Ms. S was a direct access referral for a physical therapy assessment at United Physical Therapy. She was initially assessed on April 9, 2016.
Ms. S is a 60-year-old hand physical therapist who presents with complaints of chronic neck and upper back pain predominately on the right side. Her orthopedic history is a progression of events beginning in her early 20’s. She developed left knee pain, which she attributes to excessive running. She was diagnosed with a meniscus tear. At the age of 20, she underwent an arthroscopy for meniscal debridement and resumed her running program. Approximately 6 months later she began to develop right lumbosacral pain, which was intermittent in nature. These symptoms were complicated by an injury 2 years later related to lifting a motorcycle in which she sustained a compression fracture of the tenth thoracic vertebrae. As a result, she started to experience intermittent thoracic pain. Right lumbosacral and thoracic pain became very limiting and more constant after the delivery of her second child when she was 37. It was at this point that she developed incontinence related to running which her OBGyn told her was possibly a nerve injury. For the last ten years she has episodes of various pain patterns involving the right sacroiliac joint, neck and back provoked by load or activity. She manages all these complaints with frequent massages and limiting her activity. Her current complaint of right cervical and thoracic pain has become more constant and she has difficulty finding a comfortable position to read more than thirty minutes.
At the initial assessment, Ms. S’s primary complaint was right cervical and thoracic pain, which is provoked with sitting and reading. Her other symptoms of pelvic and low back pain are not currently an issue for her.
Ms. S has been a practicing physical therapist for 35 years specializing in hand therapy. She believes that her neck pain is related to a compressed cervical facet joint that is referring pain to the thoracic area. She also believes that her pelvic pain is a separate issue.
Based on Ms. S’s story and her performance goal identified in the initial assessment, the meaningful task is to sit and read pain free for unlimited duration. The screening tasks chosen were based on the physical requirements to transition into sitting as well as sitting posture itself.
Standing Postural Screen
Even though Ms. S’s meaningful task is sitting, it is essential to assess her standing posture to determine existing postural control and alignment within and between regions as well as what strategies occur during task transitions. A painful impairment often impacts the alignment and loading tolerance of multiple regions. Optimal standing postural alignment includes a neutral pelvic girdle with no intrapelvic torsion, both femoral heads centered in the acetabulum, a smooth lumbosacral curve into a neutral thorax with symmetrical, slightly elevated, clavicles and scapulae approximated to the chest wall in slight upward rotation, and topped with a neutral head and neck.
Failed load transfer is defined as the loss of mobility, control or suboptimal alignment of a joint system within the kinetic chain and is task specific. Ms. S presented with multiple sites of failed load transfer in her standing posture. Her pelvis was rotated in the transverse plane to the right and this was associated with an intrapelvic torsion to the right and an anteriorly shifted left hip, which is congruent with this direction of pelvic torsion and rotation. Her thorax exhibited multiple ring shifts including the third and sixth ring, which were right translated, left rotated and fifth ring left translated and right rotated. Her shoulder girdle was torsioned to the right. C7 was left shifted right rotated and C2 was right shifted left rotated with her head in an intracranial torsion to the right.
Squatting is an opportunity to assess the strategy of how load is transferred from standing to sitting. Optimal strategy for squatting includes a neutral pelvis that moves as a unit and anteriorly rotates over both hips that remain centrally seated in the acetabulum. The cervical, thoracic and lumbar postural curves are maintained with a neutral head and shoulder girdle.
Ms. S did not experience any pain during the squatting task that might influence her strategy of movement. Her pelvis started and remained in a transverse plane rotation and intrapelvic torsion to the right. The left hip started anteriorly shifted and increased anterior translation early in the task.
The third ring shift right and the fifth ring shift left increased late in the task while the sixth ring shift right remained the same throughout the task.
The remaining findings including the shoulder girdle torsion to the right, C7 shifted left, C2 shifted right, and an intracranial torsion to the right remained the same throughout the task.
Once all the sites of failed load transfer of a task have been identified, then further analysis must determine which site in the kinetic chain is the driver. The timing of the failed load transfer as well as the improvement in pain or perceived effort to perform the task during correction and optimization of the biomechanics are considered in this analysis.
Correction of the thoracic rings and pelvis did not improve the strategy for load transfer through the hip. Manual correction and verbal cues to obtain and maintain a centered left hip restored control of the pelvis and rings 3, 5, and 6. Therefore, the left hip is considered the driver for this task based on the timing of loss of biomechanics relative to other areas as well as the response of the other body regions to its correction.
Sitting is a task of endurance. Her symptoms are produced after 20-30 minutes. Uneven load sharing contributes to excessive stress on joint and soft tissue that can result in chronic inflammation and tissue changes. The postural equilibrium must be maintained with appropriate levels of recruitment. Excessive muscle bracing or over activation can impact work efficiency and muscle metabolism leading to early fatigue. Sitting requires sufficient range of motion of hip flexion to allow the pelvis to maintain neutral alignment and equilibrium over the ischial tuberosities. The cervical, thoracic and lumbar spine must be neutrally stacked with smooth curves over pelvis without excessive muscle activation or kinks and hinging.
Ms. S presented with a transverse plane rotation and intrapelvic torsion to the right in both standing and squatting. As she assumed a sitting posture, her pelvis reversed direction into a left transverse plane rotation and the left SI unlocked.
Her left hip started anteriorly shifted and translated further anterior as she squat and then sat.
The third thoracic ring started translated right and further translated right during the task. The fifth ring started translated left and further translated left during the task. The sixth ring started and remained right translated. Her shoulder girdle torsion and intracranial torsion started and remained right as well as the left shifted C7 and right shifted C2.
