Old injuries and new pain?

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Most people don’t associate long term injuries that are often asymptomatic with current levels of pain. This single case study is a great way of demonstrating just how this can occur.

Brief history of client-34 year old rugby player presenting with recurrent achilles pain despite long term physio. A great case of lifitis as somebody reminded me about my own injuries recently! Two ruptured biceps over the last decade and neck injuries to boot. Presented with inhibited bilateral hamstrings, right lat, neck extensors and left rectus femoris and quadricep (hip and thigh muscles) inhibited. Also poor dorsi flexion (raising the foot from the floor) inhibited by his calf muscles. His thoroca-lumbar fascia, the piece of tissue that connects the glutes and lats was holding a lot of tension and contributing to a poor link between these two powerful muscles.

Compensation can take many forms. For example with this case the client was usiing his diaphragm to help stabilise other joints in his body that was not balanced with the pelvic floor and TVA (transversus abdominis or hoop like muscle that is a key player in spinal and segmental stability)

After testing and re-activating the muscles that were inhibited using NKT (TM) the muscles, I taped the right to left posterior oblique sling as you can see in the picture, with great results. The tape acts as a conduit for proprioception or communication between this key sling. Client has been free of achilles pain despite training heavily during pre season rugby training.tape Posterior oblique sling

Analysis in the form of SFMA selective functional movement assessment and re-establishing neural pathways through the use of NKT, appropriate treatment and exercise have ensured that this client got out of pain most effectively and the interesting part…I didn’t touch his heel to get rid of the pain! To find out how to get pain free, moving and grooving get in touch to find out more.

Is your technique driving your injuries

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Training the classics like deadlifts and squats are an integral part of training and getting strong. More often than not we tend to sacrifice key parts of our body like a sacrificial lamb to the slaughter, inviting injury with each rep. One of the most common things that I see with clients deadlifting and injuries, is the drive with the neck in a fully extended position, which is shown above.

Using a body part to drive a movement isn’t detrimental and as the motor control command is executed it has to start somehwere but extending the cervical spine shifts the emphasis on the kinetic chain. As the Cervical extensors are fully contracted, the whole extensor chain has to ensure that all the work is completed whilst a fully extended position is held. Short tight cervical extensors are a common finding in many people and their recruitment/facilitation and inhibition with many factors can be linked with issues in the calf and plantar fascia of the feet.

You will notice in the picture below as theorised by Myers and others that the superficial back line is a complete chain from head to toe. Facilitation of the cervical extensors can contribute to forward head posture and postural changes in the thoracic spine, shoulder and lower down the chain. Instead of creating injury hotspots, keeping the neck in a more aligned neutral throughout the lift and using the eyes to drive into extension can help alleviate the problems associated with facilitated neck muscles.

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Cesarean section or Chaos section? Why you may have back pain after your baby.

Medical systems can often create a vicious cycle and the Cesarean section is one such cycle. The creation of specialist departments often creates a vacuum where, what some might think as minor issues go ignored, yet affect those who have to undertake specialist procedures. In any other system say finance or banking it would be called negligence or incompetence for failing to notice where the system broke down (something not often noticed until after the debacle has occurred) but because it often involves individuals who suffer from one of the most common medical issues in the world the cause and effect often go unnoticed.

It’s a simple statement Cesarean sections could be one of the leading causes of back pain in females. A statement that can be validated fairly easily when you observe this phenomenon on a regular basis . I have never met a female client who had a C-section who didn’t suffer from either lumbar, cervical or sacroiliac joint dysfunction. Governments who want to save hundreds of millions of unnecessary cash spent on treating back pain may want to scrutinise this point. It often serves the medical insurance system to keep this cycle system in full flow.lumbar spine

Females who have suffered from back pain, most likely due to failure to rehabilitate the key stabilising mechanisms of the the lumbo-pelvic complex may have avoided back pain all together. Implementing a basic program would not only help to avoid back pain but may aid women back into exercise much sooner assisting any psychological issues such as post-natal depression.

