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Webster Technique in New York  and PowerPlate Acceleration Training , Graston Technique, SpineForce 3D Rehab, Kinesio Taping

On site  Digital X-ray read by a board certified medical radiologist, SpineForce 3D Rehab

 

Call  (212) 645-8151

About the Graston Technique

Changing the way soft tissue injuries are treated

The Graston Technique is a modern instrument assisted technique designed to treat acute and chronic soft tissue conditions and injuries. 

The Graston Technique is a soft tissue mobilization technique which takes advantage of specially designed stainless steel instruments that aid the clinician in breaking up scar tissue and myofascial adhesions. 

The Graston Technique offers many advantages and benefits.

·        Decrease overall treatment time

·        Faster rehabilitation/recovery

·        Reduces the need for anti-Inflammatory medication

·        Resolves chronic conditions thought to be permanent

 Six stainless steel instruments are the foundation to Graston Technique  

The various curves and edges of the stainless steel instruments allow the clinician to be very specific in the areas that are to be treated.  Each of the 6 patented instruments have been designed to conform to various contours of the body

Due to the firm construction of the instruments, it is possible for the clinician to actually feel and isolate adhesions and soft tissue restrictions in the injured area much better than palpation alone. 

One advantage of using The Graston Technique is that the clinician can apply a direct and specific pressure to the area of adhesions through the instrument's beveled edges.  This allows the clinician to use minimal pressure and provides maximal comfort to the patient while administering the technique. 

Dr. Steven Shoshany is certified to practice the Webster technique, Dr. Steven Shoshany is one of the few doctors in New York City that practice this fantastic technique!

Chiropractic care benefits all aspects of your body's ability to be healthy. This is accomplished by working with the nervous system--the conduit of intelligence between your brain and body. Doctors of Chiropractic work to correct subluxations(misalignments) of the individual spinal bones. When subluxated, these bones put pressure on the spinal cord and the spinal nerves causing malfunction in any part of the body and imbalance in surrounding muscles and ligaments.

 

Sacral subluxation causes the tightening and torsion of specific pelvic muscles and ligaments producing uterine constraint. It is these tense muscles and ligaments and their constraining effect on the uterus which prevent the baby from comfortably assuming the vertex position. The Webster Technique is defined as a specific chiropractic analysis and adjustment that reduces interference to the nerve system, facilitates balance in the pelvic and abdominal muscles and ligaments, which in turn reduces constraint to the woman's uterus allowing the baby to get into the best possible position for birth.

 

Any position of the baby other than vertex may indicate the presence of sacral subluxation and therefore result in intrauterine constraint. It is strongly recommended by instructors of this technique, that this specific analysis and adjustment of the sacrum be used throughout pregnancy, to detect imbalance and prevent intrauterine constraint.

 

Dr. Larry Webster, Founder of the International Chiropractic Pediatric Association discovered this technique as a safe means to restore proper pelvic balance and function for pregnant mothers. In expectant mothers presenting breech, there has been high reported success rate of the baby turning to the normal vertex position.

 

Because of the effect the chiropractic adjustment has on all body functions, pregnant mothers should have their spines checked regularly throughout pregnancy, allowing for safer, easier deliveries and optimized health benefits for both the mother and baby.

What is Kinesio® Taping?

Dr. Steven Shoshany is one of only a few New York City Chiropractors trained in this amazing technique

Certified Kinesio Taping Practioner-NYC

 

Kinesio Taping® is a technique based on the body's own natural healing process. This Kinesio Taping® exhibits its efficacy through the activation of neurological and circulatory systems. This method basically stems from the science of Kinesiology. Hence the name "Kinesio" is used. Muscles are not only attributed to the movements of the body but also control the circulation of venous and lymph flows, body temperature, etc. Therefore, the failure of the muscles to function properly induces various kinds of symptoms.

 

Consequently, so much attention was given to the importance of muscle function that the idea of treating the muscles in order to activate the body's own healing process came about. Using an elastic tape, it was discovered that  muscles and

 

other tissues could be helped by outside assistance. Employment of Kinesio Taping® creates a totally new approach to treating nerves, muscles, and organs. The first application of Kinesio Taping® was for a patient with articular disorders.

 

For the first 10 years, orthopedists, chiropractors, acupuncturists and other medical practitioners were the main users of Kinesio Taping®. Soon thereafter, Kinesio Taping® was discovered by Olympic volleyball players in Japan and word quickly spread to other athletes. Today, Kinesio Taping® is accepted by medical practitioners and athletes in Japan, the United States, Europe, South America and other Asian countries as well.

 

 

Kinesio® Concepts

 

Muscles constantly extend and contract within a normal range; however, when muscles over-extend and over contract, such as when lifting an excessive amount of weight, muscles cannot recover and become inflamed. When a muscle is inflamed, swollen or stiff due to fatigue, the space between the skin and muscle is compressed, resulting in constriction to the flow of lymphatic fluid. This compression also applies pressure to the pain receptors beneath the skin, which in turn communicates, "discomfort signals" to the brain & emdash; the person experiences PAIN. This type of pain is known as myalgia, or muscular pain

 

Conventional athletic tape is designed to restrict the movement of affected muscles and joints. For this purpose, several layers of tape must be rolled around and/or over the afflicted area, applying significant pressure; resulting in the obstruction of the flow of bodily fluids...an UNDESIRABLE side-effect. This is also the reason athletic tape is generally applied immediately before the sports activity, and removed immediately after the activity is finished.  On the other hand, Kinesio Taping® is based on a

 

different philosophy that aims to give free range of motion in order to allow the body's muscular system to heal itself bio-mechanically.

 

To ensure that the muscles have free range of motion, elastic tapes with an elasticity of 130-140% of its original length are recommended for Kinesio Taping®. This specific elasticity also will not allow an over stretch of the muscles themselves. It may look like conventional athletic tape, but tape and Kinesio Taping® is fundamentally different.

 

Ultra Low Frequency Stimulation

Development and protocols for H-Wave were based on the well-established facts that fluid shifts and pressures are essential for tissues to heal and to create homeostasis in an injured area. It's also valuable to point out that publications show that inflammation of joints and compartmental swelling are a leading cause of disability in the U.S. Therefore, the H-Wave device was specifically designed to improve circulation and enhance fluid shifts; thereby, addressing the inflammation that is so often the causative factor in pain and disabilities. By simply placing adhesive pads on the skin and connecting to the device, H-Wave can create very comfortable and strong muscle contractions. A 30 minute treatment will contract muscles and increase fluid shifts in the area, significantly addressing symptoms in the most rehabilitative way possible. The goal of H-Wave is never to mask symptoms while the equipment is on, but rather to speed recovery and/or manage chronic symptoms with several 30 minute treatments per day/week depending on the situation. Published research has shown that the specific technology of H-Wave represents a paradigm shift in electro-therapeutic treatment and produces the optimal non-fatiguing stimulation for fluid shifts.

