance, postural changes ◦ Reciprocal inhibition ◦ Cardiovascular control, pain modulation Vestibulospinal Tracts Anti gravitational muscles Lateral VT – originates from LVN in pons, activates extensor mm in body Medial VT – originals from MVN/IVN in medulla, activates cervical mm ◦ VORs and righting reflex come from here HEVM Applications Indications ◦ Cervicogenic dizziness, HEVM findings, TBI, cervical dysfunction Identify nidus/impaired mapping during HEVM, go over the area slower and combine with small saccades and pursuits with thumb Use SNAG on CL side of breakdown Sustained Natural Apophyseal Glides (SNAGs) Effective for people that are afraid of manipulations, are more fragile/sensitive, stenosis Perform HEVM to determine side of decreased gain. Hypertonicity of the upper cervical spine occurs CL to the decreased gain. Palpate to ensure the cervical hypertonicity matches up with CL HEVM– otherwise the patient will have increased dizziness after the SNAG Horizontal SNAG ◦ Take a C2 transverse process contact on the CL HEVM side, and press gently into the contact ◦ Turn the patient’s head towards the HEVM side, hold it for a few seconds, then to the same side as the contact and hold for a few seconds while applying pressure throughout Vertical SNAG ◦ Put pressure C2 spinous process, take head up while putting pressure then down After the SNAG, adjusting the segment can further improve biomechanics Indications ◦ Cervicogenic dizziness, cervicogenic headaches, HEVM findings, cervical dysfunction Cervical apophyseal joints Observe the joint plane – when performing SNAGs, apply pressure at an inferior-superior and posterior-anterior movement Hypertropia AKA vertical strabismus, when one eye is higher than the other Always considered to be pathological, commonly seen in TBI For now, we will discuss simple treatment options. But in the future, we need to solve “What is the physiological reason for the hypertropia?” Hypertropia If there is a hypertropia, fix it before doing horizontal gaze stability ◦ Otherwise the patient may feel dizzy and you have poor results due to the eyes following different targets Indications ◦ TBI, positive Park’s 3 step, visual dizziness, Hypertropia Complex ◦ Figure out the weak eye mm and perform the three exercises back to back ◦ 4:1 monocular canal gaze stability ◦ x2 gaze stability ◦ In phase OPK to promote eyes in same direction Virtualis Use Virtualis for 10-20 min per session ◦ Head-eye and Motion Program are the two most used modules ◦ Head-eye for HEVM, tracking, cervical proprioception ◦ Motion Program for postural reflexes, balance, lower body weighted proprioception ◦ Use other applicable modules that may help Gyrostim Typically patients will use Gyrostim for 10-20 min in one session ◦ Start/warmup with sinusoidal Yaw/Pitch for gaze stability/tracking ◦ Mix in some VOR/VS protocols, or facilitation of weak eye mm ◦ In between reps perform other types of therapies to facilitate weak eye mm, complex movements, divergence exercises