POST DISC HERNIATION SURGERY REHAB:
A Case study using .Trigenics® Applied Functional Neurology®
by Ted L. Forcum, DC, DACBSP, FICC, CSCS, RTP
History in Chief Complaint
Patient DH entered our office with a 45-year history of lower back pain. 2
Years prior, the patient travelled to Germany and underwent a lumbar spine
operation, whereby he had artificial disks surgically implanted at L3, L4, and
L5. The procedure was highly successful at decreasing pain and increasing
ambulation. In June of 2004, the patient was seen for difficulties with balance
and proprioception secondary to a marked scoliosis related to spasmotic antalgia.
On his initial visit the patient related that there was some post-surgical
improvement in balance, and a reduction in the angle of his scoliosis. However,
he was now experiencing intractable pain, 8 on a scale of 0 to 10 with 10 being
unbearable pain, in the left lateral ankle region, inferior to the lateral
malleolus. The pain had started 2 days prior to his initial visit. The patient
related that the pain increased upon eversion of the foot, and was felt when
walking and standing. His foot was in constant inversion with the first ray off
the floor. The patient had no prior history of foot or ankle ailments.
Examination
There was obvious swelling to the lateral ankle without erythema. Left ankle
plantar flexion was limited at 25/85 degrees (normal active range of motion for
plantar flexion is 50 degrees). Left ankle dorsiflexion was also limited at 5/15
degrees (normal is 20). Mid Tarsal joints were slightly rigid in motion
bilaterally. Hallux dorsiflexion was normal bilaterally. The first ray had
normal range of motion in a neutral bias and position. The dorsal pedal pulse
was normal bilaterally; however, the tibialis pulse was absent bilaterally. When
standing, the patient demonstrated a posture with first ray dorsi flexion
whereby the first ray was elevated at proximally 1 cm off the floor. There was
dorsiflex ion of the first through fifth metatarsophalangeal joints bilaterally.
Muscle testing of the tibialis anterior extensor pollicis longus was graded 5/5.
Muscle testing of the fibularis (peroneus) brevis and fibularis longus
demonstrated 3+ strength on the left. The eversion stress test was positive and
produced pain in the ankle. The inversion and side-to-side tests were negative.
Patient DH demonstrated moderate tenderness throughout the lateral compartment.
There was pinpoint tenderness at the anterior talofibular ligament with
exquisite pain at the calcaneal fibular ligament. The patient’s left shoe
demonstrated disproportionately marked wear on the sole at the lateral aspect of
the heel and forefoot.
Diagnosis
Based on the examination it was apparent that patient DH had S 1 inhibition,
which was being expressed by a marked fibularis longus and brevis weakness.
Patient DH was compensating for this by distributing more weight on the anterior
talofibular ligament and calcaneofibular ligament to check ankle inversion. As
such, there was no antagonist control of the stirrup effect created by the
tibialis anterior and thefibularis longus. Without this being controlled the
tibialis anterior, along with the extensor hallux longus, were overly
dorsiflexing the first ray in relationship to the foot upon stance. The
excessive lateral wear pattern on the patient’s shoe was associated with a lack
of antagonist control of the deep posterior compartment maintaining the foot in
an inverted position throughout the gait cycle and stance.
It was hypothesized that this effect could be the result of a marked aberrant
gait pattern. Prior to the disc replacement surgery, the patient was required to
ambulate via crutches or a walker. There may also be nerve root inflammation due
to the surgical procedure. Peripheral entrapment of the fibular nerve can also
occur at the proximal fibular head. This condition could also be maintained by a
supinated gait pattern at the fibular musculature which is activated during the
gait cycle. In this case, the fibularis longus may entrap the common fibular
nerve at the proximalfibular head. However, usually symptomatology and pain in
the distribution of the nerve into the lower leg, foot and ankle would precede
localized compartmental weakness.
Diagnosis was that of Si neural inhibition causing fibularis longus and brevis
weakness with aberrant biomechanics and pain.