 

 

High Frequency Stimulation

Some conditions require additional pain relief that fluid shifts don't entirely address. This is why H-Wave has a secondary mode that is focused entirely on shutting down pain and breaking the pain cycle. Again, in this setting H-Wave is not intending to mask pain while the device is on, but rather create a strong anesthetic affect with significant and lasting relief after a 30 minute treatment. The H-Wave device is so unique and capable of shutting down pain that we have FDA clearance for electrical anesthesia in the field of dentistry. The same technology employed with our medical devices is used in a dental device in which we are cleared to perform amalgams, composites and even crown preparations with nothing but H-Wave for anesthesia.

 

Kinesio Tapping

Dr. Steven Shoshany is one of only a few New York City Chiropractors trained in this amazing technique

What Does Kinesio Taping Do?

Kinesio Taping gives support and stability to your joints and muscles without affecting circulation and range of motion. It is also used for Preventive Maintenance, Edema, and Pain Management

              Kinesio Taping was invented by a Doctor of Chiropractic, and is utilized- especially by SPORTS Chiropractors throughout the world.  Kinesio Taping helps the body heal naturally, can be used preventatively, as treatment, in rehab, during competition, or as a ‘take home’ treatment applied by the Chiropractor   (medical doctors give drugs, chiropractic doctors give tape) .

              Kinesio Taping is a technique based on the body's own natural healing process. This Kinesio Taping exhibits its efficacy through the activation of neurological and circulatory systems. This method basically stems from the science of Kinesiology, hence the name "Kinesio". Muscles are not only attributed to the movements of the body but also control the circulation of venous and lymph flows, body temperature, etc. Therefore, the failure of the muscles to function properly induces various kinds of symptoms.

               Consequently, so much attention was given to the importance of muscle function that the idea of treating the muscles in order to activate the body's own healing process came about. Using an elastic tape, it was discovered that muscles and other tissues could be helped by outside assistance. Employment of Kinesio Taping creates a totally new approach to treating nerves, muscles, and organs. The first application of Kinesio Taping was for a patient with articular disorders.

               For the first 10 years, chiropractors, acupuncturists and other medical practitioners were the main users of Kinesio Taping. Soon thereafter, Kinesio Taping was used by the Japanese Olympic volleyball players and word quickly spread to other athletes. Today, Kinesio Taping is accepted by medical practitioners and athletes in Japan, United States, Europe, South America and other Asian countries.

               The Kinesio Taping Method is applied over muscles to reduce pain and inflammation, relax overused tired muscles, and to support muscles in movement on a 24hr/day basis. It is non-restrictive type of taping which allows for full range of motion.

               In contrast, traditional sports' taping is wrapped around a joint strictly for stabilization and support during a sporting event obstructing the flow of bodily fluids... an UNDESIRABLE side-effect.

              Kinesio Tape is used for anything from headaches to foot problems and everything in between. Examples include: muscular facilitation or inhibition in pediatric patients, carpal tunnel syndrome, lower back strain/pain (subluxations, herniated disc), knee conditions, shoulder conditions, hamstring, groin injury, rotator cuff injury, whiplash, tennis elbow, plantar fasciitis, patella tracking, pre and post surgical edema, ankle sprains, athletic preventative injury method, and as a support method.

 

Technology : What is Power Plate?
Power Plate® equipment is the premium vibration device powering a new dimension in wellness solutions for all ages, lifestyles and physical abilities. It uses the principles of Acceleration Training™ to stimulate the body’s natural response to vibration. These vibrations transmit waves of energy throughout the body, activating muscle contractions between 25 and 50 times per second, enhancing overall performance in sessions as short as 15 minutes a day, 3 times a week.  

Acceleration Training™ on Power Plate® equipment offers a host of benefits, ranging from an immediate improvement in blood circulation, to a variety of other measurable outcomes: such as increased muscle strength and flexibility, improved range of motion, decreased cellulite, increased bone mineral density, reduced pain and soreness and faster recovery.  Our three-dimensional vibration technology continues to lead the industry, and its benefits are grounded in extensive academic and independent scientific medical research.

Technology : How Does it Work?
Acceleration Training™ with Power Plate® machines creates instability in the human body, as with each vibration the body is forced to perform reflexive muscle actions, 25 to 50 times per second. Furthermore, these contractions must work in multiple dimensions as the Power Plate® machines actually oscillate in all three planes, exactly as the human body is designed to do. The net result is an incredible improvement in force production, or strength and power.

The principle by which Power Plate® machines work lies in the law of motion, stated by Sir Isaac Newton: that the force of an object is equal to its mass multiplied by acceleration, or f = m x a. What this means is that one can improve functional force (stability, strength or power) by either applying more mass or more acceleration to the body. Many forms of training and conditioning use mass - as seen in methods with weight machines, free weights, etc. Power Plate® machines, instead, use the second half of this equation, by applying acceleration to the body, while keeping mass, i.e. your body weight, the same.

This is a real breakthrough in training and conditioning as we can now optimally “load” the human frame while minimizing high impact, high load, and high stress factors.  Gravity is the force that adds load to the human body every second of every day for every movement we perform. Through Acceleration Training™ exercise, Power Plate® machines make the body feel as though it “weighs” more every time acceleration forces increase.

The result is that you work against a far greater influence or “load” of gravity in every movement you perform. This is the essence of all strength and conditioning programs and Power Plate® machines simply use a different part of the same equation to achieve this! In fact, the amazing outcomes seen with Acceleration Training™ exercise respect the same biological and physiological laws of the body as witnessed in other forms of training. The

Technology : Be Sure The Power Plate Method Is For You
Please remember as we are primarily concerned for your safety, we advise you to review the following list of contraindications and contact your physician or specialist should you have any questions before training with Power Plate® machines.