A general rule for low level exercise post C-section to begin is 6-8 weeks. The healing process starts immediately post op and the nutritional status and individuals immune system plays a significant role in healing time, decrease of infections and energetic processes.

During the surgery process. The skin, abdominal fascia, Rectus Abdominus and Transversus Abdominus (TrA) are easily severed with many nerves also being affected by the surgeons scalpel. This is where the chaos begins. Whilst the global implications of movement dysfunction are readily observed with restrictions to simple tasks such as standing, sitting and even turning over in bed. The local intrinsic nature of lumbo-pelvic stabilisation dysfunction is not observed until the women attends a specialist to deal with a particular pain syndrome. More often than not light cardiovascular exercise is recommended which serves to deepen the dysfunction not only due to the lack of appropriate muscle activation but also due to its effects on respiration.

The TrA whilst important with its synergistic role with the multifidi, diaphragm, pelvic floor muscles also has an essential function with respiration. During inspiration the primary muscle of inspiration the diaphragm contracts displacing the abdominal viscera outwards and downwards placing both the muscles of the pelvic floor and TrA in a stretched position. The natural recoil of the TrA assists in exhalation,helping to force air from the lungs. Post C-section this action can diminish placing additional stress on the excessory muscles of respiration. Additionally the flexors of the trunk, primarily the Rectus abdominis often become inhibited and other muscles can facilitate in response to altered movement dysfunction. In one case a patient with multiple C-sections presented with chronic recurrent cervical and lumbar disc issues. In particular the MRI showed a flattened cervical spine and it is worth-speculating that the anterior cervical flexors facilitated in response to a lack of trunk flexion. The patient was literally trying to flex her whole spine with her neck flexors. Use of Neuro Kinetic Therapy (TM) helped to re-establish synergistic neck and trunk flexion by restoring equilibrium.conceptual model

In this and 100% of all clients who have had a C-section the TrA can either be facilitated or inhibited. strategies to stabilise compromised structures and dysfunctional movement can be local or global. How Muscular dysfunction occurs

Strategies can include:

Breath holding via facilitation and compromised diaphragmatic action
Facilitation of the pelvic floor
Clenching of the masticatory muscles of the TMJ/Jaw
Local compensation such as Quadratus Lumborum facilitation
Cervical muscle facilitation and inhibition
Altered lower limb mechanics including plantar fascia and disruption of dorsi flexion and toe mechanics.

Scar tissue formation can be problematic due to adhesions of healing tissue in particular to fascial continuation, function and adhesion of tissue to internal organs. Addressing these adhesions and restoring optimal function of the TrA and its dual facilitory or inhibitory effect on both local and global structures can be achieved with therapies such as NKT and appropriate corrective exercises. Even without a Cesarean section, you can apply the same rationale to tears or episiotomy procedures and the same fuzziness that the nervous system experiences when trying to provide stability to the body.

References:
Chek, P. Posture and Craniofacial Pain. A Chiropractic Approach to Head Pain. Williams and Wilkins 1994

Weinstock, D. Neuro Kinetic Therapy. North Atlantic Books. Berkeley, California.

 

Shoulder pain…which one?

Shoulder pain is one of the most Image-1common musculoskeletal issues that I see in my practice from week to week. Its easily as common as neck, lower back, hip and knee pain.

So why is shoulder joint dysfunction so common? Well from the lay view, most people intepret shoulder pain as a rotator cuff issue, usually stemming from increased medial rotation. Common thoughts are that the use of the computer mouse, impact on this postural problem.

Too much bench press, throwing, ipad playing, racket or club, bat sports or anything that contibutes to excessive internal, external rotation, protraction, retraction, elevation or depressing of the shoulder joint and girdle and other actions will contibute to shoulder pain. Impingement syndrome is probably one of the most common shoulder problems.

Often external rotation exercises are utilised to combat these problems, often ineffectively. Determining whether the issue is one of mobility or stability and motor control should dictate which modality of therapy should be used together and the type of movement should be dictated by the dysfunction of each of the four joints of the shoulder.

