Guest Post: Acute idiopathic torticollis in a male high school basketball player.

Hey everybody! Today's post was written by my good friend Yuya Mukaihara. He was telling me about some success he was having using some Rocktape samples that I had given him so I asked him to write up one of the cases for my blog. So without further adou here it is:

I am one of Adam's classmates at Illinois State University and I work at a local HS. I am a Certified Athletic Trainer with CSCS, and NSCA-CT credentials. I have Graston Technique and Technica Gavilan IASTM certifications. I have also taken some PRI courses--Myokinematic Restoration, Postural Respiration, CCM, and I just finished Impingement & Instability this weekend. I use manual therapy, PRI, and corrective exercises in my practice but this case was an acute episode of left torticollis. So, I mostly used manual therapy to manage this case.

The athlete kind of looked like this...

Background

Torticollis, also called as cervical dystonia or spasmodic torticollis, is a condition of the neck that results in sustained involuntary muscle contractions that may cause pain and neck rigidity.^1,2 66% - 75% of the patients experience pain, which is the main cause of disability in those patients.¹ It is more common in women than men and occurs in 5 to 20 out of 100,000 individuals.² Idiopathic torticollis is considered as primary cervical dystonia due to no history of physical examination or laboratory tests whereas the secondary cervical dystonia is due to an abnormal developmental history.¹

Currently, the pathogenesis of torticollis and the anatomical origin of its symptoms are unclear; however, an onset of idiopathic torticollis is often gradual and it displays sustained co-contraction of agonists and antagonists of cervical muscules.^1,3 Commonly, it is treated with a series of Botulinum toxin A injections into overactive musculature.¹ However, torticollis can conservatively be managed by reducing pain and involuntary muscle contractions with Kinsiotaping ⁴, manual therapy ^5,6, and therapeutic exercises.³

In this case report, I used Muscle Energy Technique (MET) and Strain-Counterstrain (SCS) technique with an application of Rocktape to manage acute idiopathic torticollis in a male high school basketball player while he played playoff games.

Case Report

A 16 year-old basketball player came into the ATR 10 minutes before his practice started, c/o of left neck pain and tightness that resulted in his inability to look left. He stated that he started noticing tightness and pain that gradually becoming worse in the afternoon. Any other symptom was stated. It was in-season and was a day before his playoff game and he was needed in practice because he was one of better players on the team.

- At resting with seated, his neck was rotated and side bended to right a little bit.

- Active left cervical rotation was limited and was about 15deg with pain in the left side. Full right rotation.

- Active left side bending was also limited and was about 10 deg with pain in the left side. Full side bending.

- Palpable tightness over left cervical extensors, upper trap and levetor scapula compared to right. He c/o pain with palpation of these muscles.

- MMT to cervical flexion, extension, right rotation and right side bending were 5/5 without pain. Left cervical rotation and left side bending were 3/5 due to pain.

- No history of a car accident, head or neck injury, or shoulder pathology. No history of medical conditions or surgery that should be noted. No signs and symptoms other than tightness, pain, and limited ROM of the c-spine.

Course of Treatment

Day 1, after a quick evaluation, he had to go to the practice so I only had 10 minutes to treat him. I began with MET isometric reciprocal inhibition on left rotation and side bending. I didn't target specific muscle but general motions. I had him to rotate and side bend to the right from neutral to gain motions on the left side by inhibiting these tight musculature. There was not much improvement but he had to go to the practice.

15mins later, the player came back to me because he could not play due to pain. So, now I had a little bit more time to treat the athlete. I had him lay supine and checked his passive ROM. Passive left cervical rotation and side bending caused pain as did active, displaying limited ROM.

I used SCS on his left upper trap and levator scapulae because I suspected muscle spindle hyperactivity.  After resetting the mechanoreceptors, he had increased left cervical rotation and side bending.

After finding the most tender spot, I kept a pressure and started counting time. Then I slowly increased left rotation. Once he feels no tenderness under my finger, I stayed there for about 20-30sec and then increased a little further and repeated. At the same time, I added some side bending a little by little to gain the ROM.

After one session of this technique, his active left rotation was about 80% of his right rotation and side bending was about 30% of his right side bending. (active left cervical rotation about 75deg and side bend about 25deg).