Treatment
Initial treatment consisted of functional application of Trigenics multimodal
treatment procedures, incorporating resistive exercise neurology,
mechanoreceptor manipulation and cerebropulmonary biofeedback. With Trigenics,
the patient is essentially performing concentrative breathing with resisted load
exercise movements while simultaneous treatment is applied to the muscle
mechanoreceptors to create a cumulative afferent spinocerebellar overload.
Correction of sensorimotor dysfunction is targeted by applying neuro-stimulative
soft tissue treatment while the patient performs proprioceptive resisted
exercises.* According to Dr. Frederick Carrick, “Trigenics is consistent with
the principles ofneuroplasticity and corticoneural reorganization of the
sensorimotor and somatosensory systems.”
Trigenics was applied to the lateral compartment of the left lower leg. A
Trigenics myoneural strengthening procedure was performed and involved physical
mechanoreceptor distortion at various points throughout the lateral compartment
along with resisted antagonist manual muscle contraction at approximately 20%
effort. Concomitantly, this procedure utilized a pressurized concentrative
abdominal breathing maneuver for additional neural input by way of global
parasympathetic response. As a result of the application of Trigenics myoneural
procedures as noted, there was an immediate, significant increase in muscle
strength which improved to 4+/5. Localized inflammation of the anterior
talofibular and calcaneal fibular ligaments were treated with 1.0 W/m squared
20% pulsed ultrasound for 4 minutes and interferential with ice at 10 to 100 Hz
for 10 minutes. Post Trigenics kinetic taping was applied along the course of
the fibularis longus in a facilitative pattern with tape applied at
approximately 50 to 75% tension with the ankle and foot inverted and dorsiflexed.
Upon examination 5 days post treatment, the pain had reduced to a one on a scale
of 0 to 10, and the frequency of the pain had reduced from constant to
infrequent. Muscle strength testing of the lateral compartment demonstrated
5-/S. However there was still 2-/3, moderate, pinpoint tenderness over the
calcaneal fibular ligament, whereas the anterior talofibular ligament was
negative.
This case demonstrated the marked effectiveness of using the multimodal
Trigenics® Applied Functional Neurology® procedures in concert with kinetic
facilitative taping in the treatment of pre- or post-surgical disc herniation
and neuromusculoskeletal conditions or pain syndromes.
*Historically Trigenics is cited by its founder Dr Allan Oolo Austin, to be the
first treatment of its kind to use a multimodal cumulative neural stimulation
app roach for enhanced outcome by combining soft tissue manipulation techniques
with resisted exercise movements.
Dr Ted Forcum is a Diplomate of the American Chiropractic Board of Sports
Physicians (DA CBSP). He is also a member of the ACA Council on Sports and
Physical Fitness, the United States Sports Chiropractic Federation and the
National Strength and Conditioning Association. Dr Forcum is certified in
Kinesio Taping (CKTP), Graston Technique, NASM Certified Exercise Specialist (CES),
NA SM Performance Exercise Specialist (PES), and is a Registered Trigenics
Practitioner (RTP). The American Chiropractic Association Council on Sports and
Physical Fitness voted Dr. Forcum the 1994-95 & 2004 Sports Chiropractor of the
Year and he was also awarded the 2000 ACA Sports Council Achievement Award. Dr
Forcum has worked as an event physician for such events as the Winter Olympics,
U.S. Olympic Trials, US. Track and Field Championships and the NCAA National
Championships as well as many others. Dr Forcum has also worked extensively as a
staff chiropractor for the PGA Tour In 2004, Dr. Forcum was voted in as the 2nd
Vice President of the American Chiropractic Association Council on Sports and
Physical Fitness. He has taught postdoctoral programs for Southern California
Health Sciences University, Western States Chiropractic College. Logan
Chiropractic College and Northwestern Health Sciences University. He is
currently on the leaching faculty of FAKTR-PM and lectures nationally and
internationally on the topics of sports injuries and biomechanics.