Contraindications for training with Power Plate® machines:

Pregnancy

DVT / Thrombosis

Cardiovascular diseases

Recent wounds from an operation or surgical intervention

Synthetic/artificial joints

Acute hernia / discopathy / spondylolysis

Severe diabetes

Epilepsy

Acute diseases / inflammation processes

Severe migraines

Pacemakers

Carrying recently fitted IUDs, coils, metal pins, bolts or plates

Tumors

Retinal problems/dysfunction

Note: Should one of the contraindications listed above apply to you, you are not necessarily excluded from using Power Plate® machines. Extensive research is being performed on the effects of Acceleration Training™ exercise on specific medical conditions and, as a result, this list may soon be revised. However, to be safe, we would advise against usage until you have consulted your physician to determine whether this is a relative, or absolute, contraindication.

Technology : Scientific Support
A growing body of scientific research demonstrates how the technology behind the Power Plate® machines provides widespread therapeutic applications and health benefits. Listed below are just a few of the numerous studies detailing positive results from using Power Plate® machines as part of your exercise regime. 

Human Performance

Strength Increase after Whole-Body Vibration Compared with Resistance Training

Acute Effects of Whole Body Vibration on Muscle Activity, Strength, and Power

Whole Body Vibration Induced Increase in Leg Muscle Activity During Different Squat Exercises

Neuromuscular Effects of a Single Session of Whole Body Vibration

Effect of Knee Flexion Angle on Neuromuscular Responses to Whole Body Vibration

Neuromuscular Responses to Two Whole Body Vibration Modalities During Dynamic Squats

Comparing the Effects of Different Whole Body Vibration Intensities on Vertical Jump Performance

The Effects of 4 Different Acute Whole Body Vibration Exposures upon Indicies of Counter Movement Vertical Jump Performance

EMG Response to WBV of Different Frequencies with Progressive External Loads

Power Plate Whole Body Vibration Metabolic Study

Other Research

The Effects of Whole Body Vibration on Reflex Induced Standing in persons with Chronic and Acute Spinal Cord Injury

Hormonal Response to Whole Body Vibration in Men

Comparing the Performance Enhancing Effects of Squats on a Vibration Platform With Conventional Squats in Recreationally Resistance Trained Men

Acute and Residual Effects of Vibratory Stimulation on Explosive Strength in Elite and Amateur Athletes

Effect of Four Month Vertical Whole Body Vibration on Performance and Balance

Effect of Whole Body Vibration on Muscular Performance, Balance, and Bone

Electromyography Activity of Vastus Lateralis Muscle During Whole Body Vibrations of Different Frequencies

The Effects of Vibration on Human Performance and Hormonal Profile

"Strength training on vibrating plates: markers of muscle damage"

Whole Body Vibration and Blood Muscle Volume

Will Whole Body Vibration Training Help increase the Range of Motion of the Hamstrings?

HOW CAN WHOLE BODY VIBRATION (WBV) IMPROVE MY RESULTS?

 

The benefits of Whole Body Vibration (WBV) have been studied for decades and therapy using WBV has been utilized since the ancient Greeks.

There are several benefits to using WBV for spinal correction.

 

“Whole Body Vibration is a direct stimulation to the patient’s nervous system, especially the cerebellum, the autonomic nervous system and its reflexes (Pettibon).” This benefit will allow faster healing and rehabilitation times for spinal correction. Here are some of the many benefits of WBV.

WBV affects the loaded or stretched muscles, i.e. spinal postural muscles, rather than phasic muscles. WBV has shown to increase muscle strength and tone when used regularly. It has also been shown to help splinted or spastic muscles to relax and prevent further spasm.

“Neural drive is greatly enhanced by WBV and has been shown to increase blood flow as well as affecting the production of various and necessary for muscle rehabilitation (Pettibon).”

 

HISTORY OF VIBRATION THERAPY IN REHABILITATION

 

Vibration therapy is not new. In a patient search, one can easily identify multiple patients going back many years. Dr. J.H. Kellogg was one of the first in the modern era (1800-1900) to utilize mechanical vibration as a modality to treat health problems, although the ancient Greeks used primitive methods. Later, the Russians utilized WBV to help their cosmonauts combat the effects of minimum gravity. In the 1970s, ‘80s and

‘90s, the Soviet Union and the Dutch Olympic team trainers were the first to recognize the benefits of WBV to enhance athletic performances.

 

Language and physics

Whole-body vibration is a direct stimulation to the patient’s muscles and nervous system, especially the cerebellum, the autonomic nervous system, and it’s reflexes. Over-stimulation (use over too long of a time) may result in sweating and fatigue, and, in rare instances, the patient may pass out.

Because WBV is such a powerful tool, it is critical that those using it in their offices understand the terminology associated with its use and how to identify when over-utilization is approaching.

 

Frequency is the number of vibrations per second. Most platform vibrations are controlled and may vary from 10 up to 60 Hertz (Hz). To be effective, the Hz is varied to fit in the patient’s body type and changed as the patient’s physical condition changes.

Amplitudeis the distance the vibration forces the platform to travel, usually from 1 to 4mm.

Time is the duration a person is exposed to vibration and varies from individual to individual, dependent upon the Hz used and muscle activity of the individual during exposure to the vibration.

Physiology

Whole-body vibration and/or vibration of any kind affect postural muscles

rather than phasic muscles. Phasic muscles do not spasm or have tone. Vibrations stimulate afferent fibers in the muscle spindles, causing reflex

contractions, especially in loaded and/or stretched muscles. This increases

muscle tone and eventually one’s strength when performed on a regular schedule. Electromyography (EMG) activity is greatly increased with vibration of loaded or stretched muscles over voluntarily contracted muscles, causing them to fatigue up to 50% faster. Further, motor units

of vibration-exercised muscles are better synchronized, resulting in greater

control of balance and dexterity. Balance and dexterity may also be products

of vibration-induced somatosensory, central motor, and hypothalamus stimulation.

WBV has also been shown to cause spastic and splinted muscles to relax and prevent further spasms of muscles that have been over-stimulated. A Pulse Ox instrument can indicate when vibration efficiency of stretched and/or in the fatigued patient as soon as the patient plateaus.

 

Associated neural increases

Neural drive is greatly enhanced by WBV and has been shown to increase blood flow as well as to affect the production of various hormones, motor-unit recruitment and micro-traumas that are involved and necessary for muscle rehabilitation.

