stability

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. .

Getting to the core and why you have back pain despite rock hard abs!

The concept of ‘core’ conditioning has evolved significantly since the millennium and there have often been some common misunderstandings of the mechanisms, which can increase the prevalence of back pain. I know because I taught them in an inappropriate way, that’s the way that I was taught. But times change and increased knowledge and application go a long way for someone to determine what works and what doesn’t. Many people still have back pain despite participation in core conditioning regimes, pilates and other types of 'core' workouts. Many lay peoples understanding of the core is that a strong set of abdominal and back muscles prevents back pain. This statement is false and I have seen hundreds of people with strong trunk muscles all still prevent with back pain. Overtraining of the core is responsible for increasing back pain in many individuals. Many focus on strength, skipping key elements such as flexibility and stability paving the way for muscular dysfunction. Neuromuscular retraining should often be the focus for optimal core function but for many throwing big weights around, worrying about weight loss or how many spin classes they can get to takes precedence over dysfunctional movement and pain .

Then there is the concept of the inner unit which was touted by Richardson, Jull and Hodges, a good book and one that was part of the curriculum at the CHEK Institute (where I learnt a lot about rehabilitation) and no doubt many other institutions and how, by isolation of the Transversus Abdominus or TrA created an increase in Intra-Abdominal Pressure (IAP) co contracted with the multifidus and worked intrinsically with the pelvic floor.

Training the TrA in isolation fails to offer the complete picture and treatment for segmental stability. The diaphragm working in co-contraction with the TrA, pelvic floor and lumbar multifidus present a more appropriate method for stabilising not only the lumbar spine but provide a foundation for a more efficient methodology of rehabilitation which covers stability.

The Rehabilitation School of Prague’s model of Dynamic Neuromuscular Stabilisation offers a compelling model of stabilisation via developmental kinesiology. How the developing child moves and integrates stability is an effective method for re-integration of the intrinsic stabilisation system which comprises of the diaphragm, pelvic floor, TrA and spine flexors and extensors. The image below of the open scissors position of the rib cage and pelvis details the oblique angle that can occur when poor stability is mediated by poor diaphragmatic action.

why you get back pain, DNS

With DNS technique the flare of the rib cage and optimal contraction of the diaphragm can be corrected in the space of minutes to provide an optimal pathway for diaphragmatic breathing.

This concept is an effective method for rehabilitation but in my opinion there remain questions when utilising the concept of stability from the trunk. The diaphragm has the capacity to work segmentally too much or too little based upon a client’s injury history. Here are just some of many scenarios where the intrinsic stabilising system could become dysfunctional.

• TMJ or jaw dysfunction • C section or other significant scars on the body • Pelvic floor dysfunction • Any other muscles has the capacity to affect any other muscle in the body. • Local inhibition of synergistic, functional opposites or stabilising muscles • Emotional distress • Broken bones • Functional slings such as the posterior oblique sling, lateral sling and others • Why you get neck pain

Use of a joint by joint approach to testing such as Neuro Kinetic Therapy ™ helps to establish a baseline for dysfunctional patterns of facilitation (overworked muscles) and inhibition (underworking muscles). Decisions should be made as whether a mobility or a motor control issue exist. Motor control or the ability of the muscles to be efficiently recruited by the nervous system can be rectified by understanding patterns of inhibition and rewiring the nervous system for optimal control. Integration between both NKT and DNS techniques allows for a progression from pain and dysfunction to integrated movement patterns that can be hard wired with practice of developmental kinesiology exercises.

Many traditional and rehabilitation conditioning exercises often serve to increase dysfunction. Extension and even neutral load training based exercises such as deadlifts, bird dogs and horse stances can increase activation of the thoracolumbar fascia which serves as a conduit for force transfer especially for the posterior oblique sling. index

A release of the thorocolumbar fascia and integration of the posterior oblique sling through proprioception via taping or exercises remains an efficient method of neuro muscular activation rather than just increasing motor activity via strength and conditioning exercises. tape Posterior oblique sling and reducing back pain

Integration of techniques allows for a much more efficient treatment for clients who suffer from pain and movement dysfunction and can truly get to the core of both acute and chronic conditions. Isolated approaches yield isolated results.

To find out more about how to get out of pain and improve movement and energy please get in touch.

References:

Frank, C Kobesova, A and Kolar, P.Dynamic Neuromuscular Stabilisation and Sports Therapy.Int J Sports Phys Ther. 2013 February; 8(1): 62–73. Myers, T. Anatomy Trains. Churchill Livingstone Elsevier. 2001. Richardson C, Hodges P and Hides, J. Therapeutic Lumbo Pelvic Stabilisation. Churchill Livingstone. 1999 Weinstock, D. Nuero Kinetic Therapy. An Innovative Approach to Muscle Testing. North Atlantic Books.