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Constructivism and cognitive reasoning

Understanding constructivism (clinical reasoning) through the deconstruction of competencies required for map reading in Orienteering

by Martin Krause (2007 and 2013)

Index

Introduction

Context

Map Reading

Track Orienteering

Compass Orienteering

Blind Compass Orienteering

Contour Orienteering

Pure Contour

Negative Terraine

Cognition during supra-anaerobic map reading

Discussion

Clinical Reasoning

Conclusion

World Orienteering Championships, Vuokatti, Finland 2013

Time loss per leg

Error Frequency per leg

Route Choices

Introduction

Orienteering involves complex decision making using multiple variables of information to ascertain the optimal path. Clinical reasoning is a similar balance of gleaning the right amount of information to build a clinical picture. Too much information and we have information overload and with too little information we again arrive at an impass with the likelihood of making mistakes such as 'confirmation biases'. Information optimisation in the form of clinical reasoning, and deductive reasoning in particular, is a process of confirming expectations through the process of questioning and examination. When expectations aren't realised, then the therapist must revert to inductive reasoning, which requires deconstruction back to first principles, to rebuild a clinical picture, which makes sense, both to the client and anyone else who askes for face and constuct validity for the evidence of efficacy of treatment. When reading a map in a sport like orienteering, it is important to read the map ahead of where you are going, so that when the runner comes to the terraine they are confirming or negating their expectations. There is a positive correlation between motor performance and map reading skills. That is, the feedforward mechanisms of motor control are more finely tuned, when the runners map reading skills are more finely tuned. Importantly, in order to optimse cognitive performance, the information on the map needs to be simplified into meaningful small chunks of information. The following are map reading exercises for the development of competency in orienteering. By de-constructing various elements of map reading, greater competency can be obtained. Additionally, physiological variables can also be manipulated to enhance cognitive skill. Ultimately, feed-forward predictive reasoning skills should be accomplished. It is very rare for an injury to occur when the cognitive processing is optimal. Similarly, in the clinical situation, the more finely tuned the predictive reasoning skills are, the less likelihood of getting lost during the examination resulting in a mis-diagnosis. Additionally, by making predictions throughout the clinical reasoning process, scientific credence is given to the process of examination and re-examination, whereby variables are defined, included and eliminated. The predictive validity of testing becomes the clinicians 'null hypothesis'.  In orienteering competitions, economy of movement and information processing capacity, are reflected by the fastest time as the metric of choice; whereas in the clinic, it is the minimal intervention which derives the maximal and most optimal outcome which should define the economic value of the health intervention.

Context

When reading a map, a rock is a rock, however the identification of features on how to find the location of the rock will be different if it is in a Siberian birch forest on the side of a Japanese mountain, a baltic pine forest in Europe, beech forest in New Zealand or Eucolypt forest in Australia. What is the significance of a rock in a boulder field and how does the topography of the landscape contribute to finding the correct rock? Similarly, the features associated with a supraspinatus shoulder problem will be different in an elderly person, an office worker and a freestyle bouldering rock climber. What are the salient clinical features which make the supraspinatus significant in the presence of multiple pathology from shoulder, neck and rib cage trauma? In all cases, it is the context which drives the analytical process of reducing the problem to the most significant variables in order to construct a picture which achieves the desired outcome.

Map reading

Looking for controls in a given area based on all aspects (variables) of map reading and the control descriptions

Click on each map if you would like larger detail.

The above is the original map - the next 3 maps are variations on the original

Track orienteering - relatively simple correlation of a track network with 'sense of distance' and control description.

Compass orienteering - only variables are distance and compass bearing

Blind Compass orienteering - as hard as it gets. Only 1 variable and hence no correlations with other information is possible

 

Contour only

Pure contour map used during winter training. My first mistake was to write the control numbers upside down. The terraine was covered by at least 1 - 1.5m of snow. Due to the inherent dangers of such training, we used 'shadow orienteering' whereby pairs of orienteerers shadowed each other over alternating controls. Pure contour work. This map is riddled with tracks. Hence the exercise becomes very demanding when all other features normally associated with the forest are obliterated and yet they still exist. The brain is forced to focus on one variable - the contours. The previous exercises demonstrate how weaknesses and biases in cognitive strategy can come to the fore, thereby allowing the possibility of self analysis of their thinking through meta-cognitive strategies.

Map with tricky 'negative terraine'

An interesting loop relay event, where several different courses were run in parallel, with some common controls, in highly tricky, negative terraine. (Kaajani, Finnland 1989). Many controls were close to one another and hence it was important that the correct controls were being checked off. The physiological variable of increasing speed was correlated with the need for increased cognitive processing efficiency. That is, reducing each attack point to a clearly defined feature in the terraine, which would in turn immediately indicate the direction of the control flag, during which time it is important to commence reading the map for the following control. For example, start -> 1 : saddle, 1->2 small gully leading into depression - need to maintain height as control sits high between 2 depressions (note map had extensive 'negative terraine'), 2->3 small spur with small gully on right - exagerated due to negative and positive terraine, 3->4 large clearing, 4->5 long gully with major depression on left parallel to line of run for control feature, 5->6 clearing and then large negative depressions, 6->7 off edge of semi cleared area and get direction correct - the control feature of a gully beyond high points should be obvious, 7->8 track, 8->9 contour around the very large depression, 9->10 semi cleared then track end then depression on left, 10->finish need to get direction correct before arriving at 10. Moreover, the runner has a mental image of the terrraine before they arrive in the attack point area, where they should compare their conscious and subconscious expectations to what they see. Hereby, the imagery creates a path to the subconscious.