Research has shown that the prescription of correct vibration (Hz) and time in concert with the various weighted maneuvers during rehabilitation training increases the following:

1.The essential human growth hormone IGF-1 by 361%

2.Testosterone by 7%

3.Blood flow by 100%

4.leg strength by 15%

5.Bicep strength by 10%

 

Vibration resulted in a decrease of low back pain by 66% as well as a decrease in production of the fat-causing stress hormone, Cortisol, by 32%.

Whole Body Vibration

Whole Body Vibration (WBV) is an advanced technology that is used by major medical, rehabilitation and therapeutic centers across the country for any years. It is now available at Manhattan Chiropractic.

The therapy consists of standing on a platform that produces a vibration. This vibration is transferred to your body, stimulating absolutely every part of your body, from your cells to your organs. This whole-body-vibration offers a host of benefits:

  • Improves muscle strength and performance
  • Increases flexibility and range of motion
  • Enhances critical blood flow throughout the body (oxygenation and lymph drainage)
  • Increases secretion of hormones that are important in regeneration and repair processes, such as HGH (Human Growth Hormone), IGF-1, and testosterone
  • Increases bone density
  • Increases the “happiness” hormones serotonin and neurotrophine, substances that support our thinking process
  • Decreases the stress hormone cortisol
  • Rehabilitates injuries and ailments
  • Enhances explosive strength
  • Enhances conventional training results
  • Speeds training recovery
  • Accelerates weight loss
  • Reduces lower back pain
  • Enhances pain reduction
  • Improves collagen production
  • Reduces appearance of cellulite
  • Eliminates the effects of stress

How & why it works

The human body has an innate reflexive response to disruptions in stability (think: doctor hitting below your knee cap). On the platform, the vibration causes muscles to instinctively stretch and contract: both movements occur rapidly and intensely at a rate of 30-50 times per second.

Exercise causes the body to tire; rest allows the body to recover. By repeating this process, the body adjusts to the level of effort, resulting in an increase in physical performance. This phenomenon, called super-compensation, similarly occurs when training on the WBV platform. However, compared with traditional training methods, greater results are achieved and hormonal production is increased in much less time.

Each set is performed no longer than 30, 45, or 60 seconds in length, and training sessions need to be performed no more than 3 to 4 times per week with each session lasting about 10 minutes of actual time on the platform.

You will see the results of increased flexibility each time you do a WBV work-out. Touch your toes before your set, and again after the set. You’ll be amazed. And, by the end of the set, the work-out will have been so vigorous that you’ll be sweating – without having run, without Bikram yoga.

About Bone Density

Without the force of gravity pulling on the skeleton, astronauts lose bone at the rate of 0.2% per month. Conversely, a professional tennis player may have 30% more bone on his playing arm. Unfortunately, most of us tend to simulate the life of an astronaut rather than the life of an athlete. As a result, one gets increasingly weaker over time.

Decades of scientific studies support the effect of gentle vibration on increasing bone density. Most recently, in one study on WBV, adult sheep were treated with vibration to their hind legs for 20 minutes a day. The vibrating sheep had 30% more bone in their legs than did untreated animals after one year.

To build bone, you have to beat it up. You have to punish your skeleton a bit. Low-impact activities such as walking, swimming, and cycling are good for your heart and muscle tone, but they don't do much for your bones. High-impact activities, such as running and weightlifting, build bone. Shocks to bone only make it stronger. Bone is living tissue, and it responds to your activities. Mechanical stress—the impact of your feet pounding pavement, the weight of a barbell, or the shock that travels up your arm when you whack a baseball—creates microscopic fractures. Your bone not only repairs the tiny fractures, but it also responds by building more bone on top of them.

Post-menopausal women are the most at risk for losing bone. The end result can be osteoporosis: bones so brittle that even the stress of ordinary activities can snap them. But, men aren't immune. The rapid bone loss that leads to osteoporosis starts about 10 years later in men than in women—around the age of 60.

And, it is never too early to start. Clinicians and researchers feel that it is crucial to build up as much bone as you can during the first 20-30 years of your life, so that when you reach the age when bone loss accelerates, the effect won't be devastating. It’s a little like investing in the stock market. If you have $1 million and you lose 90% of it in a market crash, you're still left with more than most people earn in a year. But, if you've only invested $10,000, what's left probably couldn't cover a month's rent.

Whole Body Vibration on the Power Plate combined with Spinal decompression with the DRX 9000 is an amazing treatment for Herniated disc problems.

Call (212) 645-8151 in Manhattan for treatment of  herniated discs and  bulging discs without surgery. Spinal decompression combined with a core strengthing and core stabilization provides an effective treatment for chronic low back pain and herniated discs.

Rehabilitation
Not only can Acceleration Training™ exercise using Power Plate® machines prevent injuries, it can help rehabilitate them as well. Many professional sports teams have found Power Plate® machines to be indispensable for rehabilitation. The ability to strengthen muscles without strain on joints and ligaments can be extremely valuable for patients with rehabilitation needs. Increased blood circulation helps bring oxygen to inflamed areas to promote healing, while improved lymphatic flow helps drain fluid build-up from injured tissue.

 Image of Power Plate in use

Whole-Body-Vibration Training Effective in Older Women  Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

 Whole-body-vibration (WBV) training is as efficient as standard resistance (RES) training for improving strength and speed in older women, according to the results of a randomized trial published in the June issue of the Journal of the American Geriatric Society.

"Recently, WBV training has been promoted as an efficient alternative for resistance training," write Machteld Roelants, MS, from Katholieke Universiteit in Leuven, Belgium, and colleagues. "Even if performed to exhaustion, the increases in heart rate, blood pressure, and oxygen uptake during WBV are mild, so the cardiovascular risks of WBV in older adults are negligible."

In this controlled trial at the Exercise Physiology and Biomechanics Laboratory in Leuven, 89 postmenopausal women were randomized to WBV training, RES training, or to a control group that did not participate in any training. All women were not receiving hormone replacement therapy (HRT), and age range was 58 to 74 years.

Both active intervention groups trained three times a week for 24 weeks. The WBV group performed unloaded static and dynamic knee-extensor exercises on a vibration platform, which provokes reflexive muscle activity. The RES group performed dynamic leg-press and leg-extension exercises, increasing from low (20 repetitions maximum) to high (8 repetitions maximum) resistance, to train knee extensors.

A motor-driven dynamometer measured isometric strength and dynamic strength, speed of movement was measured using an external resistance equivalent to 1%, 20%, 40%, and 60% of isometric maximum, and countermovement jump performance was determined using a contact mat.