Paul CHEK used the term slave joint to decribe any articulation below C2 (2nd cervical vertebrae) as a term to describe the vulnerability afforded to any joint that could be affected by heirachical factors such as breathing, atlas ( 1st cervical), vision, jaw and others that could influence lower joints such as the shoulder. Whilst this is a particularly useful model to bear in mind, both local and global dysfunction often effect the shoulder joint in isolation or together, from the head down or the foot up.

More often than not dysfunction in the opposite ankle can increase the facilitation of shoulder muscles. A lack of dorsi flexion or movement of the ankle which raises the whole foot off the ground whilst keeping the heel on the floor, can be a common feature in shoulder dysfunction. treating the shoulder may be the last thing that needs to be acheived in restoring shoulder function and decreasing pain.

Restoring shoulder mechanics need not be lengthy periods of shoulder rehab. Identify the cullprits involved in over working, rewire the ones that don’t work enough, and create a stimulus that holds that pattern.

If you have shoulder pain and all people ever do is look at your shoulder, ask them to take a look at your ankle, breathing pattern, neck just in case they need a nudge in the right direction.

 

 

Latest Dubai Interview

Keith Littlewood joins Suzanne to talk back pain in dubai, postural issues and hormones. We also discuss health news on men gaining weight during wife’s pregnancy, and a new  study on diabetes in the UAE.

Find out some of many factors that affect your health, movement, sleep and energy.

5 reasons why you get back pain.

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There are many reasons why we get back pain. In fact the points raised above are merely what occurs when the musculo-skeletal system is out of alignment, I repeat, what occurs when the musculo-skeletal system is out of alignment. What does that mean? Well if you work on balancing structures then all of the above points can be managed and in many cases eradicated. When we breathe, sit, think and complete exercise inefficiently we start to compensate with a variety of muscles. So getting movement and structure analysed can help to determine mobility and motor control issues that need to be addressed.

If you are ever diagnosed with any of the factors above and are told that you should avoid exercise then ignore that specialists advice. One of the most important things in anything spine related that you can do is to exercise but you need to exercise correctly, understand what has caused these conditions and use a variety of therapy and exercise to rectify the faults. Here is a brief summmary of the points suggested above.

1. Sacro-iliac joint dysfunction- is one of the most common forms of back pain and one of the most commonly mis-diagnosed conditions, often mistaken for a disc herniation. Females are often more exposed to SIJ dysfunction and can often be resolved with mobilisation and exercise to support the extra width of the pelvic basin.

2. Facet (zygapophysial) Joint- is the main articulation of the vertebra and can often become dysfunctional due to the position of the spine as most of these conditions can. Mobilisation and improving recruitment of spinal muscles can help to improve the movement of the facet joints.

3. Disc Herniation- a common problem in those over 30 mostly in the lumbar spine (can occur in cervical/neck too) with pain often felt either locally or referring commonly along the distribution of the sciatic nerve into the back, glute, legs and feet. The nucleus of the disc, the hardened jelly like material between the disc can rupture causing compression of the spinal nerves and pain ensues. Flatter back people are more predisposed to herniations but rotational and lateral movements also contribute to herniations. Strengthening of the core muscles, particularly the multifidus muscles can help alleviate and remove pain. Sometimes restoring the natural lumbo-pelvic rythm can be effective in this condition too.

4. Stenosis- the hole created by the lateral structures of the spine, is the space where the spinal nerves exit. Often when there is instability, osteophytes, small growths of bone can occur to stabilise segments of the spine. A side flexion of the trunk can close down the space of the nerves exiting that vertebral segment too. This can cause irritation of that particular nerve. Once again understanding what structures are over and underworking can provide relief to this problem.

5. Spondylolisthesis- is a fracture of the pars articularis a part of the vertebra which causes a rotation (if one sided) and forward slippage of the vetebral body, which can create torsion of the disc, also placing pressure on the spinal cord itself. Some people are born with this fracture but rotational sports such as golf contribute to this condition. Rotation and flexion at high speeds can create the sheer responsible for this fracture but can easily be avoided with the right stretch, mobilisation and exercise program,.

