APIC-A2M™ is an exciting advancement in orthopedic science resulting from years of osteoarthritis research. The earlier indicators of joint destruction are discovered, the less invasive treatments can be. Early treatments can postpone the need for more aggressive and costly treatments like joint reconstruction or replacement. APIC-A2M™ utilizes a special molecule that is naturally found in your blood called, Alpha-2-Macroglobulin (A2M). Blood is drawn and through a patented process, A2M is isolated and concentrated before injecting into the injury site. The A2M molecule acts as a powerful protector against cartilage breakdown by capturing the destructive enzymes known to cause inflammation like a Venus flytrap. Once captured, the bound A2M and enzyme are eliminated through your body’s natural processes.
The discovery and advancement of Exosomes is changing regenerative medicine. Exosomes are tiny cell secretions full of proteins, growth factors and more that target injured cells in your body. Think of them as delivery trucks hauling restorative information to damaged cells who then absorb the components and begin a physical transformation.
CelaPure™ is a non-steroidal injection consisting of 100% pure Amniotic Fluid. This natural fluid is rich in growth factors, anti-inflammatory and has a fast treatment time. Amniotic Fluid injections encourage repair and rejuvenation of soft tissue, intra-articular, cartilage, menisci and join injuries. Although CelaPure™ Amniotic Fluid injections are obtained from an elective, full-term cesarean section delivery. All donors provide consent and are screened per Federal Food & Drug (FDA) and American Association of Tissue Banks (AATB) guidelines.
Also known as Platelet-Rich Fibrin Matrix (PRFM), is the next generation of Platelet-Rich Plasma (PRP) Therapy. It utilizes your own blood platelets to release growth factors and stimulate regeneration. Similar to PRP, LibertyMTX™ starts with a basic blood draw and uses a controlled separation process to remove almost all contaminants, leaving a pure platelet solution. PRFM takes this pure solution to the next level by forming a gel-like substance that protects and preserves platelets for injection. This surgery alternative has been shown to repair damaged cartilage, cells and tissue, potentially restoring pre-injury function.
Introducing Vail Integrative Medical Group's Monthly Wellness Membership program. Find time to take care of yourself once a month with our exclusive membership options that can include a combination of chiropractic, massage, and physical therapy sessions.
Our members enjoy lower membership rates, benefits for family members and increased savings on additional services. It is harder to get well than to be well. Be proactive, maintain optimal health, and invest in your health.
Monthly Membership Benefits
• Enjoy monthly sessions of chiropractic, physical therapy, and/or massage sessions depending on the program you choose.
• Share your membership services with family members.
• SAVE on additional services each month at a member-exclusive rate.
• Roll-over unused session(s) to the upcoming month.
ONE MONTHLY chiropractic session OR 60-minute massage
• Members get one chiropractic session OR one 60-minute massage per month.
• Enjoy unlimited additional chiropractic session(s) or 60-minute massage(s) at a discounted member rate of:
$75 for chiropractic
$75 for 60-minute massage
ONE MONTHLY chiropractic AND 30-minute massage session
• Members get one chiropractic session AND 30-minute massage session monthly.
• Enjoy unlimited additional chiropractic session(s) OR 30-minute massage session(s) at a discounted member rate of:
$65 for chiropractic
$45 for 30-minute massage
ONE MONTHLY chiropractic AND physical therapy session AND 30-minute massage session
• Members get one chiropractic session AND one physical therapy session AND one 30-minute massage session monthly.
• Enjoy unlimited additional chiropractic session(s) OR physical therapy session(s) OR 30-minute massage session(s) at a discounted member rate of:
$65 for chiropractic
$65 for physical therapy
$45 for 30-minute massage
Regenerative medicine seeks to heal and replace tissue that have been damaged by trauma, injury, or congenital issues, vs. the current clinical strategy that focuses primarily on treating the symptoms. One of the tools used to realize these outcomes is cellular therapies.
The medical providers at VIMG range from an interventional pain management physician and board certified physician in neurology, pain medicine and addiction medicine along with a registered nurse all working collaboratively for the greater good of the patient. Our medical services start conservative with empowering patients to take full charge of their health condition. This involves lifestyle and nutritional analysis along with in depth case histories and examinations to find out the root of a patient's pain, not just the symptoms. Our medical providers work collaboratively with our other providers in ensuring the highest continuity of care available anywhere.
Our physical therapy team is an integral part of Vail Integrative Medical Group. VIMG prides itself on providing not just fast and effective relief but also comprehensive rehabilitation services.
With extensive training and years of experience we provide our patients with the best one-on-one physical therapy care available. We offer pre and post-operative care as well as rehabilitative services that complement our other disciplines.
We are trusted health care professionals with extensive clinical experience who examine, diagnose, and then prevent or treat conditions that limit the body’s ability to move and function in daily life.
Physical therapy can help improve or restore the mobility you need to move forward with your life. If you are looking for a possible alternative to surgery and/or pain medication, consider the VIMG physical therapy department.
We commonly treat:
Back & Neck Pain
Sprains, strains, and fractures
And much more.
Blending science with inspiration, our team will teach you how to prevent or manage a health condition and help motivate you during your treatment so you can function optimally. We will work with you to help you understand your body so you will achieve long-term health benefits.
We have many, state of the art techniques that help you move, reduce pain, restore function, and prevent disability. We can also help you prevent loss of mobility and motion by developing a fitness- and wellness-oriented program tailored to your specific needs.
The VIMG physiacl therapy team is your partner throughout your journey to restoring and maintaining motion so that you can function at your personal best.
Our caring doctors of chiropractic are considered experts in their fields with multiple advanced degrees, specialties and certifications that complement their chiropractic training.
Drs. Dekanich, Pitcher and Azeltine are dedicated to delivering the highest quality chiropractic care to their patients and ensure the patient understands their problem and understand the approach to treatment.
Chiropractic addresses the structure and function of the body. Our doctors recognize the importance of manipulative therapy and specific adjustments in both the spine and extremities, but also believe that addressing the soft tissue is an important and often overlooked component to comprehensive care. In addition to manipulative techniques, our doctors often use techniques that include facilitated stretching, active myofascial release, kinesiotape as well as exercise based rehabilitation and therapies.
Our chiropractors are excellent diagnostic clinicians and pride themselves on being problem solvers, providing solution based care. They recognize when referrals are necessary and have an excellent rapport and communication with many of the best specialists in the Valley.
