mobility

Skin deep? The role of skin in motor control and dysfunction.

Many people are aware that dysfunction can occur from many different areas. Scar tissue, joint and ligament/tendon receptors, muscle fibres and many more factors contribute to pain and movement issues. The role of skin in providing feedback is not so prevalent in literature or discussed as a source of a client’s motor control, pain or dysfunction issues. Whilst muscle and joint receptors are well known as proprioceptors, the skin contains a large amount of feedback from exteroreceptors originally proposed by Sherrington. These include:

Meissner – vibrationskin copy

Pacinian- vibration

Ruffini - pressure response

Krause – pressure in mucosal tissues

Merkel - pressure/touch to skin

Free nerve endings – nociceptive/pain stimulation

The skin provides feedback from external stimulus, adjusting steps and movement. Damage to the skin can be one of the many areas that clients often forget and for that matter, surgeries such as appendectomies, c –sections and kidney removal are just a few of the ‘small’ procedures that have not been mentioned in an initial session.

Deep abrasions on young tissue, which heal and visually, present little to see on an adult body, are common. A recent finding with a client was a certain amount of dysfunction between a deep unseen scar from falling from a bike 20 years ago playing havoc with the scar tissue and stability of   the same knee from a later ACL reconstruction. Using techniques such as PDTR (proprioceptive deep tendon reflex) and NKT (neuro kinetic therapy) it is possible to assess the impact of scars, seen or unseen on stability and motor control of muscle and ligamentous tissue.

Another common issue is the role of deep coloured tattoos and their impact on surrounding muscle tissue via skin receptor dysfunction. Usually dysfunction between quick pin tracts (Neospinalthalmic tracts) and slower pain (Paleospinalthalamic tracts) are prevalent with tattoos but depending on depth and other factors, dysfunction can present via the receptors suggested above.

Tattoos can create dysfunction in underlying and other tissues

 

Addressing muscular dysfunction can be useful and effective as part of the treatment but in addition to assessment of joint, ligament, tendon and pain pathways; assessment of the skin and its associated receptors should be an integral part of the client’s treatment.

 

References:

Palomar, J. Proprioceptive Deep Tendon Reflex. Course manual.

Purves D, Augustine GJ, Fitzpatrick D, et al. Neuroscience 2nd edition.

Sinauer Associates 2001.

What is regional interdependence?

What is regional interdependence and why do we need to know more about it? History is often the most prevalent factor for the exposure to future injuries. Many clients and surprisingly clinicians are often blissfully unaware of the impact of previous injuries on current and future injury scenarios. Here are five key examples of actual clients that I have worked with.

  1. Left sided lower back pain, not resolved with surgery, from 40 year-old scar, left by kidney removal at the age of 1.
  2. Ankle injury causing lower back pain.
  3. Appendectomy scar, decreasing core function, causing lower back pain.
  4. Ear piercing creating shoulder dysfunction on the opposite shoulder.
  5. Hyper –contracted toe muscles creating mobility issues in neck.

Of course there are more, hundreds, perhaps thousands more. For the evidence medicine biased people, I am not about to create theoretical models for you to shoot down with a lack of scientific literature. Although there are increasing studies that support the rationale for regional interdependence. There are also many methods of assessment that create adequate reasoning to show how restriction, lack of stability and dysfunction in one area of the body may have a significant impact on other areas of the body. SFMA (selective functional movement assessment), Gray institute, Anatomy in Motion and many other forms of assessment provide insights to how a lack of mobility and stability at the ankle has an impact on say mechanics of the knee, hip, spine, shoulder and head.

Many practitioners and clinicians have often been taught to view each issue in isolation, which to a degree can be helpful; As local problems can often be responsible for a global issue. Think a scar, such as a C-section, inhibiting core function, increasing dysfunction in the posterior chain not addressed by anterior chain function. But what about when symptoms persist? True, there are many factors that can contribute to pain and dysfunction that simply will not be addressed by massage/trigger points, needles and corrective exercise and I might suggest that some gains may serve as mask to the actual underlying dysfunction.

 

10264312_699027360144587_8762295179813694115_nYou may have observed the concept of regional interdependence after having a good calf massage. Ever noticed how good your neck feels after having your feet and calf massaged? There’s a clear fascial line between the feet and the neck as proposed by Myers in the superficial back line. There is also literature to support the concept of viscerosomatic pain referrals. This may include pre menstrual issues on back pain or gastro-intestinal dysfunction involved in headaches. To address these dysfunctions truly we need to get to the root cause of the issues. That neck often gets tight again after having those feet massaged as the compensatory muscles are overworking for an underworking area.