There are many other causes of back pain all of which can be rectified or avoided with the right program. One thing to take away from this blog is that if you are experiencing pain then you need to change what you are doing. Don’t worry pain is a communication from your body to change but find someone who can deal with structural issues decribed above. You may often find that the solution is with doing less but more intelligently.

1. Bogduk, N. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone. 2003

2. Porterfield, J.A., DeRosa, C. Mechanical Lower Back Pain. W.B. Saunders Company 1991.

Are nipple cream and formula increasing food allergies?

As I am about to become a father again, I am often interested in the recommendations that are suggested to my wife when it comes to food and tips that might be of use once junior has arrived.  With the huge rise in sensitivities and allergies (some valid and some just neurotic) that are seen both in my practice and across the globe I thought it might be worth looking at possible etiologies of these issues. Now I am not someone who recommends expensive food allergy tests. I would rather look at other factors that can help to bring resolution with the digestive system and simple exclusion diets can help to determine food allergies.  If we look at gluten and wheat for example, there are some well founded issues such as celiac disease which warrant exclusion from the diet. When the digestive system is stressed we can often become more sensitive to gluten but many people do not have gluten issues. Poorly produced grains may be part of the problem of a failing metabolism. easy way to try, cut it out, do you feel better. Ok exclude it for a short while!

It’s nothing new to say that the quality of air, food and water, have gone dramatically downhill, I think most intelligent people agree on that. The ingestion of poor quality and chemically loaded foods can do a great deal to trigger immune responses in both mother and baby. It is also clear that the ingestion of Poly-unsaturated fatty acids or PUFA’s can lead to these changes too. The sad thing is that many of these products find their way into milk replacements such as baby formula.  I am not going to get caught up in the, how long a mother should breast feed for, as it is clearly beneficial to breast feed for as long as possible. In a recent study the following was suggested

‘PUFAs may predispose to allergy and a diet rich insaturated fatty acids and low in PUFAs may be one factor explaining the low allergy prevalence among children growing up on dairy farms.’

A previous blog talks about PUFA’s

This is part of my own confirmation bias that PUFA’s are far worse than saturated fats so I would encourage you to make your own conclusions on this.From the suggestions that my wife has received there have been two very clear factors that struck a cord with me and warranted further investigation.

These were pre and post and post natal nutrition recommendations and nipple cream. Yes nipple cream but first the nutrition recommendations!

 The doctor recommended a supplement that had omega 3 fatty acids which by many accounts show links to increased allergies, as can omega 6 PUFA’s.  Another recommendation was for baby formula. Below are the ingredients of a well-known baby formula that made my eyes roll…

Lactose, Vegetable Oils (including Structured Vegetable Oil), Skimmed Milk Powder, Whey Protein Concentrate (enriched in Alpha-Lactalbumin), Emulsifiers (Soy Lecithin), Sodium Citrate, Magnesium Chloride, Calcium Carbonate, Potassium Bicarbonate, Potassium Citrate, L-Tyrosine, Vitamin C, Calcium Chloride, Potassium Chloride, Calcium Hydroxide, Potassium Hydroxide, Choline Chloride, Taurine, Inositol, Ferrous Sulphate, Zinc Sulphate, L-Tryptophan, Cytidine-5′-Monophosphate, L-Carnitine, Antioxidants (Tocopherol-Rich Extract and Ascorbyl Palmitate), Disodium Uridine-5′-Monophosphate, Vitamin E, Niacin Adenosine-5′-Monophosphate, Pantothenic Acid, Disodium Guanosine-5′-Monophosphate, Disodium Inosine-5′-Monophosphate, Vitamin A, Thiamin, Copper Sulphate, Vitamin B6, Riboflavin, Vitamin D, Folic Acid, Manganese Sulphate, Potassium Iodide, Vitamin K, Biotin, Sodium Selenite, Vitamin B12.