When choosing chiropractic care at Vail Integrative Medical Group you know you are in the best hands available in the profession.
All back pain has a cause. The comprehensive low back assessment is an in-depth 3-hour consultation and evaluation using the McGill Method to identify what causes your pain, so we can develop a plan to get you relief.
This specialized assessment is meant for more challenging low back pain cases. Typically, these patients will have already tried other approaches to get relief for their back pain without success.
Through this problem-solving process, you will learn what is the root cause of your pain, how to avoid it, desensitize it and begin to rebuild a more resilient back. You will receive a copy of the book “Back Mechanic The step by step method to fix back pain” as well as a detailed report with precise description of your pain triggers, methods to avoid them and a blueprint for developing good spinal hygiene and a rehabilitation program.
We will also be available for follow up and to answer questions you may have as you recover as well as be available for additional coaching to work through progressions or transition from rehabilitation to performance enhancement as needed,
If you think this approach may benefit you, send us a message directly, outlining your back pain trouble, and Dr. Pitcher will review your case and contact you personally to discuss your problem to see if you are a good candidate for this type of approach
Trigger point dry needling involves inserting an acupuncture needle into a tight or sore muscle. The needle then changes the muscle’s physiology so that the muscle is able to relax. It can be an effective method to address long standing muscle pain or joint problems related to chronic muscle tightness.
The benefits of dry needling can be
• Decreased muscle soreness
• Increased flexibility
• Muscle relaxation
• Decreased pain
If you decide that dry needling is something you would like to include in your treatment you should expect all or some of the following responses
• Muscle twitch when the needle is inserted.
• Referred pain and or a deep ache
• Muscle soreness that may persist for 12 to 24 hours.
• A general fatigue
Keep in mind that an acupuncture needles are used and generally are not painful when entering the skin
The number of treatments for dry needling is dependent on how long the problem has been present and will vary on tissue response. How many needles used every treatment is based on the number of muscle involved and how big of area those muscles cover.
HISTORY OF MANUAL THERAPY
There is a range of references to manipulation and manual medicine. The first references of manual medicine are ancient and have numerous origins.
Today, soft tissue mobilization is more science-based than ever before. Early theories of some of the pioneers in these fields such as Cyriax, Nimmo, Rolf and others are becoming more scientific than just "feel good massage.". Many chiropractic and medical physicians, physical therapists, and athletic trainers are not aware of some of these pioneers and just how far back their theories date. Current knowledge supercedes some of the data, but some of their concepts may still have a degree of validity, and certainly contain historical value.
HISTORY OF MANUAL THERAPY
There are many ancient references to manipulation and manual medicine. Even the word massage has numerous origins:
the Arabic verb mass = to touch;
the Greek word massein = to knead;
the East Indian word macer or masser = having oneself massaged
the Sanskrit word makch = to strike or press
the Latin word manus = hand (as in handling or management)
There are Babylonian-Assyrian records of massage being used for cramps.
Hippocrates, Greece (460 BCE) – used to treat kyphosis by having the patient use steam heat, followed by traction from the head and foot while the patient was in a prone position. Several methods of pressure application were utilized including a padded board with a long lever to the kyphosis. (Harris)
Galen, Greece (131-202 CE) – described manual medicine in extremities and cervical spine. (Harris)
Abu’Ali ibn Sina, Saudi Arabia (980-1037 CE) – wrote a textbook on medicine, including manual medicine, and this was utilized until the 17th century. (Harris)
Ambroise Pare, (1510-1590) – described medieval Turkish manipulation during traction. (Harris). He applied massage to surgical patients. (Kamenetz)
There are several mentions of some type of clinical soft tissue mobilization that date back 150-200 years. These references and quotes are included to illustrate that many subjects of debate and of academic questions in the area of manual medicine have been proposed previously. A few of the pioneers include:
P. G. Hensler, MD, Kiel, Germany (died in 1805) believed that massage to the dermatome could affect organs correlating to that area. (Cyriax)
E.D.A. Bartels, MD, Berlin, Germany (1835) continued Henlser’s work. The work was called “bindegewebsmassage” = connective tissue massage. (Cyriax)
Per Henrik Ling, Sweden (1776-1839) – Swedish physical education teacher who brought a system to therapeutic exercises and massage. One of his students (Augustus Georgii) coined the term “kinesitherapy”. Ling’s method of massage received international acclaim and became known as “Swedish massage”. (Kamenetz)
Hooker, MD, 1849 – wrote, “tendons are benefited by a persevering course of friction”. (Cyriax)
Andrew Taylor Still, DO, USA (1828-1917) – founder of osteopathy. Manual medicine had declined during the 17th and 18th centuries.
Johan Georg Mezger, MD, Netherlands (born 1838) – presented his doctoral dissertation on “The treatment of the foot sprain by friction” in 1868. Mezger cited two others: Girard from a paper at the Academy of Medicine in Paris in 1858 entitled “Frictions and massage alone in the treatment of sprains.” He also cited Millet of Tours, France who published his own method in 1864. (Kamenetz)
A collection of physicians described early mobilization for fractures: Norstrom (1884), Just Lucas-Championniere (1843-1913) and was supported by Berne, Leonardon-Lapervenche, Keith. “In 1881 Lucas-Championneiere began to introduce another innovation in the treatment of fractures – the application of massage, not only to the parts in the neighbourhood of a fracture, but actually at the site of the fracture….He claimed that massage allayed almost instantly the pain at the site of the fracture; it accelerated the process of repair; it dissipated inflammatory exudates, reducing swelling and tension in the damaged parts; it maintained muscles, nerves, tendons, ligaments and joints in a state of health. The application of massage to the immediate treatment of fractures and dislocations he counted amongst his chief services to surgery.” (Kamenetz)
James Cyriax, MD, is a British physiatrist who is a pioneer in manual treatment. He certainly deserves significant mention and reference. Cyriax’s text, Deep Massage and Manipulation, was first published in 1944. Later editions were published as Textbook of Orthopaedic Medicine, Volume Two, Treatment by Manipulation, Massage and Injection (11th edition published in 1984 and reprinted in 1990). Cyriax always questioned the underutilization of manipulation. He carefully noted that the usual response to the success of manipulation, particularly after the conventional medical model failed, is to attack the manipulator as opposed to attacking the conventional model for failing. Cyriax was very concerned with specificity of treatment to the lesion. He questioned the manipulation of an asymptomatic area.
