Active Assisted Isolated Stretching Treatment of a race car driver patient with persistent back and neck pain

Objective:

The purpose of this Case Study is to demonstrate and discuss the effectiveness of Active Assisted Isolated Stretching treatment as applied by caregivers at Motion Dynamics on a patient with persistent mild to severe back and neck pain.

Clinical history:

The patient is a 40-year-old male with a sedentary working lifestyle. He is also an amateur racing car driver. He suffered from chronic lower back pain, neck irritation, lack of shoulder flexion from adhesive shoulder capsules and poor finger grip strength.

This condition proved especially challenging for the patient given his specific activity. His limited range of motion in the neck can caused stiffness and irritation as well as discomfort. His driving was hampered, especially at high speeds.

This kind of persistent comfort can also be dangerous for more conventional driving. It is difficult to drive a car safely if an individual cannot turn their neck far enough to check their ‘blind spot’.

The patient had previously tried conventional physiotherapy for his back and neck pain, including massage, heat treatments and electro therapy, but these had proved ineffective.

As a first step, the patient did a full postural screening and a range of motion testing on all the major joints to see where his movement restrictions were, and to identify musculoskeletal compensation that could have been contributing to his lower back pain.

This postural assessment was performed standing (weight bearing) and lying down (non-weight bearing) to check for tilts, torque and rotation throughout the body structure.

[Photo: Chris Watts stretching and aligning Jonathon Hui]

The observational findings were as follows: Subject’s entire right hip was depressed by 1.5 inches and his left hip was up-slipped by 1 inch. His lower left lumbar quadrant was hypertonic, especially the quadratus lumborum muscle. It was also very sore to the touch.

His left hip was twisted and torqued to the right side creating irritation in his sacroiliac joint on his left side. The sacrum was also torsioned to the right with some muscular and ligamental strain on L4 and L5.

The head was tilted to the right side, compressing the right side neck flexors and shoulder elevators. There was some referred pain through the brachial plexus nerve bundle translating through into the tips of the fingers.

Treatment: Active Assisted Isolated Stretching and Strengthening (AIS) is a uniquely effective exercise system developed by Aaron Mattes. Motion Dynamics uses AIS and expands on the application of the method together with other physical therapy methods. AIS is a specific program of flexibility exercises, based on sound physiological principles. AIS, which is carried out actively or assisted by a practitioner/therapist or by the subject’s own efforts (often assisted by a rope or band), is designed to specifically increase range of movement of muscles, fascia and connective tissue. During AIS, movement is carefully monitored in order to prevent activation of the stretch reflex.

The patient underwent 5 months of treatment in an attempt to transform and rehabituate his alignment. This required deconstructing his existing poor postural patterns and then reconstructing the balance and alignment.

This consisted of 40 treatment sessions, with each session lasting about 90 mins. The patient underwent these sessions twice a week.

At the start of treatment, the patient’s shoulders had only 140 degrees of shoulder flexion with a very hard end feel, suggesting a very adhesive joint capsule on both sides.

His sideways elevation was restricted by a non-gliding acromio-clavicular joint that prevented the fluid motion when the arm was raised to only 120 degrees of range.

The shoulders were also protracted forwards by a very tight pectoralis minor and weak and tight serratus anterior muscle.

The head was also forwardly protracted by 2-3 inches creating strain on the posterior extensors of the neck.

The neck could only laterally tilt less than 25 degrees to the left side due to the right side constriction of scalene and upper trapezius shortening.

Cervical rotation was only 45 to 50 degrees on each side showing strong restrictions in range at C1 and C2

[Photo: Chris Watts chatting with Phil Whelan]

 

The application of the Active Assisted Isolated Stretching method used multiple sets of active and dynamic repetitive movements to slowly bring his soft tissue flexibility and joint mobility to a functional range.

These movements consisted of:

Cervical rotation with flexion at end of range In this movement, the patient tucked in the chin and rotated the neck to the right side 80 to 90 degrees, then flexed the neck by bringing the chin down towards the shoulder. He aimed to turn far enough that his chin was almost in line with your shoulder. The patient then repeats the exercise on the other side.