If perhaps the calf muscles are overworking due to a lack of function in their antagonistic muscles such as the dorsi-flexors or shin muscles. You may well see the neck tightness dissipate, when this relationship is addressed. Follow up mobility work may also be useful for the neck.

Determining mobility versus stability issues is paramount. A decrease in mobility may come from many sources such as:

  • A lack of stability -( how to determine video)
  • Breathing pattern dysfunction (a stability issue)
  • Biochemical – vitamin D/K2/A/calcium factors
  • Gluten –stiff person syndrome, A tentative link between the consumption of gluten and muscle stiffness.

Here we can see the futile task of mobilising joints via releasing and stretching muscles, when there exists factors that contribute to the lack of mobility, that will not resolve with mobilisations.

It’s important for the patient to bring a complete injury history to the table and for the clinician to assess the impact and hierarchy of all factors. Determining mobility against stability factors, improving motor control and treating via the suggestion of regional interdependence may be more beneficial than simply just treating overworked painful areas.

 

References:

 

  1. Cook, G et al. SFMA Course Manual. 2011
  2. Hadjivassiliou M1, Aeschlimann D, Grünewald RA, Sanders DS, Sharrack B, Woodroofe N. GAD antibody-associated neurological illness and its relationship to gluten sensitivity. Acta Neurol Scand. 2011 Mar;123(3):175-80. doi: 10.1111/j.1600-0404.2010.01356.x
  3. Myers. T. Anatomy Trains. Elsevier. 2014.
  4. Sueki D. G., Cleland J. A., Wainner R. S. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy. 2013;21(2):90–102. doi: 10.1179/2042618612y.0000000027

Working with Amna

In the past few months I have had the pleasure of working with Amna Al Haddad. She is a motivated, strong woman with a goal of training for the 2016 Olympics in Rio. When I first met Amna she was a little disappointed with her progress and felt like she had hit a wall with her training. Initially the goal was to tweak her energy levels by analysing her metabolic rate and modifying diet to get the optimal amount of energy, to improve performance. When people participate at high level sports they can often become very strong through compensatory mechanisms. Using bio-mechanical assessments and motor control evaluations such as SFMA and Neuro Kinetic Therapy, we were able to change the way that Amna's nervous system communicated with the appropriate muscles and present some strategies that kept them optimal.

Understanding the difference between mobility versus stability issues is key.This ensures that movement remains great and injuries are reduced.

It's been great to see Amna hit some new PB's and stay motivated for her goals ahead. Really looking forward to see her excel over the next few years as it has been a pleasure working with someone so motivated to achieve their targets.

Amna's face book page 

"Working with Keith in the past few months have been absolutely great. My performance, energy levels, and stability definitely increased after our treatment sessions. My muscles have been compensating a lot, often causing a lot of dysfunction and irritation that has affected my weightlifting and strength levels.Keith understands the human body in a different way than what I have seen before from a performance consultant; he can immediately show you how to activate a muscle and restore its strength, reduce pain, and more in just a few seconds! BUT..you have to do your homework to reinforce the new movement patterns."  Amna Al Haddad, UAE national Olympic Weightlifter

 

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The difference between mobility and stability issues

Do you have an injury that keeps reoccurring? Finding the difference between mobility and stability issues can be the key to eradicating pain for good If you have ever suffered from an injury and there was no difference made between a mobility or a stability issue. Chances are you may still have the injury.

You often see many trainers and therapists focusing on mobility, mobility and more mobility. Release this muscle with that foam roller release the fascia with this ball but unless the distinction is made between whether a mobility drill or stability training or re-programming of the nervous system needs to occur, All you will end up with is one mobile injured body. It’s a simple thing to do. Just determine whether the movement can be conducted through the desired range. If it can’t, the question should be asked can this be done passively, with someone else guiding you through the movement. If the answer is yes. You have a stability or motor control dysfunction.

If you are the one of many going through the insurance/treatment mill or simply not getting any resolve from massage, exercise or whatever therapy that you are undertaking. Don’t be scared to ask the person treating you…Do I have a mobility or stability issue? It will help to cut through all the fluff. .