Raymond L. Nimmo, DC (1904-1986) was a chiropractic who also was a pioneer in soft tissue therapy. Nimmo was a 1926 graduate of Palmer College of Chiropractic.
Nimmo made the leap of faith that treating the muscles with manual therapy could also improve joint mobility. Nimmo developed neurophysiological theories (receptor-tonus technique) to explain the trigger point phenomenon. He also developed tools for the “Nimmo technique” to reduce the mechanical stress on the provider’s hands, fingers and thumb.
Ida Rolf was a biochemist who developed an aggressive massage technique that became known as “Rolfing”. Rolf addressed fibrosis in myofascial tissues and planes. Rolf developed the theory of “emotional release” through Rolfing. Rolf felt that emotional stress is “remembered or stored” in the muscles. This stress can be released through the Rolfing treatment. The system evolved into a 10-treatment protocol to treat the entire body. John T. Cottingham in Champaign, IL does carry on research based on Rolf’s work. The Rolf Institute is located in Boulder, CO. Brief changes in parasympathetic tone in young adults have been reported with a combination of pelvic lift (Rolf soft tissue manipulation) and moderate pressure over the epigastrium.
Janet Travell, MD – instrumental in promoting and developing the trigger point theories in America. Travell authored texts on trigger point treatment. Travell gained notoriety as the personal physician to John F. Kennedy. Travell expressed her admiration for Nimmo’s work. Personal communication from Travell was most interesting: “I realize what every patient can understand, but many chiropractors seeming cannot, that no bone can move unless a muscle moves it, and no muscle moves a bone unless a nerve impulse reaches it. I decided the lumbar lordosis was due to tight sacrospinalis muscles. I would release them, but the patient would go back into the same position, with return of pain. I looked for muscles that pulled the front of the pelvis, which were of course, the quadriceps” (Cohen, Gibbons 1998).
J Maitland, PT – incorporates Rolf-based soft tissue mobilization to improve posture, Alexander-based guided movement mobilization to improve posture, and pain
modulation procedures consisting of relaxation techniques.
GD Maitland -- not to be confused with J Maitland who has had a major influence in manipulation and mobilization with various techniques that are used today.
Paul Williams – best known for the Williams flexion exercises: pelvic tilt, bridging, and knee to chest. Most common for of basic low back exercises until McKenzie extension exercises became popular.
Robert Salter, MD – performed research, which revealed that continuous passive motion (CPM) promoted healing of articular cartilage vs. immobilized subjects (1980). This is commonly used today in post-op management. This is a landmark study that produced trickle down effects in post-op care as well as rehabilitation. Takai et. al. reported that more cycles of movement per unit of time in CPM resulted in greater tensile properties than in lower cycles. Ahl et. al. found that malleolar fractures that had weight bearing exercise vs. nonweight bearing exercise had better outcomes.
Salter’s research also altered the perception of immobilization vs. early mobilization rehabilitation after injury. Mealy et.al. reported a decrease in pain and increase in range of motion in cervical whiplash patients when they received Maitland-based early mobilization versus traditional immobilization by cervical collar and rest. Maitland techniques included repetitive passive range of motion, low amplitude, and high amplitude motions. Brodin also reports similar findings to Mealy et. al. in cervical cases. Brodin’s study employed Stoddard-osteopathic mobilization techniques – no large amplitude thrusts were used. The general trend appears to be one of increased mobilization and earlier intervention to derive better outcomes.
Respected doctors of chiropractic who have taken a more recent interest in soft tissue mobilization include Griner, Ferrell, Leahy, Hammer, Hannon, Scaringe and Horrigan.
Vladimir Janda, MD – Czech Republic physiatrist who works in the area of muscle recruitment patterns in area such as low back pain. Janda successfully documented tight lumbar paraspinal muscle activity during spine flexion. Janda stretched the tight lumbar paraspinals and repeated the active spinal flexion and found decreased paraspinal activity coupled with increased abdominal muscle activity.
“Bone setting” has been described in numerous cultures. Gypsies of central Europe were known for bone setting. Indians of Mexico had manipulation techniques. The Hawaiian massage of “Lomi-Lomi” is 800 years old. East Africans, Norwegians, Swedes, and Finns have similar descriptions. Whorton Hood gave bone setting its first formal description in the 19th century. Richard Hutton had taught Hood. Sir Herbert Barker was taught bone setting by a relative of Richard Hutton. He was granted Knighthood, but denied an honorary medical degree. The Lancet in 1925 had this to report: “The medical history of the future will have to record that our profession has greatly neglected this important subject…The fact that must be faced, that the bone setters had been curing multitudes of cases by movement…and that by our faulty methods we are largely responsible for their very existence”. (Harris)
Daniel David Palmer, DC (1845-1913) – founder of chiropractic. DD advocated the manipulation of the spine and extremities – origin of “mixers”. This history is well known to those enrolled in this course.
B.J. Palmer, DC – son of DD, advocated manipulation of the spine only – origin of “straights”. This history is also well known to those enrolled in this course.
There were a number of chiropractic treatment methods for soft tissue that have been forgotten, lost or filed in the archives. Some of these methods included “Bio-Engineering”, MacIntosh system of Fascia Release, Chromaffin Synapse Theory which believed treated the sacral ganglia but Nimmo’s opinion was it released muscles (Cohen, Gibbons 1998).
HISTORY OF MANUAL THERAPY
1991 found 73% of the chiropractic profession utilized massage and soft tissue techniques, but by 1998 the percentage increased to 83% (Rupert et. al. 2002). It is not clear if these figures indicate soft tissue mobilization performed by the doctor or is it performed by a massage technician in the office.
Soft tissue adhesions, tendonitis, tendinosus, fascial restrictions and chronic inflammation and dysfunction often respond poorly to conventional treatment (Melham et. al. 1998).
As previously noted, James Cyriax, MD was a pioneer in manual treatment. Cyriax’s manual methods included soft tissue mobilization and joint manipulation (Hutson 1989) (Wright 1988). When we read about the theories Cyriax developed, he could participate in any current academic or scientific discussion regarding soft tissue mobilization today. Cyriax created an extensive clinical model and methodology for treatment of musculoskeletal injuries. His work was based on three principles:
1. 1. All pain arises from a lesion.
2. 2. All treatment must reach the lesion.
3. 3. All treatment must exert a beneficial effect on the lesion.