This specifically worked on the insertion of the upper trapezius muscle on the left side of the neck at the site of the acromium on the shoulder blade.

The patient reached a range of motion of the neck in rotation between 80 and 90 degrees. His lateral cervical flexion or side bending reached around 45 to 55 degrees.

Cervical flexion and extension This exercise has the patient touch his chin to his chest from a tucked chin position. Over the course of treatment, he reached an acceptable athletic range of motion for neck flexion of 40 to 60 degrees. Neck extension involved the patient tilting his head back. He attained a normal range of motion that allowed him to look straight up at the ceiling. The patient reached a range of motion from the neutral neck position of 45 to 70 degrees.

Cervical oblique hyperflexion and oblique hyperextension For the lateral cervical flexion exercise, the patient bent his neck to the side so that his ear was leaning towards his shoulder while looking straight ahead. He then brought his left ear toward his left shoulder, then rotated his neck 45 degrees to the right side and then drew the left ear towards the left chest. This exercise targeted the upper trapezius and levator scapular muscles. He would then perform the same exercise to the opposite side.

Having reached a normal range of motion in lateral cervical flexion, the patient was able to move halfway between straight ahead and his shoulder, which is a 45 degree angle. Shoulder forward elevation

For this exercise, the patient kept his shoulder blades set in a downward rotated position, raising his arm straight up with his thumb pointing upwards, lifting his arm through a full range of 180 degrees of forward elevation.

He then performed the same movement with the palm facing forward, followed by the arm fully internally rotated with the thumb pointing forward.

Sideways shoulder elevation For this exercise, the patient set the scapular in a downward depressed position and then abducted the shoulder with the thumb pointing upwards until the arm reached just behind the ear.

He then repeated this action with the fully internally rotated so that his thumb was pointing upwards and then abducted the shoulder until the arm touched the ear.

For these movements, the patient endeavoured not to elevate the shoulder, nor allow shoulder impingement at the acromioclavicular joint.

Shoulder internal and external rotation in multiple positions of horizontal flexion and adduction The patient held his shoulder positioned with the arm abducted to 85 degrees, horizontally adducted 5 degrees and the elbow positioned at 95 degrees of flexion. Over the course of treatments, his internal rotation range of motion with a fixed glenohumeral joint reached 80 – 90 degrees.

 

The patient also changed the position of the humerus by horizontally adducting the humerus by 5 degrees to release the posterior shoulder capsule. For external or backward shoulder rotation, the patient worked towards developing a range of motion between 45 and 65 degrees.

 

Each set of the movements described above consisted of 10 to 15 repetitions to slowly and gradually unlock the patient’s shoulder joint capsule and fascial adhesions.

The patient was taught how to stabilize and eventually strengthen the neck and shoulders to maintain all the structural work undertaken to realign and reposition the shoulder and hip joints.

He accomplished this by a process of light stability training, using his own bodyweight as well as the natural weight of gravity. We worked in all planes of motion and through full functional ranges to build stability at the origins and insertions of the entire neck structure.

Over the course of this treatment, the patient became acutely aware of where his centre of mass was located and how to gauge a neutral pelvic base.

During the initial phase of treatment, the patient showed radical improvement, and there was a slow upward curve of benefits through the rest of the period.

 

Results:

As a result of the Active Assisted Isolated Stretching Treatment, the patient no longer experiences any pain or irritation in his back or neck.

Prior to beginning treatment, the patient neck movement was limited to 25 degrees of lateral neck flexion and less than 10 degrees of extension at C1 and C2. Neck flexion was less than 20 degrees. degree tilt in any direction. After treatment, he had a full range of neck movement in all directions.