Then, I performed a 1st rib MET on the left for one set of five isometric contractions to inhibit his left scalenes and to regain the function of left side bending.

Fortunately, I had a sample of Rocktape from Adam, so I put the player’s neck into flexion, right rotation and right side bending to place his left neck muscles on stretch then applied two strips of Rocktape.

One strip was applied from the occiput to about T3 level and the other strip was applied from the mastoid process to scapular spine. My intension to use Rocktape was to inhibit the hyperactive or hypertonic muscles. I had some personal experience of inhibiting hypertonic muscle with Rocktape previously.

After those interventions during 15 mins of treatment, he was still limited to left sidebending with pain, but was able to complete the practice with the team. He ended up keeping the Rocktape on for the next four days.

Day 2, the day of the playoff game, he returned with full left cervical rotation without pain and improvement on left side bending, which was 80% of right side with minor pain. On that day, I used MET for left 1st rib, upper trap, and levator scapulae with isometric autogenic inhibition. He played the game without any complaint, and we won the game.

Day 3 and 4, he had no limitation on both left rotation and side bending and no pain. On that day, I used MET for 1st rib only. No deficit with RROM for flexion, extension, both rotation, and both sidebending. He completed a practice without any complaint.

Day 5, he had returned to play without treatment. He completed a practice without any complaint.

Day 6, he had no complaint from day 5.  He played the playoff game without limitation or complaint. We won the game.

Conclusion and Discussion

In conclusion, Rocktape and manual therapy were a lifesaver for this athlete, his team, and me. Without them, I think he would continue to suffer from his tight and painful neck muscles, which could have affected the dynamics of our entire team and lost their first playoff game. Also, I was satisfied with the immediate improvement of cervical motions, especially rotation, with SCS technique. I wonder how an outcome would have been if I did not know SCS technique and just provided a very traditional intervention, such as heat modality and stretch. I need to thank my undergraduate program and faculty, which brought a SCS technique expert from University of Oregon for us to learn.

Further, I think the tape maintained immediate effects of the SCS and MET techniques and even more so enhanced inhibition of those hypertonic muscles that caused pain. Overall, I was happy that he responded so quickly and positively to the intervention thus allowing him to return to play very quickly.

References

1. Crowner BE. Cervical dystonia: Disease profile and clinical management. Phys Ther. 2007;87(11):1511-1526.

2. Patel S, Martino D. Cervical dystonia: From pathophysiology to pharmacotherapy. Behavioural Neurology. 2013;26(4):275-282.

3. Dool JVD, Visser B, Koelman JH, Engelbert RHH, Tijssen MAJ. Cervical dystonia: Effectiveness of a standardized physical therapy program; study design and protocol of a single blind randomized controlled trial. BMC Neurology. 2013;13(1):1-8.

4. Pelosin E, Avanzino L, Marchese R, et al. KinesioTaping reduces pain and modulates sensory function in patients with focal dystonia: A randomized crossover pilot study. Neurorehabilitation & Neural Repair. 2013;27(8):722.

5. Godse P, Sharma S, Palekar TJ. Effect of strain-counterstrain technique on upper trapezius trigger points. Indian Journal of Physiotherapy & Occupational Therapy. 2012;6(4):77.

6. Iqbal A, Ahmed H, Shaphe A. Efficacy of muscle energy technique in combination with strain-counterstrain technique on deactivation of trigger point pain. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal. 2013(3):118.

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Rock Tape Technique for Anterior Knee Pain

Hey Readers! I use a lot of different tapes, and taping techniques in my toolbox when dealing with athletes and their injuries. A lot of these things are just "tools" from my toolbox to help athletes cope with their injury(s). I don't think I can think of a single incidence where I consider the tape to be a fix to a problem but it does work as a great complementary treatment to reduce pain and increase function for my patient's when used in combination with rehabilitate/corrective exercises.

About two months ago I attended Rocktape's Fascial Movement Taping level 1 & 2 certification seminar (read that review here). Since then I have experimented with various taping techniques and have had results ranging from mediocre to outstanding for some of my athletes. One technique in particular that I have used with great success is one for anterior knee pain. I have used this with a number of athletes suffering from anterior and/or medial knee pain and they have noted definite rapid and dramatic differences in knee pain with activity. Some people might argue that this tape is purely placebo and if that is true, so what! I use a neuro-based model for a lot of the manual therapy and corrective exercises that I use on a daily basis. So if I am just tricking the brain into thinking that it is feeling less pain with this tape job then mission accomplished!