The efficacy of Cyriax’s work depended upon the performance of a thorough evaluation (Chamberlin 1982). This cannot be emphasized enough. Hammer noted the utilization of post treatment functional testing as a measure of efficacy when using Integrative Fascial Release (Hammer 2000).
Cyriax noted “We attempted direct action on the lesion, ignoring the unaffected muscles. Similarly, we no longer waste time giving quadriceps exercises to a recently sprained ligament at the knee; we treat the ligament itself, thus enabling the patient to use his knee so well that no wasting has time to come about. When contraction of a muscle pulls on a painful scar within itself or in a tendon, we try to rid the inflammation in the scar, or even the excess scar tissue itself” (Cyriax). This is a significant position today, much less in the 1940’s and 1950’s. This train of thought went against the common way of thinking. This is part of what made Cyriax a pioneer, along with Nimmo and Travell, in the field of soft tissue treatment. The terms “transverse friction massage”, “cross-friction massage” and “deep friction massage” were derived from Cyriax’s work.
Cyriax always emphasized the detail of the treatment and the accuracy of the diagnosis. “Throughout, the choice of treatment depends on the diagnosis. Accurate treatment follows as a logical result and requires a high degree of knowledge and skill.” (Cyriax)
There is a definite learning curve and the more cases the provider has seen and treated with a given diagnosis, then usually the better is his/her skill.
“Adequate manipulation demands knowledge of the range of movement at a joint and of the sensations imparted to the hand as each extreme is approached and the ability to estimate that tissue resistance has mounted to the point when the thrust should be applied. The different effects of different techniques must be appreciated, together with the capacity to choose the correct measure different types of lesion. During treatment by deep friction great precision in treating of the patient and of the physiotherapists hand is essential: throughout the session she keeps her mind on her finger-tip. This type of work involves her in much more concentration and care than most of her other work. There is nothing routine about it; each patient and each lesion must be assessed and given expert and individual attention”. (Cyriax)
“When mobility is to be maintained at, or restored to, those moving parts which form their nature or position are apt to develop adhesions or scarring, deep friction is often the method of choice, either alone (as in the case of tendons) or in association with passive movements (for some ligamentous lesions) or with active movements without tension on the healing breach (for minor muscular ruptures)”. (Cyriax)
Cyriax’s theories to support deep friction massage included: “A penetrating technique is required in the treatment by massage of deep-seated lesions. Given properly, deep friction has a four-fold effect. It induces:
(1) traumatic hyperemia,
(3) increased tissue perfusion,
(4) mechanoreceptor stimulation”.
Traumatic hyperemia – “ …enhancement of blood supply diminishes pain”. Cyriax felt that this increased the destruction of p-substances and this would produce temporary analgesia (although he felt this analgesia was longer than from counter-irritants).
Movement – “By moving the painful structure to and fro, it is freed from adhesions both actually present and in the process of formation”.
Cyriax developed a theory for his method of treatment. Some still follow his idea completely. Others simply view it as the best theory he could develop with the knowledge of his time. There are different points of view today. Cyriax noted the following: “The main function of muscle is to contract. As it does so it broadens. Hence full mobility in broadening muscles that have been the seat of inflammation, whether caused by one or repeated strains. Resolution by fibrosis is occurring or has already occurred. The effect of deep transverse friction clearly consists in mobilizing the muscle, i.e. separating the adhesions between individual muscle fibers that are restricting movement. If passive restoration of full mobility of a muscle is followed by adequate active use, these adhesions do not reform: cure results”.
Cyriax continued “The principle governing the treatment of muscles during the acute or chronic stage is the same. The endeavor must be to prevent the continued adherence of unwanted young fibrous tissue in recent cases, or to rupture adherent scar tissue in long standing cases. To stretch out a muscle does not widen the distance between its fibres; on the contrary, during stretching they lie more closely. Whereas, then, for the rupture of adherent scars about a joint forced movement is required, interfibrillary adhesions in muscle can be broken, not by stretching, but by forcibly broadening the muscle out…Thus, deep transverse frictions restore mobility to muscle in the same way as manipulation frees a joint. Indeed, the action of deep transverse friction may be summed up as affording a mobilization that passive stretching or active exercises cannot achieve”.
Cyriax addressed the acute phase: “In recent cases, after any oedema that may be present has been removed by effleurage, the site of the minor tear in the ligament should receive some minutes’ friction. The purpose is to disperse blood clot or effusion here, to move the ligament to and fro over the subjacent bone in imitation of its normal behaviour (thus maintaining its mobility) and to numb it enough to facilitate movement afterwards. The least strength of friction which achieves these results is called for. Hence, when friction is started during the first day or two after a sprain, the ligament need be moved only a few times. One minute’s treatment thus suffices, since as yet there are no unwanted adhesions to break down. But it may well take ten to twenty minute’s effleurage and gentle friction to enable the patient to accept the one minute’s valid treatment – actually moving the damaged tissue. When the lesion becomes less severe and tenderness is abating, friction maintained with increasing strength for five, ten, then fifteen minutes is called for”. “No scar tissue has yet formed unwanted adherences; hence it is a question of maintaining the capacity of the muscle to broaden fully and to render such active contractions painless. If immediate local anaesthesia is carried out, the massage starts the next day; if not, as soon as the patient is seen. The intention is to prevent scar tissue from matting the muscle fibres together, without interfering with the fibres consolidating themselves in the healing breach. Broadening out in the absence of tension is secured by transverse friction; the massage must reach the right spot but at first need not last long or be really vigorous. It should be followed by active movement of the damaged muscle; this maintains the added excursion towards broadening resulting from the massage”.
Hannon and Scaringe emphasized a few key points about Cyriax’s work:
1. The right spot must be found [Cyriax was noted for a comment that if you are off by
one-quarter of an inch, you may as well be off a mile - Horrigan].
2. The therapist’s fingers and the patient’s skin must move as one.
3. Friction must be given across the fibers composing the
a. affected structures
b. the friction must be given with sufficient sweep
c. the friction must reach deeply enough
d. the patient must be in a suitable position
e. muscles must be kept relaxed during treatment
f. tendons with a sheath must be kept taut.
