11/18/2014


When a 68-year-old female patient came to my clinic presenting with a possible Parkinson’s  diagnosis, her first words after stacking an enormous medical file folder on my desk was, “I wish they could figure this out.” She informed me that she had had numerous tests, had seen a myriad of specialists, yet they were still trying to assimilate all the data for the best course of treatment. Was it multiple system atrophy (MSA) or Parkinson’s? As I watched her enter my clinic, I noticed her kyphotic posture, a strained limp in her gait, balance issues, and a grimace across her face as she sat. I said, “Forget about all of that. How are your daily movements?” She then proceeded to tell me that although she had none of the common symptoms (tremor, etc), she could no longer be on her feet for more than a few minutes without having to sit, and that she no longer could do many of the things she used to.

 

stand opaqueWhile Parkinson’s disease (PD) and its related diseases manifests in the brain, its symptoms affect, and can eventually disable, normal movement. Changes in connective tissue, kyphotic postures, and muscle atrophy are rarely addressed in a typical physical therapy treatment, and this is something I’ve experienced in all of my PD patients. Sadly, most of them are coming from 6-12 weeks of this type of therapy, which is the common allotted time under medicare. While exercise programs such as Dance for PD,  LSVT BIG, and others are recommended and can be beneficial, most PD patients have such a high amount of pain and movement dysfunctions that they cannot comfortably engage in these classes. Or, if they do, they develop injuries that compromise their movements.  Also, balance is often poor in part due to the changes in postures and weak soft tissues. It does not mean they can never do these type of classes, it just means the dysfunctions should be addressed first.

PD patients can exhibit many common physical symptoms – tremor, bradykinesia (slow movement), and freezing – yet the symptoms themselves should not be the focus of treatment. It’s not that these symptoms shouldn’t be considered, after all, they can be helped; it’s that all of these symptoms often come with pain and reduced quality movement that stems from soft tissue-fascia dysfunction.  While we cannot guarantee a cure of these symptoms, what we can do is focus on improving the quality of the movements.  And this will likely improve the symptoms as well.

Shortened front lines, before and after treatmentShortened fascial front lines before (a) and after treatment (b)

The latest research on human fascia is fascinating, and clinicians cannot exclude its connection to pain and dysfunction . Not only does this tissue contain nociceptors (nerve receptors that perceive pain) and proprioceptors (receptors that perceive pressure), fascia can contract and relax.¹ It is also believed to be involved with emotional health. This knowledge becomes extremely important, especially when approaching treatment of the PD patient.  While a definitive “map” of human fascia, at least in Western medicine, remains hypothetical, I support what was “mapped” by the ancient arts (see Chen)2  – yoga, martial arts, et al. – and what Thomas Myers has done so nicely. The fascia has distinct “lines,” or myofascial meridians, that have distinct patterns in the human body. These “lines” should be a focus when considering exercises (and hands-on work) in manual therapy. Fascial tissue development can be taught to patients via simple yet specific exercises aimed to improve overall movement and health. 3

Before embarking on group exercise classes, the patient must be assessed for posture (i.e. kyphosis) dysfunctions and carefully examined for other possible pain patterns (i.e. what I consider fascial sensitivities such as plantar fasciosis and hip or shoulder bursitis).  PD patients have a high degree of soft tissue (fascial) hyperacuity. 4  In layman’s terms, the tissue that covers everything from head to toes is like a great communicator to the entire body.  For example, pressure, via acupuncture needle,  pulsed electromagnetic field current (PEMF), or thumb under the large metatarsal (toe) might produce pain or other sensations in theopposite shoulder or even ear.  Sometimes the sensation is intense, and removing the force (or pressure) from the toe eliminates the discomfort. This type of fascial sensitivity is something I don’t see with healthy individuals, at least not in the level of intensity experienced by PD patients. Another way to think about fascia is as if you were to grab a shirt and pull, all the threads in the shirt would be “pulled,” not just in the area you are pinching.   Why is this important? The fascial system must be considered as part of treatment. And it’s not in traditional healthcare.

Before beginning any exercise protocol,  treatment sessions should be devoted to “correcting” dysfunctions that will inhibit those exercises, or make them uncomfortable to perform. This treatment could be many things, such as helping correct posture (kyphosis, or a shortened front line in the fascia), by “bowing” the front line (or front of the body) by thoracic hyper-extension (lifting the shoulder back while supine) , or improving limb movements that have limitation or pain. With a limited range of motion, PD patient cannot perform those big movements in group classes comfortably. The PD patient must be placed on a therapy table and manipulated through gentle range of motion (ROM) movements, with a focus, first, on the center of the body, the hip (gluteal) region. The pelvis is the center of the body, and the gluteal region should feel freely movable, without restrictions.The entire fascial line from the back of the cranium to the toes should be assessed for shortness and pain. The fascial lines are “unhinged” with gentle, short hold range of motion exercises.