After 24 weeks of training, isometric and dynamic knee-extensor strength increased significantly in both groups (P < .001 vs. baseline), and the training effects were similar in both groups (P = .56). Isometric and dynamic knee-extensor strength were 15.0% ± 2.1% and 16.1% ± 3.1%, respectively, in the WBV group, and 18.4% ± 2.8% and 13.9% ± 2.7%, respectively, in the RES group.

After 24 weeks of training, speed of movement of knee extension significantly increased at low resistance (1% or 20% of isometric maximum) to 7.4% ± 1.8% and 6.3% ± 2.0%, respectively, in the WBV group only. There were no significant differences in training effect between the WBV and the RES groups (P = .39 and P = .14, respectively).

Countermovement jump height improved from baseline (P < .001) after 24 weeks of training in the WBV group (19.4% ± 2.8%) and the RES group (12.9% ± 2.9%). Most of the improvement in knee-extension strength, speed of movement, and in countermovement jump performance occurred after 12 weeks of training.

"WBV is a suitable training method and is as efficient as conventional resistance training to improve knee-extension strength and speed of movement and countermovement jump performance in older women," the authors write. "As previously shown in young women, it is suggested that the strength gain in older women is mainly due to the vibration stimulus and not only to the unloaded exercises performed on the WBV platform."

J Am Geriatr Soc. 2004;52:901-908

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

  • Describe features of WBV training.
  • Compare effects of WBV training with RES training on knee-extension strength and movement in older women.

Clinical Context

Age-related decrease in physical activity and reduction in sex hormones are linked to strength loss and muscle atrophy. The latter predispose elderly women to falls and fractures with subsequent morbidity and mortality. WBV consists of standing unloaded on a platform generating vertical sinusoidal vibration at a frequency of 2.5 to 40 Hz with amplitudes of 2.0 to 10.5 mm transmitted to the body to stimulate sensory receptors such as muscle spindles. Unloaded exercise is performed on the platform. Tonic vibration is believed to facilitate activation of high-threshold motor units affecting fast-twitch fibers, which play a role in muscle strength and power. The major part of the gain in strength is believed to be due to muscle activity provoked by vibration.

One study by Delecluse and colleagues published in the June 2003 issue of Medicine and Science in Sports and Exercise showed increased isometric and dynamic knee-extensor strength of 16.6% and 9.0%, respectively, in previously untrained young women. WBV has the potential to enhance muscular performance in older adults who are unwilling or unable to perform standard RES exercises.

This is the first randomized study to investigate long-term (24 weeks) effects of WBV training on muscle strength, measured as knee-extension isometric, dynamic strength and speed in postmenopausal women not receiving HRT and to compare these effects with similar standard RES training.

Study Highlights

  • Inclusion criteria were postmenopausal women not receiving HRT and not engaged in regular organized physical activities.
  • Exclusion criteria were metabolic or neuromuscular disease, osteoporosis, osteoarthritis, orthopedic injuries, or two or more cardiovascular risk factors.
  • 89 women were randomized to a WBV group (n = 30), a RES group (n = 30), and a control group (n = 29) with no exercise program. 69 women completed the program (n = 24, 20, and 25 for the 3 groups, respectively) and were included in the analysis.
  • The study was powered at 80% with an α of .05 to detect a difference between the training and control groups assuming a dropout rate of around 30%.
  • Baseline assessment included complete medical examination, ergometer test for maximal exercise capacity, and modified Baecke Questionnaire for Elderly to document baseline activity level.
  • The 2 training programs consisted of seventy-two 30-minute sessions for 24 weeks. Training frequency was 3 times a week with at least one rest day between sessions.
  • The WBV group performed a supervised total-body training program with high, deep, and wide-stance squats and lunges with warm-up and cool down. Training volume was increased by extending the duration of the vibrations. Training intensity was progressively increased by reducing rest periods or increasing the amplitude or frequency of vibrations.
  • The RES group performed cardiovascular exercises with increasing resistance for leg extensions and leg presses under supervision from instructors. Repetitions were increased using the American College of Sports Medicine guidelines for individuals older than 60 years.
  • Outcomes (comparing baseline to 12 and 24 weeks) were percentage changes in strength of knee extensors, dynamometry for isometric and dynamic knee strength and speed, maximal strength, speed of movement, and countermovement jump performance.
  • Participants in the 3 groups were similar for age (64 years), weight (66-70 kg.), and body mass index (26 kg/m2). The 69 who completed the program attended all 72 sessions.
  • Isometric and dynamic knee strength increased significantly (P < .001) in the WBV group (mean, 15.0%) and the RES group (18.4%) compared with no change in the control group, after 24 weeks of training. There was no significant difference between the two groups (P = .56).
  • Speed of movement of knee extension significantly increased at low resistance in the WBV and RES groups after 24 weeks of training compared with the control group which showed no improvement from baseline. Improvements in speed of movement were greater in the WBV than the RES group at low resistances of 1% and 20%.
  • Countermovement jump height enhanced significantly (P < .001) in the WBV group (19.4%) and the RES group (12.9%) after 24 weeks.
  • Most of the gain in knee-extension strength and speed of movement and in countermovement jump performance were realized after 12 weeks of training.
  • Reasons for dropout before 24 weeks included incompatibility of training program with lifestyle, mild knee discomfort, and health problems unrelated to the programs. 3 participants dropped out because of anterior knee pain (patellofemoral dysfunction and patellar tendinopathy) associated with the training program.

Pearls for Practice

  • WBV is a safe, appropriate, and efficient strength-training method that can be applied in geriatric settings as a low-impact exercise program.
  • Regular WBV training three times weekly for 24 weeks in postmenopausal women not receiving HRT significantly improved knee-extension isometric strength, dynamic strength, and speed of movement at levels comparable to similar RES training.
  • Since its introduction to the U.S. in 2001 by vibration pioneers - Power Plate North America, Acceleration TrainingTM (a.k.a. vibration training") acceptance continues to increase steadily within the mainstream sports performance, fitness and wellness communities nationwide. Meanwhile, its stronghold in elite athletics, particularly professional and college football, surges onward. With more than 30 professional and college football teams, currently utilizing Power Plate® Acceleration Training products, Advanced Vibration TechnologyTM has quickly established itself as arguably the most relevant new strength and conditioning technology in elite football circles.