Hannon and Scaringe also emphasized the hand positions:
1. index finger crossed over the middle finger
2. middle finger crossed over the index finger
3. two finger-tips
4. opposed fingers and thumb
The indications for Cyriax’s transverse friction massage:
1. Muscular lesions
a. recent trauma
b. long standing scars
c. lesions at the musculotendinous junction
2. Tendinous lesions
a. tendons with a sheath
b. tendons without a sheath
3. Ligamentous lesions
a. recent sprain
b. chronic sprain
Contraindications for transverse friction massage:
1. 1. inflammation due to bacterial infection
2. 2. traumatic arthritis of the elbow joiont
3. 3. ossification or calcification of soft tissues
4. 4. bursitis
5. 5. rheumatoid types of arthritis
6. 6. pressure on nerves
Cyriax identified a number of disorders that he thought were curable by transverse friction massage only:
Supraspinatus—musculotendinous junction, biceps tendon—long head, biceps—
distal musculotendinous junction, brachialis belly, supinator belly, ligaments
around the lunate, thenar adductors, interossei belly, interossei tendons,
intercostals muscle belly, oblique muscles of abdomen, psoas major—distal
musculotendinous junction, quadriceps expansion at patella, coronary ligament
of the knee, biceps femoris—distal musculotendinous junction, posterior tibial
musculotendinous junction, anterior musculotendinous junction, peroneal
musculotendinous junction, posterior tibiotalar ligament, anterior fascia of ankle,
and interossei bellies of foot (Hannon, Scaringe, 1992).
Regretfully, as insightful as Cyriax was with regard to the significance of soft tissue injuries, he was certainly no friend to the chiropractic profession. Cyriax spoke out against chiropractic.
Raymond L. Nimmo, DC (1904-1986) was a chiropractic who also was a pioneer in soft tissue therapy. Nimmo made the leap of faith that treating the muscles with manual therapy could also improve joint mobility. Nimmo developed neurophysiological theories known as “receptor-tonus technique (RT) to explain the trigger point phenomenon. He also developed tools for the “Nimmo technique” to reduce the mechanical stress on the provider’s hands, fingers and thumb.
Nimmo coined the phrase “noxious generative points” referring to “spots on the shoulders which when pressed on referred pain to various areas, and these results were spectacular in case after case” (Cohen, Gibbons 1998). Nimmo stated in 1986 “Although it is called the Nimmo Technique, the correct designation is Receptor-Tonus Technique for the reason it deals exclusively with muscle tonus and nerve receptors which initiate pain. The early development of the method was necessarily somewhat experimental and empirical. It was different from anything I had ever been taught but it was the most efficient method and permanent release from pain I had ever used or observed” (Cohen, Gibbons 1998) (Schneider 1994).
Furthermore, Gatterman and Lee noted that “Nimmo found noxious generative points in muscles that referred pain in characteristic patterns. Viewing these hypersensitive areas, the trigger points of Travell, as abnormal reflex arcs he developed a manual technique designed to reduce the irritable loci. He referred to the inter-relationship of muscle tonus and the central nervous system as “reverberating circuits,” whereby the stimulus was self perpetuating until the cycle was broken…This procedure referred to by Travell as ischemic compression offers a noninvasive chiropractic technique instead of common medical practice of injection of the painful trigger points” (Cohen, Gibbons 1998).
Nimmo felt the malfunction of a normal tonus process could be caused by a variety of sources including trauma and the now referred to term of repetitive stress injury. Nimmo relied on the idea that afferent stimulus to the cord produced a ten-fold efferent discharge, a term that Guyton later called “after discharge”. Insults such as trauma and repetitive stress injury result in an increased stream of efferent impulses to the muscles causing a state of abnormal contraction. This then would send additional afferent impulses which produce even more efferent impulses back to the muscle resulting in a viscous, self-perpetuating cycle. There is a reflex spillover to the sympathetic nerves which causes local vasoconstriction trapping metabolites of muscle action. (Cohen, Gibbons 1998).
This latter description matches the current myospasm theory. The focus of the irritability within this abnormal muscle contraction and vasoconstriction becomes the trigger point (Cohen, Gibbons 1998). As the process continues, it spreads to other levels of the cord causing secondary trigger points and also the well known phenomenon known as referred pain (Cohen, Gibbons 1998). It is suggested that Nimmo and Travell developed these concepts concurrently and independently.
Travell was best known for the trigger point injections and spray and stretch to treat the concept of ischemic compression to relax the muscle. Nimmo stated” I have found that a proper degree of pressure, sequentially applied, causes the nervous system to release a hypertonic muscle” (Cohen, Gibbons 1998). Nimmo’s work has been generically referred to as “ischemic compression” and has been used by many fields (Schneider 1994).
Janet Travell, MD – the late Dr. Travell performed a significant amount of work with trigger points, referred pain, myofascial pain, spray and stretch, and trigger point injections. She collaborated with Simons in her textbooks. The work of Dr. Travell is voluminous and I recommend the doctors in this course purchase her text and have it in your reference library.
A variety of equipment have been developed to determine the presence of trigger points. The equipment includes the pressure threshold meter, pressure tolerance meter, and tissue compliance meter. Studies have demonstrated improved pain tolerance in trigger point areas after coolant spray and stretch or trigger point injection (Hou et. al. 2002).
Ida Rolf was a biochemist who developed an aggressive massage technique that became known as “Rolfing”. Rolf addressed fibrosis in myofascial tissues and planes. Rolf developed the theory of “emotional release” through Rolfing. Rolf felt that emotional stress is “remembered or stored” in the muscles. Rolf utilized motion with the soft tissue mobilization. It is not clear if Rolf was the first in recent medical history to incorporate motion with the soft tissue mobilization. This stress can be released through the Rolfing treatment. The system evolved into a 10-treatment protocol to treat the entire body. John T. Cottingham in Champaign, IL does carry on research based on Rolf’s work. The Rolf Institute is located in Boulder, CO. A soft tissue mobilization technique in Rolfing in which moderate pressure is placed over the epigastrum while concurrently receiving posterior tilting and pelvic traction. Cottingham et. al. noted previous osteopathic studies in which lumbosacral decompression and pelvic lift maneuvers have been associated with increased parasympathetic activity and decreased sympathetic activity (Cottingham et. al. 1988).
SOFT TISSUE MOBILIZATION
The definition of manipulation implies that there is a high velocity and high amplitude of the movement//thrust to the joint. Mobilization is defined to have a lower velocity and lower amplitude to the joint movement. A traditional diversified chiropractic adjustment falls into the category of manipulation. The soft tissue manual procedures fall into the category of mobilization.