One of the more effective ways to treat “dysfunctional functional” movements is the concept of what I call “opposites.” It is not an uncommon pattern, and like many range of motion exercises it has been around a while.  Since the brain is wired so that the left side controls the right, these patterns are complimentary. In fact, many athletic trainers force the athlete to swing a tennis racket etc. in the opposite hand to achieve better coordination. What I would like to introduce is a more specific approach to this old pattern. It involves utilizing, for one, the fascia spiral lines – those lines that crisscross the body in the front and back. In simple terms, it involves lifting opposite leg and arm (or even fingers and toes) against gravity. This can be done in multiple ways, from standing postures to prone or supine on a therapy table. If the patient is prone (on back) on the table or floor, lifting a straight leg and opposite straight armtogether has enormous benefits. Not only is it a brain challenge, it forces the cross-body soft tissues to develop. This strengthens some of the major core muscles, and it also helps condition the fascial tissue to be stronger and offer a more supportive role, especially along the thoracolumbar fascia. Yet this movement has to be precise, in that the patient must be instructed via palpation and verbal cueing, that the arm and the leg are not separate units. There must be an intent to begin the unified movement. The limbs are connected as one, and the movement is as though one will not move with out the other. This is a complex thing, and it often takes a lot of coaching to get the patient to perform the movement as such. I will often have the patient close her eyes and begin the movement, and if any limb is out of sync, we will begin the movement again. It is so important to get this oneness with the movement, and it makes the exercise that much harder to achieve, but with so many other benefits. Also, to further involve the spiral lines, the leg and arm should be rotated internally during the lift, and then a set is performed with the limbs rotated externally. Weight (ankle and hand weights) can be added upon progression, but I never like to use the popular (and old school) multi-colored elastic bands. Why? While it’s  an honest resistance, the resistance changes with the stretch in the band, placing great stress upon the joints. (see Hooke’s Law). 5

Opposites are also extremely effective when employing the fingers and toes. For many PD patients (and athletes), this exercise is difficult, because of the difficulty in coordinating the small movements. The patient can be seated, with the arms gently flexed in the lap. With the hands open, the patient is instructed to flex first the small finger to the palm of both hands, yet again the movement only begins as a unit, as both fingers move as a one. And the movement is slow, with each finger only moving if the other one does. When a precise movement is demonstrated with one finger, it is repeated with the others, and the thumb. This exercise helps functional daily movements, such as gripping (brushing teeth) and picking up items. A much more difficult progression is to have the patient remove shoes and socks, and repeat the same movement with opposite small toe/little toe. This is when things get interesting, as it is very difficult to flex only the small toe. The intent, though, is the crucial part. Again, it is effective when the patient closes her eyes and sends the intent to the toe being moved.  Yet repeated repetitions and weekly work can change gait and balance issues. Another creative option is to have the patient perform the movements with the eyes closed, or with the opposite eye open, and the other closed.

There are endless treatment possibilities for the PD patient when the fascial system is considered, and when the focus is placed on helping correct the patient’s everyday functional movements. Quality of life should not suffer because of oversights in physical assessment of the patient’s every day movement patterns.  We cannot alter the diagnosis, but we can help improve coping with it.

All of the latest research on fascia can be found in The Tensional Network of the Human Body. 1

References:

1. Fascia: The Tensional Network of the Human Body: the Science and Clinical Applications in Manual and Movement Therapy. Robert Schleip, Thomas W. Findley, Peter A. Huijing
Churchill Livingstone/Elsevier, 2012

2. The Illustrated Canon of Chen Family Taijiquan. Chen Xin, 2007

3. Müller DG and Schleip R (2011): Fascial Fitness: Fascia oriented training for bodywork and movement therapies. FF Yearbook.

4. Gibson, W. (2007). Pain sensitivity and referred pain in human tendon, fascia and muscle tissue. Aalborg: Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark

5. Hooke’s law is a principle of physics that states that the force needed to extend or compress a spring by some distance is proportional to that distance. That is: where is a constant factor characteristic of the spring, its stiffness. The law is named after 17th century British physicist Robert Hooke.
– Wikipedia, the free encyclopedia