    Neuromuscular training using Power Plate® has a wide variety of benefits," said Jeff Fish, Oakland Raiders Head Strength and Conditioning Coach. It increases strength, quickness and reaction time and provides warm-up, cool-down as well as injury-reduction benefits. The low impact nature of the Power Plate also makes it an effective tool for injury rehabilitation. The Power Plate® provides several physiological advantages in our program, and is critical in the overall development of our players."

    Professional and college football strength and conditioning coaches, as well as head athletic trainers, are driven by three primary motivators: providing players a competitive edge, ensuring players safety and health every step of the way and keeping players on the field and out of the training room. Acceleration Training through vibration training is unique in its ability to achieve these ends.

    Fish and the Raiders are among 15 NFL teams using Power Plate®, a list that also includes the Baltimore Ravens, Miami Dolphins and New York Giants. In the college ranks, the impact is no different with Power Plate North Americas client list comprising another whos who list of elite programs, including UCLA, Notre Dame and National Champion University of Florida Gators (the aforementioned teams do not officially endorse Power Plate North America or its products).

    We used Acceleration Training with Power Plate® products extensively during our national championship run and traveled with it to Phoenix for the title game last year, said Mickey Marotti, University of Florida Football Strength and Conditioning Coach. Not only do I love the versatility and effectiveness of Power Plate®, our players also recognize the variety of benefits.

    Athletes Performance, the nations preeminent athletic training franchise, has championed Acceleration Training with Power Plate® products since its inception in the United States. Athletes' Performance facilities prepare more college prospects for the annual NFL professional football combine than any other training organization. Through this use and the outspoken endorsements of Athletes Performance founder and nationally-renown athletic training specialist - Mark Verstegen, Acceleration Training has established itself within professional and collegiate football.

    Acceleration Training is integral to sports performance methodology and Power Plate is the only choice for the elite athletic population, said Verstegen. We use Power Plate products across our entire methodology, from high performance to medical rehabilitation and regeneration.

    Backed by a host of published research, Acceleration Training with Power Plate® products offers a wide variety of benefits, including improved muscle strength, flexibility, balance, reaction time and quickness, hormonal release, pain reduction and expedited recovery of damaged muscles and tendons.

    Acceleration Training via Power Plate® equipment exploits the body's innate reflexive response to disruptions in stability in order to achieve its varied benefits. Just as the leg kicks forward involuntarily when the doctor strikes the lower knee to test reflexes, the body's muscles engage in an involuntary reflexive muscle contraction in response to the vibration stimulus from Acceleration Training. Muscles are forced to contract 25-50 times per second in response to mechanical vibrations delivered to the body from a central platform upon which static and dynamic exercises are performed.

Graston Technique NYC
 
How does the Graston Technique Work?
The Graston Technique is an innovative, patented form of instrument-assisted soft tissue mobilization that enables clinicians to effectively break down scar tissue and facial restrictions. The Technique utilizes stainless steel instruments designed specifically to detect and effectively treat areas exhibiting soft tissue fibrosis or chronic inflammation.
Treatment with the Technique is conducted in concert with a rehabilitation regimen designed to restore athletes to their pre-injury level of activity. This is accomplished by implementing a functional progression program, which zeros in on imbalances throughout the kinetic chain. Flexibility, strengthening and muscle re-education is employed to provide the athlete/patient with optimal results within a minimal number of treatment sessions.

The positive clinical results achieved thus far have led to additional research that explores patient responses to the Graston Technique. Athlete outcome data that measures pain and function - including activities of daily living - continues to be gathered.

Product Use and Procedures
The patented Graston Technique Instruments - shaped to fit the contour of the body- are used to scan the area and assist clinicians to locate and then treat the injured tissue that is causing pain and restricting motion. Clinicians utilize the instruments to supply precise pressure to break up scar tissue, which relieves the discomfort and restores normal function.

Frequently Asked Questions

Q: How does the Graston Technique Work?

A: It is theorized that the Graston Technique is effective because it provides controlled micro trauma to the affected soft tissue structures. It also stimulates a local inflammatory response, which leads to remodeling and repair of affected soft tissues structures. The instruments allow therapists to specify the area that is being treated.

Q: Who can benefit from the Graston Technique?

A: Individuals who are experiencing pain and loss of motion and function following surgery, injury, cumulative trauma disorders and tendinitis may benefit from the Graston Technique. Some clinical diagnoses which have responded well to the Graston Technique include:

• Carpal Tunnel Syndrome (wrist pain)
• Scars
• Plantar Fasciitis (foot and arch pain)
• Adhesions
• Cervical Strain/Sprain (neck pain)
• Restrictions
• Lumbar Sprain/Strain (low back pain)
• Muscle Spasms
• Achilles Tendinitis (ankle pain)
• Muscle Pulls
• Rotator Cuff Tendinitis (shoulder)
• Trigger Points
• Patellofemoral Disorders (knee pain)
• Tendinitis
• Later Epicondylitis (tennis elbow)
• Muscle Strains
• Medial Epicondylitis (golfers elbow)
• Shin Splints

Q: Why is scar tissue a problem?

A: Scar tissue limits range of motion, and in many instances causes pain, which prevents the patient from functioning as he or she did before the injury.

Q: How is scar tissue different from other tissue?

A: When viewed under a microscope, normal tissue can take a couple of different fashions: dense, regular elongated fibers running in the same direction, such as tendons and ligaments; or dense, irregular and loose with fibers running in multiple directions.  In either instance, when tissue is damaged it will heal in a haphazard pattern--or scarring--that results in a restricted range of motion and, very often, pain.

Q: How are the instruments used?

A: The Graston Technique Instruments are used to enhance the clinician’s ability to detect adhesions, scar tissue or restrictions in the affected areas. Skilled clinicians use the stainless steel instruments to comb over and "catch" on fibrotic tissue, which immediately identifies the areas of restriction. Once the tissue has been identified, the instruments are used to break up the scar tissue so it can be absorbed by the body.

Q: Is the treatment painful?

A: It is common to experience minor discomfort during the procedure and some bruising afterwards. This is a normal response and part of the healing process.

Q: What is the frequency of treatment?

A: Patients usually receive two treatments per week over 4-5 weeks. Most patients have a positive response by the 3rd to 4th treatment.

In July, the Journal of Orthopaedic & Sports Therapy published a study of 42 people with shoulder injuries. Half of them were treated with Kinesio tape applied in a pattern designed to support the injured muscle. The other half were given a “sham” treatment in which two strips of tape were simply pressed across the arm. The study was conducted by physical therapists at Winn Army Community Hospital in Fort Stewart, Ga., who didn’t receive funding from the tape company. Notably, the study participants who received the real therapeutic tape treatment reported an immediate improvement in pain.