EXAMPLES OF VARIOUS SOFT TISSUE MOBILIZATION TECHNIQUES IN THE PUBLISHED LITERATURE
A method of soft tissue mobilization using a sold instrument was reported to have key physiologic components (Davidson et. al. 1997). This method was named augmented soft tissue mobilization (ASTM). This method was initially introduced to address the fibrosis of tendon healing. The creators theorize this tool allows the therapist to introduce a more effectively controlled amount of microtrauma to an area of excessive scar or soft tissue fibrosis (Davidson et. al. 1997). A study was performed in which there were four groups: control; tendonitis; tendonitis and ASTM; ASTM without tendininitis. This was performed on rats. The tissue samples were examined by light microscopy, electron microscopy and immunoelectron microscopy and by gait analysis. The ASTM was performed on days 21, 25, 29, and 33 after injection with collagenase into the Achilles tendon unilaterally. The tendonitis group treated by ASTM revealed statistically difference with fibroblast count (Davidson et. al. 1997). The rough endoplasmic reticulum was also highly developed in the ASTM groups. Only the group with tendonitis and ASTM had significantly improved gait on day 21 and the final observation. The ASTM improved gait function and facilitates tendon healing by recruitment and activation of fibroblasts.
Similar results were reported by Gehlsen et. al. (1999). These authors found that augmented soft tissue mobilization did stimulate fibroblast proliferation in an Achilles tendon (rat) and the proliferation was dependent on the amount of pressure utilized (Gehlsen et. al. 1999). Other research has suggested that mechanical stimuli can alter many cellular functions including: ion transport, release of second messengers, protein synthesis, and gene expression (Gehlsen et. al. 1999).
Another study was published using ASTM (Melham et. al. 1998). A case a a 20-year-old junior offensive guard was utilized who had chronic right ankle pain and loss of range of motion. There was a history of five ankle sprains and two arthroscopic procedures to remove bone fragments. The patient received two treatments of ASTM per week for seven consecutive weeks. The results were the subject did not have pain with activity, ROM increased, surgical scar matured and the excessive fibrotic connective tissue around the ankle softened and diminished. The patient was also able to cease taking NSAID’s. Pre and post treatment MRI did not reveal any change (Melham et. al. 1998).
Hou et. al. investigated myofascial release, interferential stimulation, TENS, spray and stretch, hot packs for the treatment of trigger points in cervical myofascial pain. Patients with cervical myofascial pain syndrome have a very high recurrence rate (Hou et. al. 2002). The hypothesis by Simons and Travell for the pathophysiology of myofascial pain is injured or overstressed muscles leads to involuntary shortening and loss of oxygen and nutrient supply with an increased metabolic demand on local tissues. The trigger point is a painful or sensitive spot in a palpable, taut band of skeletal muscle. An active trigger point is one with spontaneous pain or pain in response to movement. A latent trigger point is a sensitive spot that causes pain or discomfort only in response to compression (Hou et. al. 2002). Hou et. al. feel that ischemic compression is a viable treatment method for muscles that are not suitable for spray and stretch and overly bone. Spray and stretch and myofascial release are popular forms of treatment today.
Instruments to measure soft tissue pressure include the pressure threshold meter, the pressure tolerance meter, and the tissue compliance meter. Researchers have found these instruments useful in measuring an increased pain threshold of trigger points after coolant spray, passive stretch or trigger point injection (Hou et. al. 2002). Significant results were found from ischemic compression, spray and stretch, interferential current and myofascial release therapies (Hou et. al. 2002).
The manual methods of Mills, Cyriax, Kaltenborn, Mennell and Stoddard were compared for efficacy in the treatment of tennis elbow (Kushner, Reid 1986). The varus thrust manipulation acts primarily on the capsular structures causing gapping and restoring joint play. Manipulations with the elbow in extension and pronation have the greatest chance of effecting the contractile elements (Kushner, Reid 1986). It was also understood that the success of treatment of tennis elbow includes not only manual procedures, but also exercise, modalities and modification of the activities involved in the etiology (Kushner, Reid 1986).
The Graston technique is gaining popularity in the short time it has been publicized (Wilczewski 2002). The method entails the use of an instrument to cover a large area of skeletal muscle (e.g. hamstring group, upper trapezius, quadriceps) and reduces the strain on the hands of the health care provider.
The description of myofascial release has been used by many practitioners in the field (chiropractic, osteopathic, physical therapy) and the name is currently protected by a physical therapy group. However, it’s loosely used name has been applied by many. Shea and Keyworth noted that myofascial release had been used for many decades but little has been done to document its results. The work and development of myofascial release by osteopathic physicians
This author addressed a case of stride length deficiency in a world class sprinter. The data was tracked by The Athletic Congress (T.A.C. now known as USA Track and Field) during a research project known as The Elite Athlete Project: The Sprints. The subject won the 1986 national championships in the 200m sprint (written permission obtained from patient to discuss findings). The patient had a left hamstring injury earlier in 1986 and this resolved. The left stride length was found to be 4.4 inches shorter than the right stride length at the national championships. The biomechanist performing this project (Ralph Mann, PhD) indicated this discrepancy equated to 0.2 seconds over 200m. An 11cm region of fibrous tissue was palpated in the long head of the biceps femoris. The patient received soft tissue mobilization to the hamstring group, rectus femoris, gluteal group, psoas major, adductor group, and piriformis. The patient entered the 1987 national championships and won again. The Elite Athlete Project was analyzing the top three finishers in each event in 1986 and 1987. The analysis by Mann revealed the patient had not only regained the 4.4 inch deficit, but increased an additional 6 inches for a total left stride length change of 10.4 inches. The right stride length decreased by 1.1 inches. The patient had a personal record in the 200m sprint. The biomechanist and provider were blind to each other. This is unpublished data but has been submitted to a journal and is currently under editorial review (Horrigan, unpublished data).
An investigation was performed with regard to the exposure of physical therapy faculty and program directors (Ehrett 1988). 1% had a single unit of craniosacral therapy. 15% had a unit of myofascial release. 15% had units of both craniosacral and myofascial release. 69% included neither (Ehrett 1988). The lack of exposure in physical therapy, or any other field, may account for the low rate of inclusion in these forms of therapy in practices.
A case presentation indicated myofascial release had a favorable result with failed surgical decompression of the carpal tunnel (Browne et. al. 1999) (Miller 1997). Other authors presented the efficacy of myofascial release with cases of pronator syndrome misdiagnosed as carpal tunnel syndrome (Leahy, Mock 1992).