Without further ado, lets get to the tape job. I use Rock Tape myself because I feel from previous experience that it is stickier, better elastic recoil, cooler colors and patterns (more placebo power), and great construct quality compared with competing brands of "kinesiology" tape. Nevertheless, I feel that this technique would work when using those competing brands of tape as well.

Step 1 (After prepping the skin)

• No stretch at anchors/ends
• No stretch as you lay down the tape, just tension off tape.
• Rub down tape to set adhesive
• Distal/Proximal pull doesn't make a difference.

Step 2

• Repeat step 1 (above) but in the exact opposite fashion.
• Do not begin tape on top of tape if you want better results in terms of application longevity.

Step 3 (Final)

• Apply a "decompression" strip over the sight of pain/soreness
• This means you apply a stretch in the middle of the tape (25% - 75% stretch)
• No stretch to the anchors or ends of the tape
• Supposedly this applies a very nice "lift" to the middle portion of the tape where the stretch is at.

Here is a video I made for all of you that shows how to do this taping technique in real time! Check it out! Ignore my mint green shirt! It was made to support National Athletic Training Month 2014...which coincidentally is right now (March)! 

I hope you guys enjoy this post and video and I hope you are able to find similar results like the ones that I have. If you don't, then don't waste your time continually applying this method and find something else that works! When you find that something else...come back here and let me know about it so I can learn from you! In conclusion, this is a great adjunt therapy but it is important to remember that this isn't the fix and you should be doing other stuff to address the true source of the knee pain.

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Where Have I Been?

Howdy Folks! I am sorry that I haven't been blogging even a quarter as much as I would like to be lately. However, in all fairness I have been pretty busy. What have I been busy with you might ask? Well...on top of being an athletic trainer for a collegiate basketball team (that is ranked #4 in its division for the entire country and likely to win their second conference championship in a row), I have been busy working on and trying to complete the research project for my master's thesis.

Dr. Erson Religioso over at The Manual Therapist has been interested in my research project and asked me to write a guest blog for him where I would discuss what I was doing with and looking at for my research. I was honored but it also gave him some time off from blogging to spend with his new-born baby girl! Congrats to him for sure! Anyways, here is a link to my guest blog where I talk about my research! I need to get back on the blogging train and finish my self-SFMA series as well! Sorry for the delay, everyone.

I've got some cool cases related to my patients, SFMA, PRI, and Rock Tape to blog about once I get some more free time! Can't wait to share them all!

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Rocktape: Fascial Movement Taping Levels 1 & 2 Course Review

Swollen Knee? Try this on for size.

Howdy Folks, this past weekend I had the opportunity to attend both levels of Rocktape's Fascial Movement Taping(FMT) Seminars. This was a Saturday/Sunday conference and to an outsider it probably looked like an odd waxing/hair removal ritual with the use of some brightly colored kinesio-tape. In the past, I have been very skeptical of things like kinesio-tape and other various magical fixes for ailments. However, I have a background with and an interest in using movement assessments as an integral part of injury evaluations, treatments and prevention work. Therefore, I found myself intrigued at the description of the FMT course and by the amount of respected clinicians that were beginning to incorporate this tape/taping school of thought into their clinical practices. Here is the description straight from Rocktape's website:

"...Not your average taping course. Fascial Movement Taping Certification is a 2-part certification process led by industry leading experts in functional movement assessment and treatment. Fascial Movement Taping (FMT) is based on the obvious yet largely overlooked concept of muscles acting as a chain. Say good-bye to thinking about origins and insertions and memorizing directions of tape. Say hello to a framework of ‘taping movement, not muscles’."

I was immediately attracted to what they were promoting ("Taping Movement, Not Muscles") and how they were separating themselves from the reductionist style of taping muscles via origin and insertion. So...I signed myself up for the most readily available seminar! I also noticed that Dr. Perry Nickleston, DC, FMS, SFMA, NKT was lecturing/teaching this conference. This excited me because I knew of his writings via his blog, Stop Chasing Pain, and I also knew that he was integrating this style of taping with movement assessments via the SFMA and FMS. Perfect. This seminar was hosted on the campus of the National University of Health Sciences in Lombard, Illinois.