A transverse plane rotation of the pelvis to the left is incongruent with a left anteriorly translated hip, which was an unexpected finding so this was the first correction assessed. Manual and verbal cues to assist in centering the left hip while squatting to sit resulted in both a resolution of the left transverse plane pelvic rotation and restored control of the left SI. All of the thoracic rings shifts resolved with this hip correction allowing for neutral stacking of the spine over the pelvis, which also included the neck. C7 and C2 were restored to good alignment and control as well as the shoulder girdle and head.
Screening Task Summary
Choosing screening tasks related to the meaningful task directs the assessment to remain focused on the primary complaint and avoids distraction of unrelated findings. The goal of identifying the driver is to identify the best place to intervene in the body that is related to the patient’s goals and meaningful task.
Quick summary of Ms.S’s findings:
- Squat: primary driver- left hip
- Sitting: primary driver –left hip
Once the primary driver has been identified, then more information about the underlying system impairment of the driver is required. There maybe multiple impairments involved which include articular, neural, visceral, or myofascial, all of which require very different interventions. Analysis will help us understand how to best remove the underlying system impairments that are creating non-optimal strategies so we can restore the optimal alignment, biomechanics and control for the desired goal or task.
Vector analysis of the left hip was carried out in a crook lying position. The femoral head position was monitored as passive flexion was performed revealing a limitation in available ROM of less than 90 degrees.
At the end range of hip flexion, a pulling restriction was identified posteriorly which was palpated to be the piriformis muscle. Upon its release, the tensor fascia lata and then the adductor were identified contributors to restriction of hip flexion.
The hip capsule and articular system were ruled out with the scour test and gliding the joint, which did not present as the limiting factor of range of motion. Vector analysis revealed loss of alignment and biomechanics to be the result of tonically over active muscles, which were neural in origin.
Ms. S’s primary complaint is chronic neck and upper back pain related to sitting and reading more than 20-30 minutes. She presents with a significant limitation in available hip range of motion that does not meet the requirements necessary for sitting which results in shifting loads throughout the pelvis and spine to make the range required available. Suboptimal alignment of a static posture can potentially result in compensation and altered muscle recruitment throughout the entire spine. This hypothesis is supported by her history of injury in the left knee, which potentially contributes to origin of hip stiffness as well as the progression of chronic pain originating in the lumbosacral spine. The analysis of this history with assessment findings supports the hip as the primary driver.
The ISM treatment plan is based on releasing sub optimal strategies to restore alignment progressing towards regaining lost connections for recovery of functional movement. Identification of sub optimal strategies is based on the meaningful complaint and task defined by the patient. Ms. S’s initial treatment plan is as follows:
R: Primary driver-Left hip: piriformis, tensor fascia lata, adductors
A: Align and center femoral head- best cue was to “create space in the groin and let the sitz bones go wide”
C: Restoring femoral mobility resulted in restored control of pelvis and spine therefore additional connect cue was not indicated
M: Alignment cues were incorporated into stand to sit movement pattern
Ms. S. initially responded very well to self mobilization and release cues for her left hip; however, as her hip mobility improved, she began to experience a reoccurrence of her right sided neck and upper back pain associated with complaints of constant right SIJ pain which feels fragile and more painful as she bends forward.
Reassessment of Ms. S’s screening tasks revealed a new driver for her pain experience. Results are summarized as follows:
- Cranium: ICT right
- Thorax: Rings 6 right translated left rotated. Ring 5 left translated right rotated.
- Pelvis: TPR left Right SIJ unlocked
- Thorax: Ring 5 starts and stays left translated. Ring 6 starts and stays right translated.
- Cranium: Starts and stays in an ICT right
- Pelvis: TPR start and remain left with unlocked right SI
- DRIVER: Correction of thoracic rings 5 and 6 results in control of TPR and alignment of right SIJ
- Thorax: Ring 5 starts and increases in left translation. Ring 6 starts and increases in right translation
- Cranium: Starts and stays in a ICT right
- Pelvis: TPR left with unlocking of right SIJ
- DRIVER: Correction of thoracic rings 5 and 6 results in alignment and control of TPR and alignment of SIJ as well as resolving ICT right to neutral
Initial treatment restored the left hip alignment and ROM such that Ms. S could sit with better cervical alignment however she presented with an intracranial torsion right, translation of rings 5 & 6 as well as a left transverse plane pelvic rotation and an unlocked right sacro iliac joint in all three tasks – standing, squat and sitting. Correction of thoracic rings 5 and 6 resulted in recovery of control and alignment of the cranium and pelvis.
Vector analysis of thoracic rings 5 and 6 (the current driver) reveal increased tone and overactivation of right iliocostalis fascicles to the fifth ring. The iliocostalis originates at the angle of the rib and inserts along the posterior medial iliac crest. Over activation of this muscle can result in a right rotation of the fifth ring as well as a left transverse plane rotation of the pelvis and potentially impact control of the right SIJ. Correction of thoracic rings 5 & 6 resulted in control of the right SIJ during squatting and sitting tasks as well as resolving intracranial torsion
A new treatment plan was established to release the long vectors of the right iliocostalis and restore alignment of thorax with cues to create space between ribs and thoracic vertebrae progressing to incorporating cues with stand to sit movement.
Ms’ S was a highly motivated and extremely compliant patient whose educational background as a therapist enabled her to make rapid gains toward recovery of function within fewer visits. She was seen for a total of six visits and achieved resolution of her symptoms as they related to this task of sitting.