Thursday, June 13, 2013

Physical Therapy / Rehabilitation after Hip Impingement (FAI) Surgery: The Benefit of Neurokinetic Therapy for Muscle Re-Education

A few weeks back, I mentioned I’d be back with a guest blogger, a physical therapist who uses Neurokinetic Therapy (NKT) in his practice. Here he is. Meet Kristopher Bosch, PT, DPT, ATC, FAAOMPT!

Most rehabilitation and wellness professionals eventually end up asking themselves: “Why do patients/clients come in with pain, go through a treatment session, leave pain-free or with significant improvement noted, and then return the next week with the same symptoms (often times over and over again)?”
It is important to keep an open mind to new treatments as we never have all the answers and the only thing a closed mind will do is limit ourselves to possibilities or modalities that may benefit our practice and our patients. Neurokinetic Therapy offers us new ways of evaluating and treating patients.

Neurokinetic Therapy was developed by David Weinstock, and expert bodyworker who has been practicing and teaching in the field of Bodywork for over 35 years. Briefly, NKT is a technique that looks at compensation patterns from a motor control perspective. Neuroscience tells us that the Motor Control Center (MCC) of the brain in the cerebellum stores movement patterns. This occurs in normal development, in response to our repeated habits and activities, or as a result of injury as the body attempts to protect itself and avoid pain. Often times these movement patterns may be faulty or dysfunctional, and pain results from imbalance, overuse, or overloading of tissues. The site of pain may not even be in the area of the dysfunction, but merely is a result of it.

NKT utilizes manual muscle testing to identify and address compensation patterns in which muscles may test weak (or inhibited) due to other muscles which have become overactive (or facilitated). A commonly seen example of this in the hip would be facilitated obturators [obturator externus and internus are hip rotators] inhibiting the rectus femoris [an assisting hip flexor], or a facilitated iliacus inhibiting the psoas muscle [a main hip flexor].

Another concept looks at the idea of relational inhibition, whereby one muscle, when activated, results in inhibition of one or more other muscles. Relationships can be found when looking at muscles that are functional opposites (traditionally we think of agonist/antagonist scenario), synergists or along functional fascial lines

The manual muscle testing in NKT can be looked at as the key to unlock the MCC to elicit lasting change in movement patterns. The MCC is open to learning most effectively by failure, meaning, you perform muscle testing and find a muscle that is inhibited. The lack of a successful outcome (i.e. a ‘strong’ test) engages the MCC which now has a window of opportunity to learn from the failed muscle test.

It is attention to the motor control component which is often missing in traditional muscle testing and drives the question posed above about why treatment effect doesn’t stick. The muscles which are inhibited or facilitated may vary greatly, and may arise for a variety of reasons. Take hip pain for example: common relationships seen are the gluteus maximus and psoas inhibited by a facilitated iliacus; rectus femoris inhibited by facilitated obturators; and TFL inhibited by peroneals [outside of the lower leg]. In this example the amount of large muscle inhibition and facilitation of smaller musculature also results in increased compression of the hip joint, as the body attempts to create more stability.

Over time, this scenario may lead to increased wear and potential pathology of the articular cartilage, labrum, and soft tissues that cross over the hip joint. Often times the facilitated muscles are also areas of pain and/or trigger points due to the development of soft tissue restrictions and increased tissue tension. Treatment is often aimed at stretching or soft tissue mobilization, which may provide some temporary relief at the tissue level. However, symptoms tend to return as a result of the underlying movement patterns which have not yet been addressed. NKT allows us to access the motor control center and gives us an opportunity to alter the faulty movement pattern. (The process of how this is done by the clinician is beyond the scope of this blog post).

It is also important to recognize that the MMT is not utilized in the traditional sense of strength testing and rating on a 0-5 point scale as I had learned in PT school. The testing in NKT is done very lightly, and it’s a key into the nervous systems response: either it activates or it doesn’t. You can’t fake it!

NKT can be used in a variety of ways. Some use NKT and manual therapy primarily, with a little corrective exercise to reinforce and re-educate. I personally like using the Functional Movement Systems (FMS) or Selective Functional Movement Assessment (SFMA) as a movement screen. The screening gives me an idea of where to target treatment as well as focus manual therapy and correctives. NKT becomes a bridge between the assessment and treatment. It is an assessment in that it helps identify the relationships and compensations in muscle balance (inhibition/facilitation) and has manual therapy built into part of the NKT reset. Subsequently, you can then retest the patient’s top tier SFMA after treatment and see what effect the intervention had.

Thanks, Kris, for sharing your insights to NKT! This is me, Anna-Lena, again. Hip pathology often leads to a number of complex muscle relationships, imbalances and compensation patterns. Labral tears cause the muscles around the hip to work a little harder. I believe NKT can fill an important function in muscle re-education after hip surgery – or other surgeries and pathologies too. I do think it is like finding a puzzle piece that’s been missing for many patients. There are other muscle activation techniques but NKT takes muscle testing and re-education it a bit further.

I explain a lot of the muscles and concepts (such as relational inhibition) mentioned by Kris in my book because I believe that understanding our anatomy and pathologies is essential to actively participate in the rehabilitation process. The more detailed feedback we can give our healthcare providers (doctors and physical therapists etc.), the more likely we are to have good outcomes – having a great PT is absolutely crucial!

As a patient of Kris, I’m impressed with NKT and the patterns of facilitation and inhibition that the testing has revealed me. Getting the treatment to stick is an equation of how much dysfunction there is, and, is of course individual. Imagine how long it’s taken you to acquire some of your muscle firing patterns. Undoing them can take time – or be quick.

The NKT testing has led me and my physical therapist to look in the direction of pelvic floor muscles. I think they are more often than not overlooked by doctors and PTs, and that might even be an understatement. How many hip patients’ PTs really dive that deep into muscle dysfunction? Stay tuned for more on pelvic floor in relation to hip musculature and core dysfunction!

6 comments:

  1. Interesting. Thank you for the post. Re-training the muscles to function in proper order definetely was an issue for me. My piriformis muscle likes to take over the work of the glutes and causes sciatic nerve pain. Even at 18 months post surgery, if I over due it, the piriformis muscle kicks in and causes pain. I really have to concentrate on using the right muscles in the right order to be pain free. This post confirmed what I already thought I knew. Thank you!

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  2. Wow! I never had hip issues until my children were born...then wham-o...lose of range of motion, clicking, pain, leg muscle weakness...MRI shows a little degeneration of the joint but no answers. I believe weak or damaged pelvic floor muscles are the culprit. Where do I go from here??? Anyone in Las Vegas that can do NKT testing?

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    1. Email me at theentrepreneurialpatient@gmail.com. I'll get you the names and everything I know about where to go for these issues in Las Vegas. Best regards, Anna-Lena

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  3. I recently came across your blog and have been reading along.I'm impressed. You're truly well informed and very intelligent. You wrote something that people could understand and made the subject intriguing for everyone. I'm saving this for future use.

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    1. Hi Charlie,
      Thanks for your kind words. Feel free to check out my book too on Amazon. That is where the biggest treasure of patient-friendly information is to be found.

      Best regards,
      Anna-Lena

      http://www.amazon.com/Entrepreneurial-Patient-Patients-Guide-Impingement/dp/0988637200/ref=sr_1_1?s=books&ie=UTF8&qid=1378256041&sr=1-1&keywords=hip+impingement

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