Shea and Keyworth noted that myofascial release is a complex form of soft tissue work that is highly effective for reducing pain and restoring motion and optimal function on a permanent basis (Shea, Keyworth 1997) (Barnes 1997). These authors noted this method was developed by American osteopathic practitioners and was presented almost exclusively in the osteopathic literature, but only after 1950 (Shea, Keyworth 1997).
An investigation into the efficacy of treatment for various forms of headaches revealed two interesting statistics: 1) multiple forms of modalities produce better outcomes than a single modality; 2) regardless of headache type, myofascial release had the most effective relief of symptoms (Ranieri et. al. 1998).
A case was presented of a trigger point in a well-healed surgical scar that referred pain. The trigger point was treated with transverse friction massage and therapeutic stretching (Updyke 2000).
Hunter described a procedure known as specific soft tissue mobilization (SSTM) which uses specific, graded and progressive application of force to promote collagen synthesis, orientation, and bonding in the early stages of the healing process or to promote viscoelastic response of the tissue in the later stages of healing (Hunter 1998).
---Author Joe Horrigan, DC
Active Release Techniques®
ART ® is a soft tissue management system that effectively treats soft tissue problems, which frequently do not respond to other traditional treatments.
The goal of ART® is to restore optimal texture, motion, and function of the soft tissue and release entrapped nerves. This is accomplished through the removal of adhesions or fibrosis in the soft tissues via the application of specific protocols. Adhesions can occur as a result of acute injury, repetitive motion, and constant pressure or tension. ART® eliminates the pain and dysfunction associated with these adhesions.
Some of the more common conditions are:
Carpal tunnel and other peripheral nerve entrapments Spinal pain and dysfunction Tendonitis and other soft tissue inflammatory disorders of the hand, wrist, elbow, shoulder, hip, knee, ankle, and foot. Sciatica, TMJ, recurrent sprains and strains
Only a credentialed ART® provider can ascertain whether ART® might prove beneficial for your condition. Providers must extensive training and pass a rigorous examination rule to become credentialed They must also attend annual update seminars to maintain their credentialed status and keep current of any new protocols and research.
ART® is sought after by nearly every professional sports team, Olympic athletes, movie stars and insurance carriers. This technique has filled a void in the management of soft tissue conditions.
Learn more at www.activerelease.com
Graston Technique® is an innovative, patented form of instrument-assisted soft tissue mobilization that enables clinicians to effectively break down scar tissue and fascial restrictions. The Technique utilizes specially designed stainless steel instruments to specifically detect and effectively treat areas exhibiting soft tissue fibrosis or chronic inflammation.
How can something so gentle be so effective to reduce pain?
KTM allows for full range of motion. It does not negatively affect circulation, since there is no wrapping, and therefore no impediment of blood flow. KTM is a “light” modality. In rehabilitative applications it works continuously, so each treatment can continue for 2 to 3 days. KTM is like having healing hands to put on the area 24 - 7.
To illustrate: When you bump your knee, your elbow, your head, (any part of your body) what is your first, unthinking response? You rub on it. That works; it feels better. Why?
What is in effect here is something called Gate Control Theory: The rubbing provides a distraction, impeding the brain’s message of pain, closing the “gate” on pain receptors, at least temporarily. But this sensation effect is only the beginning.
Dr. Kase bases his techniques on three important concepts. They are Space, Movement and Cooling. Muscles that are painful and/or inflamed lack space. When the KTM technique is applied to create space, it is helpful in and of itself, but also leads to the opportunity for improved movement and circulation. This space and movement then allows for cooling of the affected muscles, often combined with cryotherapy.
By targeting different receptors within the somatosensory system, the KTM alleviates pain and facilitates lymphatic drainage by microscopically lifting the skin. This lifting affect forms convolutions in the skin thus increasing interstitial space and allowing for a decrease in inflammation of the affected areas.
The KTM starts with two basic muscle taping techniques. These are used to balance muscles and bring them up to functional level. The first is applied for overuse and acute injuries and for rehabilitation. In such cases the tape is applied insertion to origin. The second is applied for increased muscle function and to address chronic conditions. Origin to insertion taping is used here.
In addition to these basic techniques, there are many correctional procedures that deal with positioning as well as other specific purposes such as pain relief. All the correctional procedures are specific, including treatments for cerebral palsy, pediatric needs, lymphoedema and a host of other specific conditions.
The following areas are addressed by correctional procedures:
•Fascia (Fascial) Correction
A key focus of KTM training and practice is the process of assessment. Assessing the patient’s condition, looking at both the symptoms and the likely cause of each individual patient’s condition, is the only way to successful treatment.
Evaluation and assessment dictate the treatment of any clinical condition. In order to get the desired results from a Kinesio Taping® Method application or any other treatment, a full assessment of the patient is necessary. In some cases, the treatment of a condition may also require that other underlying conditions be addressed. Assessment should include the Kinesio screening test: manual muscle testing, range of motion testing, gait assessment, and any other orthopedic special tests that the practitioner may deem necessary.
The findings of the clinical evaluation or assessment dictate the specifics of the KTM application and other possible treatments or modalities. Delicate adaptations are necessary, whether utilizing of single “I” strips or modifications in the shape of an “X”, “Y” or other specialized shapes, or calibrating the direction and amount of stretch placed on the tape at time of application. The KTM is applied in hundreds of ways and has the ability to re-educate the neuromuscular system, reduce pain and inflammation, provide support, prevent injury and promote good circulation and healing. All these work toward the goal of balance, of returning the body to homeostasis.
The information gained from proper assessments will allow for the most effective treatment protocol to be laid out. The Kinesio Taping® Method has been shown to have positive physiological effects on the skin, lymphatic and circulatory system, fascia, muscles, ligaments, tendons, and joints. It can be used in conjunction with a multitude of other treatments and modalities, and is effective during the acute, chronic and rehabilitative phases of injury as well as for preventative measures.
Vertebral Axial Decompression, or VAX-D for short, offers a first choice non-invasive therapy for patients with disabling low back pain. Advances in medical technology have led to the development of the VAX-D Therapeutic Table.
VAX-D Therapy applies clinically proven principles to relieve pressure on vital structures of the lumbar spine that may be causing low back pain and peripheral pain associated with herniated lumbar discs, degenerative disc disease, sciatica, nerve compression and posterior facet syndrome. VAX-D Therapy is non-surgical and is an inherently safe procedure that is not just aimed at treating symptoms but is designed to alleviate the underlying problems that cause low back pain.