Prior to his beginning treatment, the patient experienced persistent back and neck pain that he described as being between an 6 to 8 on a scale of 1 to 10. After treatment, his level of constant discomfort was reduced to Zero. He was experiencing a lower back compression that was referring pain into his mid gluteal region. His neck pain had also significantly reduced when driving and also post driving when dehydration can typically cause muscle spasms in the areas of common weakness. Most importantly, the patent was experiencing improved energy output during the day and also during the race event too. The physiological effects from improving posture and mobility were profound.

 

After receiving the treatment described above, he was able to participate in a 24 hour car race. For this event, the patient was driving over 10 hours during a 24 hour period. Throughout, he experienced no significant pain or discomfort in his lower back.

 

Conclusion:

The conclusions obtained from the application of the relevant aspects of Motion Dynamics therapy are especially effective and successful in addressing the immediate symptomatic issues experienced by the patient, and also exponentially raised his level of mobility and comfort in his neck and back. The reduction of constant pain and discomfort has a direct effect in improving his sports performance.

Footnote:

[1] Chris Watts is the founder of Motion DynamicsTM in Hong Kong. He holds certifications from National Certification Board for Therapeutic Massage & Bodywork; Active Release Technique; Master Trainer of Active Isolated Stretching (AIS): The Mattes Method; Myofascial Release Therapy – John Barnes Technique; Neuromuscular Therapy – Paul St. John Method; and Positional Release – Kerry D’Ambrogio Method. He has studied with Aaron Mattes, who is the creator of AIS, and Paul St. John, founder of Neuromuscular Therapy. Watts has been in private practice for over 25 years and is the author of “The Beauty of Posture” (2014). Email: info@motiondynamics.hk

Active Assisted Isolated Stretching Treatment of a patient with chronic back during pregnancy

Objective:

The purpose of this Case Study is to demonstrate and discuss the effectiveness of Active Assisted Isolated stretching treatment on a patient with back pain caused by pregnancy.

Clinical history:

The client was a 38-year-old woman who experienced chronic back pain during and after her first pregnancy. The discomfort was most severe first thing in the morning. Initially, this pain was highly debilitating. The client described it as feeling as though it moved in multiple “arcs”, vertically and horizontally, across her lumbar spine. On rising, she would engage in movements that warmed the lumbar joints, and the pain would quickly diminish. The symptoms of her back pain started during the 2nd trimester of her first pregnancy. She would wake up with an inflamed and sore back at the L4 and L5 region of her lumbar spine.

The client had been diagnosed with disk herniation with a right-side bulge and disk narrowing in L4 and 5. This diagnosis was made by her orthopedic doctor after she underwent a physical examination and performed a range of motion tests. At the request of the patient, no x-rays or MRI scans were performed at that time, due to concerns regarding the potential damage to the fetus from radiation.

The pain was localized to the segments mentioned above but did on occasion refer down the right side of her body. The client is generally very fit, engaging in Pilates classes and stability resistance training 2 times a week. She otherwise led an active life, caring for and playing with her first child on a daily basis. She also has a very positive demeanor and is very determined to stay fit and pain-free.

The back pain described above began during her first pregnancy and persisted right through to the end of that pregnancy. She still experienced back pain after giving birth to her first child, but it was much more tolerable than during the pregnancy. However, she continued to wake up with soreness and irritation in her back. Her first child is now two-and-a-half years old. It was when she became pregnant for the second time that her back pain returned with increased severity.

She came to Motion Dynamics for alignment training (postural re-balancing) on the 2nd month of her 2ndpregnancy.

Analysis:

On performing the initial postural assessment, it was noticeable that the misalignments were all around her hip/lumbo/pelvic structures where there was significant anterior pelvic tilting on both ilia with ensuing lower back lordosis.

The pelvis was tilted 25 degrees forward on the right side and 15 degrees on the left side, with a distinctive right dominant hip shift translating the extra weight to her right hip. The right gluteus medius and minimus were weak and hypertonic with poor range of motion in abduction (25 degrees).