There are many factors in here which could provide a possible pathway to the development of a food allergy. It’s worth noting that most (90% of produced) vegetable oils and soy (which is highly estrogenic) come from genetically modified sources. There are significant studies that show that these foods are known carcinogens and could certainly assist in the development of an allergy.

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Now onto that nipple cream! Lanolin was recommended some of my wife’s friends. Lanolin..I had only heard that word echoed by the great Ron Burgandy in Anchorman so I decided to check it out.  Lanolin is a moisturiser secreted into sheep’s wool  and used in treating cracked skin but get this. When ingested it can lead to poisoning and skin conditions…and women put it on their nipples when breast feeding!?  Is it possible that lanolin ingestion by new born babies could trigger allergenic responses? It’s a possibility for sure.  Instead of reaching for creams like lanolin, using good quality saturated fats like coconut oil can provide a much safer alternative and cost next to nothing.

Less is often more and whilst I believe that we may still be evolving to deal with threats of known toxins that permeate life across the globe. Natural products like coconut oil can serve to help protect both mother and child without the need for chemicals that may cause a problem.

1.  Van den Elsen, L; van Esch, B; Hofman, G; Garssen, J; Willemsen, L. A high fat soy oil diet prevents oral tolerance induction and enhances allergic symptoms in a mouse model of cow’s milk allergy Utrecht University, Utrecht, Netherlands

2. http://publications.lib.chalmers.se/records/fulltext/140637.pdf

3. http://www.sciencedaily.com/releases/2011/09/110908161444.htm

Big Moves..small muscles

Muscular pain is one of the most treated issues globally and there are hundreds of modalities for treating musculo-skeletal issues. In my practice I often see many injuries that have often  been dealt with in such a passive manner that there is never real hope of treating the issue.  Identification of structural issues is key to changing the pattern of facilitation and inhibition that often occurs with many so called pain syndromes. An example of this pattern would be the Pec Minor’s inhibitory effect on the opposite hip flexor when facilitated.

Why is it that so many people often fail to have successful responses to treatment? Here are just a few reasons.

  • Incorrect biomechanical evaluation
  • Poor treatment modality
  • Patient compliance
  • Imposed working postures, seated position.
  • Over exercise and pattern overload

Much postural analysis fails to observe dynamic actions and test specific local to global muscle actions that could be responsible for the facilitation/inhibition cycle that is present when dysfunction and injury is present. Much soft tissue work that is used is often only used to treat facilitated tissue. For a treatment to be effective inhibited muscle tissue is required to be taken from an inhibited pathway to an activated functional muscle that executes the desired motor program and helps to reduce inhibition of facilitated muscle tissue.

Neuro Kinetic Therapy (NKT) is an effective form of analysis and treatment that allows a joint by joint and functional approach to assessing muscular dysfunction and addressing both facilitation and inhibition in an effective and efficient manner. Once dysfunctional tissue that is either inhibited or facilitated, has been located, a strategy to restore function can be achieved by observing functional links between muscles either synergistic or antagonistic.  NKT is a favourable approach as it compliments many other rehabilitation, corrective exercise and performance exercise modalities.

If you take a look at the adaptation of Schmidt and Wrisburgs conceptual model of performance which is below. You’ll note that the stimulus and response stays the same to the activity undertaken, on a continuum of walking to complex sporting actions.  However due to Sherrington’s law of reciprocal innervation the motor program can ultimately be changed to reflect the same outcome and other muscles can be recruited in compensatory mechanisms.  This can occur during motor program execution and following muscular recruitment, can be impeded by either over training or poor motor recruitment.

There can many reasons why injuries occur which can include a simply repetitive over/underworked relationship between two muscles or through an entire muscular sling or line. Analysis of these relationships using NKT can reduce the amount of guesswork and increase the quality of both treatment and pain eradication. The days of laying on a physiotherapy or massage couches being treated by interferential machines and inappropriate cookie cutter exercises are numbered.

conceptual model