Last year, Research in Sports Medicine published a study from San Jose State University showing that in 30 healthy test subjects, use of the tape along the lower trunk area appeared to increase the range of motion.

Exercises for Herniated Disc Patients


Exercises for the back muscles and spine can help in all cases and stages of herniated disc disease. As the herniated disc heals, back exercises can be used to help manage pain when combined with other treatments and physical therapy. These exercises are also helpful in regaining mobility and extending your level of activity after a back injury. Finally, back exercises can help you prevent further or additional injury, and avoid recurrences of a herniated disc disease.

There are two exercises that are exceptional for easing back pain while recovering from a herniated disc. The first exercise requires you to lay flat on your back on a bed or the floor. You then raise your knees with your feet on the bed. Wrap your ivy tech online courses or hands around your thighs and lift your knees as close to your chest as possible. It is recommended by most physical therapists that you repeat this exercise for five repetitions several times per day.

Another exercise that you can do to relieve back pain caused by a herniated disc requires you to stand flat footed, away from a wall. You simply place your hands on your lower back, lean back as far as you ivy tech online courses and hold for a few seconds. Physical therapists suggest that you repeat this exorcise as needed when your herniated disc is causing you severe amounts of pain because it takes pressure off of the disc.

There are many great exercises that are great for strengthening your back to prevent further injuries or herniated discs as well. In fact, there are so many that they cannot all online course management here. Most of the exercises that will strengthen your back make use of an exercise ball, available at most department stores or work out supply shops.

One such exorcises requires you to simply lie back on the ball with your feet flat on the floor, and your arms crossed on your chest. Crunch up slowly from your waist and lie back. This exercise will my credit score you to stabilize your spine and take pressure off of any painful areas or the herniated disc. It will also help strengthen the muscles in your back to help prevent any other injury or another case of a herniated disc.

Hip rolls are also great for strengthening the back for the prevention of a herniated disc. Simply lie flat on your back on the floor with your online course management bent and your feet flat. You allow your knees to fall toward the floor first right, then left. It is recommended that you turn your head in each direction while doing this, and repeat the exercise about ten times.

Our Physical therapist in our NYC Physical therapy center offers treatment for patients suffering with herniated disc.

Non Surgical Knee Pain Treatment

When there is a problem with this part of the knee it manifests as pain in the front of the knee after strong exertion (running, walking, or stair climbing.) This may be due to erosion of the cartilage on the under side of the patella, poor tracking of the patella in its groove on the front of the knee, or an inflamed tendon on the lower edge of the patella.

The patella is covered on its back side with the thickest layer of articular cartilage of all the joints in the body. Erosion of this cartilage is called "chondromalacia patellae." On x-ray it is seen as a decrease in the amount of cartilage underneath the kneecap. It may be caused by trauma or occur spontaneously. If the patella is fractured, pain may still persist after the fracture heals. Prolotherapy, a non surgical alternative to knee surgery  is excellent at relieving all of these pains.

Prolotherapy  helps chondromalacia patellae or patellar tracking problems because the pain-producing structure is generally the patellar tendon or the musculoskeletal support around the patella. Prolotherapy for chondromalacia involves intra-articular (inside) injections as well as injections on the outside of the knee, stimulating the growth of many musculoskeletal structures around the patella. It is for this reason the knee gets stronger and the pain of chondromalacia is relieved.

Patients with pain  often succumb to surgical procedures, even drastic ones. A good example of drastic surgery is the recommendation to surgically remove the patella in order to remove the pain. This sometimes does relieve the pain, but at a significant cost to the body. The strength to extend the knee is reduced by about 30 percent, and the force exerted in the knee is increased. There are a host of other risks associated with surgery. The athlete must realize that with each procedure and each shaving or cutting of tissue, NSAID (non-steroidal anti-inflammatory drug) prescription, or cortisone shot, the odds of developing long-term arthritis are greatly increased. The key to keeping the knee strong is to stimulate the area to heal, not to cover up the pain with a cortisone shot or NSAID. Even worse is to eliminate the painful area by shaving or cutting. This just delays the pain for a few years until the remaining tissue becomes degenerated. The best approach is to stimulate the area to heal. The best way to do that is with Prolotherapy.

Prolotherapy NYC


The Evolution RMT Repetitive Motion Table



Rehab following a full decompression therapy treatment series is extremely important if the patient is to ensure themselves against reoccurrence and further injury. The Evolution DT has two computerized rehab programs incorporated within its 8 total programs available. These two programs are available for strengthening of the lumbar soft tissue. However, for more rehab we offer the Evolution RMT known for its outstanding results.

The Evolution RMT “Repetitive Motion Therapy” Table addresses mechanical disorders of the lower back using clinically proven techniques. The Evolution RMT Table is used in the clinical setting to enhance the effectiveness of repeated end range movement therapy for the low back. The RMT table enables the lumbar spine to be moved to the full degree of end-range movement in flexion and or extension a greater number of times than is physically possible by the patient alone. In the beginning stage of rehab, the patient often times has a hard time getting to full end-range position due to pain and because of poor physical endurance levels of the patient they cannot do movements long enough for a good enough response. The evolution RMT allows the patient to start rehab earlier and maintain the success of their prescribed home exercise program.


Evolution RMT Philosophy and Centralization Principles

The treatment protocols of the RMT Table are based on the patient’s directional movement preference and provides measurable and positive outcomes particularly in the management of acute & chronic, severe low back and leg pain (without a neurological deficit). Directional movement preference theory uses the rule of “Centralization” to evaluate and proceed into rehab using activities that “Centralize” the patient’s pain. Recently published scientific research articles have established that the presence of “Centralization” can be a strong indicator of discogenic pathology and is a highly accurate and reliable predictor of treatment outcome. Movement, activities and postures that cause the symptoms to “centralize” indicates the “preferred direction(s)” for the Doctor/Therapist to use in developing both an in office and self-treatment strategy for each patient. Simultaneously, the Doctor/Therapist must teach the patient how to avoid those positions, activities, and movements that cause the symptoms to move “Peripherally”. Many patients suffering from low back or neck pain, with or without referred pain, will unmistakably exhibit a “direction preference” when repeated movement and/or static positioning are applied to the spine. This means there will be a particular movement or position which will cause the symptoms to shift to a more central (proximal) location. Frequently there will be other movements or positions which will cause the symptoms to shift to a more peripheral (distal) location. An example of this is the patient who when asked to go into an extension movement (restoring normal lordosis) which in turn reduces the pain. This is the directional movement we want to begin exercise movements that will start their rehab. The Evolution RMT takes the patient through end-range passive range of motion repetitive movements and reduces the patient’s pain while increasing the patient’s range of motion.