Day 1

Both days the course started at 8:00am and while I usually like to arrive to things like this at least 20-30 minutes early I have to admit that I ended up being about 5 minutes late for this course. There were primarily two reasons for this, a fresh blanket of snowfall left us with undesirable travel conditions and I ended up getting lost on the campus due to the poor communication of the room location. Fortunately, it seemed as if the bulk majority of people got a little lost including Dr. Perry himself!

The first day of the course followed a rough outline of these topics:

• History
• Effects & Potential Benefits of Taping
• Differences between other kinesiotaping schools of thought and FMT's
• Importance of and the interplay between the brain, skin, the nervous system, pain and the relationships with human movement.
• Tape Properties
• Taping for Acute Care/Fluid Dynamics/Edema Control
• Indications
• Contraindications
• Precautions
• Taping for Acute & Chronic Pain Control
• Taping for Proprioception
• Taping for Posture
• Neuro-Taping
• Scar Taping

That is a lot of stuff to cover in just the first day alone but in reality so much of the different topics build upon one another and have a lot of interplay. Also, this is a rough outline of what Dr. Perry went over...in reality Dr. Perry jumped between topics, subjects and ideas at seemingly random times. Not because he was unorganized but because he wanted to promote critical clinical thinking that sometimes begins as unorganized and seemingly random observations. Skilled clinicians must then take these random puzzle pieces and turn them into something meaningful for both the patient and themselves.

Edema strips...I pretended to have some bursitis for my partner

Dr. Perry also delivered the content with an energetic and interested tone. He wasn't the boring monotonous type but you could tell he had a vested interest into what he speaking about. While he did use colorful language at times it was definitely not tasteless and provided some much needed levity for when your brain started reeling from all of the knowledge bombs being dropped upon it.

For this review I can't go into everything that I learned nor does anyone want to read that much about it. I also don't want to spoil all of what we learned but I would like to highlight some of the things that I really liked.

• Integration of many schools of thought, such as:
• Regional Interdependence
• Tensegrity Theory
• Current Neuro-Pain science
• The works/ideas of great minds like:
• Shirley Sahrmann
• Vladimir Janda
• Lorimer Moseley
• Gray Cook
• David Butler
• Karel Lewit
• & More
• Movement Assessment

Things were both practical and philosophical.

Day 1 was definitely a day for developing a framework or laying the foundation for what we would learn on day 2. However, there were many universal concepts and taping techniques that we learned on day 1 that could be used and applicable after walking out the door that night. In fact, that is exactly what I did...Let me set the stage:

In the morning when the conference had begun I had received a text message from one of my patient's (a collegiate basketball player) that their back was very stiff, painful and locked up. They were barely able to dress themselves because of this. This wasn't pleasant news considering I was 2 hours away at the conference and wouldn't be able to treat him until that night...even worse was that he had a basketball game to play that night at 7PM. However, one of my colleagues was going to travel with the team and prep them before the game. He was able to help treat him before the three hour bus ride began and when they finally arrived. The bus ride was reportedly miserable and the athlete had to stand up or lie in the aisle for the bulk of the ride. With 30 minutes to go before tip-off the athlete was better than that morning but still wasn't sure of his ability to perform.

This is when I arrived to the game, I had been thinking of applying a tape job that I had learned that morning that involved taping the thoracolumbar fascia and the paraspinals for pain control and muscle spasm. I thought it was worth a shot and would hopefully work in synergy with the other various treatments he had received that day. I didn't have any Rocktape with me and just used some cheap kinesiotape from my kit(ended up starting to fall off halfway through the game). Nevertheless, the athlete reported that he felt much better and more comfortable with the tape and subsequently was able to play the entire game. Could this have been purely placebo? Possibly. Could it have been related to the prior treatments from my colleague? Absolutely. However, I don't care if it was just a placebo that made him able to perform...There was no downfall to trying and he wasn't suffering from an injury that should have removed him from participation. The entire experiences was a giant +1 for how I felt about what I was learning from the seminar.  Potentially I am even biased because of this experience but pain is a construct and I was able to help alter how he assessed his status.