The right-side rectus femoris at the AIIS origin was very sensitive to the touch as were the right-side hip flexors indicating weakness and hypertonicity to those important postural and phasic muscles groups. There was a distinctive shift or translation of her body weight to the right side with a very noticeable head tilt to the right side and shortening of her right sterno cleido mastoid muscles.

 

The entire spinal erectors were weak and unsupportive, and the client was incurring a lot of neck pain especially in the suboccipital region. The levator scapular on the right-side insertion point on the superior angle of the scapular had trigger points and was very sensitive to touch, as was the transverse process of C2 on the right side.

Treatment:

We mapped out a flexibility protocol plan for the coming weeks of her pregnancy to re-balance the client’s musculo-skeletal system. With optimal alignment and good functioning joint mechanics, we were able to have her move well and freely without restrictions and irritation. Then we addressed the muscle imbalances, especially in the lower back and gluteal muscles. These were all very weak and neurologically deficient.

We started the first trimester deconstructing some of her faulty structure and movement patterns, building a strong but balanced foundation using Active Isolated Stretching techniques to unwind the right-side muscle shortening.

I used the principle of 3 sets of AIS stretching on the right side to one on the left to help retrain the neuromuscular patterns of movement. The tightest tissues were in the Iliopsoas muscle group. She only had 5 degrees of hip extension on the right side.

Once we gained the full 20-25 degrees of extension and reactivated the gluteal and hamstrings on both sides, she was able to stand much more upright since her pelvis had shifted back to its neutral position.

Her postural muscles were very slack and weak, and much work was done to stabilize the spinal extensors using Active Assisted trunk hyperextension stability exercises and Assisted oblique trunk hyperextension for the latissimus dorsa, intervertebrales and quadratus lumborum muscles.

The client initially found these very challenging. At the start of treatment, she was only able to perform 4 repetitions of each exercise. Eventually, we were able to build these muscles so that she could perform up to 3 sets of 10 repetitions.

The client could only perform these exercises in the first trimester due to the fact they were performed in a prone position off the table. During the second trimester, all back-stability work was performed on a mat using the isometric tabletop exercises that target the deep multifidus muscles.

At the start of her 2nd trimester, she was only able to perform a 60-second hold on each side. When we finished the 2nd trimester she was doing 3 minutes holds on each side.

Most of the pain that she experienced when we first saw her had diminished by the end of the 2nd trimester.

The 3rd trimester saw the client grow rapidly around the trunk and at one point she was carrying 38 pounds more weight. Her calves were cramping at night and she was retaining fluids around her ankle.

We used Active Isolated Stretching for her lower body, having her lie in a side position with a wedged pillow under her abdomen to provide support whilst working on her calves, hamstrings hip flexors and quadriceps, as well as her gluteus maximus.

Conclusion:

The client gained pain relief from the Active Assisted Stretching to the point where she rarely experienced calf cramping. Her lumbar spine was aching and uncomfortable, but she had no sharp pains from the excessive forward pelvic tilting.

We used an elastic belt to help support the extra-abdominal load and I used manual therapy soft tissue release more specifically Neuromuscular (NMT) techniques to relax the lower back and make sure the lumbar vertebrae were gliding well.

I kept up the AIS flexibility and stability training right up to the final session even using AIS for the adductors to open up the pelvic floor which was fully functional in terms of range and stability. The maximal range in abduction is 90 degrees with an internally rotated hip. She was at this end range by the final session.

Notes:

We found that the client really enjoyed knowing the tiniest detail of each area of progress that we were able to make. She developed a strong kinesthetic and somatic sense along the journey. Her understanding of her own positioning and center of mass was key to the client being able to subconsciously make the necessary long-term changes to help de-pressurize the joint and soft tissue structures.

The mother had a natural birth and delivered on March 26th 2019. The baby was 7lbs and 6 ounces. The birth was comfortable and, after the month of confinement that is tradition for Chinese mothers, I was able to see her at the beginning of May. She is now having a period of abdominal bandaging to firm the abdominal muscles and I will start to see her again for post-natal stability training. The focus will be on the pelvic floor and the pelvic and lumbar extensors.