VIMG is happy to announce an exciting new service for our patients and guests, hyperbaric oxygen therapy.
What is Hyperbaric Oxygen Therapy (HBOT)?
Simply put, HBOT is a non-invasive therapeutic treatment that delivers oxygen to cells in the body. All living creatures require air, water and food and nothing is more vital than oxygen. It is possible to last weeks without food, a few days without water but only mere minutes without oxygen. HBOT involves breathing oxygen in a pressurized chamber in which the atmospheric pressure is raised up to three times higher than normal. Under these conditions, your lungs can gather up to three times more oxygen than would be possible breathing oxygen at normal air pressure. The body's tissues need an adequate supply of oxygen to function and when tissue is injured, it may require more oxygen to heal. "Hyperbaric oxygen therapy increases the amount of oxygen dissolved in your blood," says Nayan Patel a biomedical engineer in FDA's Anesthesiology Devices Branch. An increase in blood oxygen may improve oxygen delivery for vital tissue function to help fight infection or minimize injury.
Hyperbaric chambers, used in HBOT are any number of enclosures, which can be pressurized to allow a person inside to experience higher atmospheric pressures than the normal environmental pressures. For example, a treatment at an elevation of 12,000 feet above sea level using a 4 psi (1.27 ATA) can simulate a decent of ~5,843 feet to 6,157 feet above sea level. At higher elevations, the barometric pressure is lower. This decrease of pressure also decreases the oxygenation of blood, and is known as anoxia—where molecules of oxygen exert less pressure on the walls of the alveoli (Dalton's Law). HBOT follows this law.
How does Hyperbaric Oxygen Therapy (HBOT) work?
Hyperbaria - Increased atmospheric pressure as a means of increasing oxygen uptake without an enriched oxygen source
Hyperoxia - Increased total oxygen content
Hyperbaria is based on the concept of the relationship of gas pressure and uptake in liquids (blood, plasma and tissues). Henry's Law states that "a gas is dissolved by a liquid in direct proportion to its partial pressure." For example, at sea level, atmospheric pressure is 760 mm Hg, the oxygen concentration is 21% and the body's oxygen content or partial pressure, pO2, in blood and plasma is ~ 40 mm Hg.
Red blood cells have a limitation as to how much oxygen can bind with hemoglobin. The plasma portion of the blood typically has about a 3% oxygen concentration. By placing someone in a 3 psi pressure hyperbaric environment, the increase in atmospheric pressure at sea level goes from 760 mm Hg to 915 mm Hg. This increase in gas pressure, increases the partial pressure of the oxygen gas and thus forces more oxygen to be dissolved in the plasma. This saturation of oxygen in the blood that occurs due to the HBOT therapy, allows the extra oxygen to be diffused or transported to the surrounding body tissues. Thus, oxygen transport by plasma is significantly increased under this specialized treatment. At three atmospheres pressure, enough oxygen can be dissolved in the plasma to support the oxygen demands of the body at rest in the absence of hemoglobin!
The FDA and Medicare have approved the use of Hyperbaric Oxygen Therapy for 13 conditions such as diabetic and other wound healing, anemia and compartment syndrome to name a few. In addition, current research shows that HBOT is a viable treatment for the growing list of “off-label” conditions. These include various disorders from brain injury, peripheral nerve issues, stroke and sports injuries to name a few. Of these ‘off label’ indications, there is growing research on the effectiveness of HBOT although they are not yet formally approved by the FDA. Hyperbaric chambers are medical devices that require FDA clearance. FDA clearance of a device for a specific use means FDA has reviewed valid scientific evidence supporting that use and determined that the device is at least as safe and effective as another legally U.S.-marketed device.
HBOT is very effective for acute mountain sickness. This is a common occurrence for guests to the Vail Valley when traveling from sea level. The initial symptoms of altitude sickness can include: Headache, lethargy, a drop in performance, lack of coordination, insomnia, appetite loss, dizziness, nausea and vomiting. A session in the hyperbaric chamber will simulate a decrease in altitude of approximately 7,000 feet.
For more on Hyperbaric Oxygen Therapy, check out our article in the Vail Daily by CLICKING HERE
NormaTec Recovery system is one of the best recovery systems available on the market today. They are used by the top athletes in the NFL, NBA, MLB and by the top triathletes and cyclists.
NormaTec is a compression device originally designed to aid in vascular disease, but later adapted to aid in sports recovery. The boots deliver compression with wavelike pulses creating dynamic compression and increasing circulation.
Dynamic compression is fall better than other types of compression garments. The dynamic compression helps pump lymph out of swollen tissues. The wavelike compression also helps reduce inflammation.
DOT Physicals at Your Convenience
VIMG now offers DOT physicals in a comfortable setting in both our Edwards and Eagle offices. Our qualified Federal Motor Carrier Medical Examiners comply with federal law by completing a specific DOT physical form.
When you come for your visit:
The Functional Movement Screen™ (FMS) is a system of simple quantifiable tests for evaluating fundamental movement patterns and abilities.
If you are exercising with altered movement patterns, then at best you are not performing at your potential and at worst are reinforcing poor patterns than can lead to injury.
Put simply, the FMS is a ranking and grading system that documents movement patterns that are key to normal function. By screening these patterns, the FMS readily identifies functional limitations and asymmetries. These are issues that can reduce the effects of functional training and physical conditioning and distort body awareness.
The FMS generates a score out of a possible 21, which is used to target problems and track progress. This scoring system is directly linked to the most beneficial corrective exercises to restore mechanically sound movement patterns.
The FMS trained professional will address these limitations by prescribing corrective exercises, giving the athlete greater movement efficiency and leading to improved performance and decreasing the potential for injury.
Call us to have yourself or your team screened with the FMS. You can learn more at http://www.functionalmovement.com
The Titleist® Performance Institute (TPI) is a three level certification program that encompases the largest collection of golf-specific health and fitness information from the world's leading experts in the game. This program is the mainstay in elite player development.
As part of the PGA Tour medical staff, Dr. Joel Dekanich uses the TPI physical assessment screens and functional movement tests to determine a player's limitation in relationship to their swing. Any one of these findings can greatly effect the golf swing and cause any number of the 12 most common swing faults. Through proper physical testing, video swing analysis, corrective manual treatment and specific rehabilitation exercises, players find effeciency in their swing, reduce or eliminate pain and lower their scores.