Pre-FMT Seminar.

Post-FMT Seminar...Much better.

Day 1 Memorable Quotes/Knowledge Bombs:

• Tape Movement, Not Muscles (Rocktape Slogan)
• "Movement Never Lies"
• "Treating scars is really cool s#^t!"
• "Movement is the common denominator of injury"
• Your body is always training and working out...against gravity.
• "If you have a body, then you are an athlete."
• "...you need all of that s**t to be STABLE!"
• "If I change your posture, can I change your mood?"
• "You need to have blueballs if you want to stick out"
• Go stronger, longer - It's viagra for the whole body.

Day 2
Because I already made a novel out of day 1 let me try and keep this short and sweet. While day 2 definitely was full of mental "sweets" it definitely did not come up short. Day 2 was more dedicated to assessing movement and then applying taping techniques in attempt to change movements.

Applying the spiral chain tape job to one of my athletes.

To start off Dr. Perry began with a segment on the importance of movement for life, how movement is a behavior, and how we all have our own unique movement habits or patterns. All things I whole-heartedly buy into and believe in. He then tied that part all together nicely by throwing this classic Gray Cook quote at us, "It took a habit to make that pattern, and it's going to take a habit to break the pattern."

Dr. Perry then had a great slide where he compared using the Snellen Eye Chart as a vision assessment to using movement as an assessment. He stated that if you weren't able to read the letters he knew you needed corrective lenses and if you can't move well then you probably need corrective exercise. Albeit he admits that some people can't reach perfect, whereas some only need a tiny tweak.

Let me outline the major areas of what we learned about on day 2:

• Movement Science
• Fascia and Fascial Anatomy
• Big influences from both Schleip and Thomas Myers here...
• Fascial Chains/Slings
• Movement Assessment, Taping Movement, and applicable Rehab/Corrective Exercises
• Maybe you don't like the SFMA or FMS...Doesn't matter, the importance of testing any motion that is used for ADL's or sport specific exercises is just as beneficial and vitally important.
• The Importance of Breathing and the role of the diaphragm
• Releasing the diaphragm
• Taping the diaphragm
• Tweak Taping
• Process of testing and then taping various skin glides to improve movement or patient's asterisk(*) sign
• Pregnancy Taping
• A nice tape application to assist pregnant women with low back pain, etc.
• & Performance/Sport Specific Taping

We were not discussing abstinence, yet.

There was a lot of discussion during these two days about the importance of the brain & nervous system and the role they play in both pain and movement. I really appreciated a lot of the theories that this course was basing its methods from. There was a very simple slide at the end of the first day that summed up the differences between FMT's theories and other brands or styles of taping:

• Functional vs. Structural
• Movement vs. Muscles
• Sensory vs. Mechanical
• Assisting vs. Resisting
• Elastic vs. Rigid
• Integrated vs. Isolate

There was a lot of SFMA/FMS type movement tests and many of Dr. Perry's own favorite movement tests thrown into this day. We discussed important aspects of the movements, potential compensations, movement lynchpins, and ways to approach correcting and taping said movements. There was a lot of moving and not a lot of sitting during this course.

Here I used the "Big Daddy" 4 inch tape, for posture.

Overall, I would say that I definitely enjoyed the course and I have found myself practicing a lot of what I learned in the clinic this past week. I don't think the tape is a be-all-end-all treatment and it is definitely not taught as one but it is another tool for the toolbox. I enjoyed the discussion and dissection of movement, nerves and the brain, and the implications of everything combined. Would I sign up again if I had to remake the decision? In an instant. Do I recommend it to others? Yes, but I feel like I definitely benefited from having previous exposure to the SFMA/FMS. There were a few massage therapists and personal trainers in the class and I couldn't help but wonder if they were able to digest everything as easily.

Day 2 Memorable Quotes/Knowledge Bombs:

• The brain wants to feel safe, there is no safer place than the ground
• "Pass your finger through the fuzz" - keep moving.
• "If you don't own breathing, you don't own movement"
• "The feet are the window to the soul/sole." - Karel Lewit
• Flip them over and tape their yang.

Dr. Perry, Myself, and Dr. Nick...Both of them making me look tiny.

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