Indications for use of the Evolution RMT

  • Patients who are assessed to benefit from the repeated movements on pain centralization, intensity, and location in flexion or extension.
  • These may include Disc patients, Stenosis patients, Facet Syndromes, or Sacroiliac syndromes where a limitation of movement occurs in the direction of “Centralization”.


Contraindications

  • Grade 3 and 4 Spondylolisthesis patients
  • Tumor or infection of the spine: Paget’s Disease etc.
  • Active Inflammatory diseases: Rheumatoid Arthritis, Ankylosing Spondylitis, Osteoporosis, or severe Osteomalacia (-2.0 or higher on T Scale)
  • Advanced diabetes
  • Fractures, dislocations, ligament tears or ruptures.
  • Instability of lumbar segments or has peripheral signs on both flexion and extension.
  • Patients with Neurological signs: Cauda Equina Lesions, Neurological Deficits, Loss of Bladder control, etc.
  • Patients that have surgical fusions.
  • Pregnancy


Evolution RMT Advantages

  • Variable Speed 1 – 8 Cycles per minute
  • Touch screen Digital Readout
  • Exact, Measurable Movement
  • Pause Button to Change Function During Treatment
  • Sliding Face and Lower Back Sections for Added Comfort During Motion
  • Automatic Return to Horizontal Neutral Position at the End of Treatment
  • Slide out Foot Section.
  • Programmable Timed Automatic Hold at end of Extension or Flexion.


Safety in Using the Evolution RMT

  • Table must never be used by untrained people.
  • Never have patients get on or off the table while it is in motion.
  • Instruct the patient to never reach underneath the table while it is in motion.
  • Instruct patients to keep their arms on the arm rests ensuring they do not allow their arms to go below the bed level.
  • Make sure patient’s clothing does not drape below the table top while in motion.
  • Always dismount table when in the Horizontal Neutral Position



Treatment Protocols

The Physician’s diagnosis and treatment of back and neck problems involves the use of repetitive end range movements that can influence the location and intensity of pain that arises from the spine. A skilled physical examination will reveal the direction of therapeutic motion that is used to resolve the condition. This is referred to as the “directional preference.” While restoring function can be an overwhelming task, the focus can be narrowed down to the primary goal of increasing the patient's functional range (FR). Initially, this consists of the painless or pain-centralizing activities revealed in the patient's history or range-of-motion examination. Therefore, the limits of the patient's FR consist of the aggravating movements and positions, and the key functional pathology related to those symptoms. So logically, before exercise can be prescribed, a thorough history and examination of the patient's mechanical sensitivities should be carried out.

Both history, examination, and imaging tests (X-Ray, MRI, CAT Scan) are involved in this analysis. For instance, the history should identify what positions or movements aggravate, relieve or are neutral to the patient's symptoms, in particular, peripheral symptoms. An example of this would be; the patient’s sitting and forward-bending intolerances strongly suggest a disc problem, and initial setting for the RMT and self-treatment would be "biased" toward extension. Another example of the importance of a thorough history is that many patients explain that they are worse after sitting or standing for a prolonged period of time. Such postural findings are often the only clues when the examination cannot reproduce time-dependent mechanical sensitivities.

Clinical examination should include orthopedic tests that seek out the movements or positions that provoke the patient's characteristic symptoms. Examples of these would be Kemp’s, Ganslens etc. Adding the use of repetitive tests of movements, such as those in the active and passive full range ROM tests, with the intention of better simulating normal activities that are typically repetitious is very important in establishing treatment parameters. In addition, the patient's own historical report of functional activities that aggravate symptoms can be confirmed by the examination of functional activities.

The movements and positions found to aggravate symptoms are used as an audit for pre and post-testing to assess the patient's progress. In contrast, the pain-centralizing or relieving positions and movement ranges are utilized for exercise training.


Patient Treatment General Safety Precautions

  • The Evolution RMT provides repetitive end-range of movement for the mitigation of pain with recovery of function for mechanical spinal disorders. It is a very effective tool but it should be used with some caution. Use the following guidelines in your treatment protocols.
  • Start your treatment in the mid-range of movement until familiarity has provided finer conclusions to be made in selecting starting and treatment angles.
  • We had said before that a Grade 3 or 4 Spondylolisthesis should not be treated with the RMT but if treating a Grade 1 or 2 the fixation belt should not be used.
  • In the presence of significant fixation of joint movement, joint and soft tissue scarring can be overstretched if the end range of movement is too excessive or if too many cycles are performed. Always be conservative in choosing end range points and cycle repetitions.
  • Posterior Disc Derangements will respond very well to the RMT. It is possible to reverse the derangement but once they appear to be stable it is to the patient’s advantage to place to transfer the patient to a more active therapy of self improvement procedures.
  • It is especially important to watchfully scrutinize the patient’s pain and or neurological status before, during, and after treatment. Communication of treatment results will ensure modifications that will improve results.
  • Patients should always be reminded to use the control “Stop” treatment button when treatment is uncomfortable or increasing symptoms.
  • Belt fixation with the patient prone creates the opportunity to cause injury. Before applying belt fixation it is important to manually test for appropriateness. Provided the “more pressure, less pain” test is answered in the confirmatory, belt fixation may be applied. Always apply belt fixation with the patient in their maximum tolerated extended position.



Treating the Chronic Low Back Pain Patient

The patient with “Chronic Low Back Pain” is our most difficult low back case. These patients typically enter the office complaining of constant pain and have been told they will have to “Live with their pain”. In actuality they do not have continuous pain. They actually suffer from recurring episodes that create the notion that their pain is continuous. The use of the RMT will increase the mobility of soft tissue, increase joint flexibility, and increase muscle strength. When these goals are accomplished the pain often has periods of days, months, and even years of discontinued pain and healthy function. In the beginning of treatment the clinician must be aware that the chronic patient may experience a pain of a different quality. His mobility may be restored but some persisting aching, probably of chemical origin may be present for 48-72 hours after the initial treatment. The patient should be made aware of this possibility. If pain persists proper modifications to treatment should be made.

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