Enhanced cognitive capacity at supra-anaerobic threshold

In this last scenario, there were several parallel courses and/or 'dummy controls. The objective was to run from the bottom of the hill up to the loop and repeat the exercise at least 4 times in a given period of time (e.g. 40 minutes). Ideally, the athlete preforms better on each loop, even though they should in theory be fatiguing. If the loop is the same then the cognitive demands should reduce on each loop, whilst the physiological demands are increasing. The concept involved the use of anaerobic threshold cognitive capacity. At an elite level we demonstrated that at least half of the Swiss elite orienteers could concentrate better at supra-anaerobic threshold. Unfortunately, Dr Toni Held's thesis, on this phenomenon, was never published as it went against the consensus of the time. Since, early this century, researchers have come to recognise lactic acid is an important fuel for aerobic-anaerobic exercise through the production or conservation of the energy substrate, pyruvate, via the Ciori cycle in the liver. The pathways of lactic acid metabolism probably depend upon the internal metabolic conditions when exercise stops. High levels of lactate and slightly reduced levels of other substrates such as liver glycogen and blood glucose appear to favor lactate oxidation to pyruvate, thus saving some glycogen; whereas, the effects of prolonged exhaustive exercise may favor lesser oxidation and greater conversion to glucose. Thus lactate is an important reservoir of carbon energy during recovery (Brooks et al 1999, Exercise Physiology : Human Bioenergetics and Its Applications; Mayfield Publishing). In this case, the downhill running was the recovery phase, even though it was at maximum speed, but the soft ground also allowed for maximum efficiency of elastic recoil in the bounding muscles.

Discussion

The previous discussion revolves around map reading, the reduction of variables and the use of this reductionist approach to become self-aware of strengths and weaknesses in different information biasing scenarios in the same terraine. Similar exercises should be done in various terraines, to help the orienteer determine which strategy is best for which terraine or more importantly, which combinations of variables optimises the decision making cognitive processing to determine the best strategy. Also, which predictive reasoning variables from the map can be used as 'checks and balances' in determining that the runner is still going in the correct direction. By using these meta-cognitive strategies the runner can reflect on the reasonableness of their biases which weigh more heavily in their reasoning. It is important to remember that 99% of our cognitve processing occurs at the subconscious level. Through verbalisation and visualisation and using strategies such as predictive reasoning we can gain access to our subconscious. Ultimately, the runner wants to run efficiently and cleanly to the control without cognitive overload. Flowing through each and every control in an effortless manner until the finishing line is the ultimate 'da sein'.

Using the analogy of the orienteer running throught the terraine, we can examine clinical reasoning or 'the unbearable lightness of being' in a similar way. In the forest the runner wants to come across features in the terraine which ultimately leads them to their destination. Clinically, the practitioner wishes to do the same thing. During the 'subjective' examination, questions are asked to confirm or negate the 'working hypothesis'. Whilst during the 'physical' examination, tests are carried out and treatments undertaken and signs and symptoms are assessed and reassessed to confirm the diagnosis as well as create a prognosis. During this entire process 'feed forward' predictive reasoning mechanisms are being put in place which act as 'checks and balances' that attain the desired outcome, which is the amelioration of suffering and the improvement of impairments.

The map for clinical reasoning may look like the following (taken from the Maitland concept), whereby a structured process of deductive reasoning allows the organisation of knowledge retrieval, to take place, whilst creating a mechanism for the correlation of information. Clinical pattern recognition reflects the storage of the correlated information into meaningful chunks. Clarification and refining of information is what is referred to as inductive reasoning. When pattern recognition doesn't take place, then the clinician needs to revert back to 'first principles' reconstructing information into a new clinical picture. Incorrect confirmation biases, and hence getting lost in the examination and treatment process, should be reduced by reflecting on the 'checks and balances' in questioning, so as to correlate these with differential diagnostic manouvres, so that all aspects of the subjective and physical examination are covered in a precise and effective manner.

 subjec1

Conclusion

Just as the orienteer uses a map to develop a picture of the terraine ahead, the clinician also forms needs to form a picture of the expected clinical presentation from the narrative of questions and answers with the client. Hence, the features of the signs and symptoms create the picture. The narrative between the clinician and client, with the appropriate questions and reasoned explanations allow the conscious to access the subconscious where 99% of our cognitive processing occurs. The working hypothesis creates the scientific rationale by making a prediction. Further construct validity is attained by testing the prediction, through the reduction of the clinical variables. The correlation of the confirming and negating information also reduces the likelihood of making a mistake through confirmation biasing when using too few clinical features. Ultimately the power of the prediction is verified through successful clinical outcomes. Constructing a clinical picture through the correlation of all the significant variables is the ultimate objective of a successful outcome. Successful outcomes can then be laid down in the brain as a template, for quick recognition, in future use for a now familiar clinical problem. Similarly, in new terraine, the orienteer needs to consider the familiar and unfamiliar features and decide whether they need to revert to first principles of reasoning. By considering all the unfamiliar features, the cognitively more demanding short term memory and conscious processing comes into play, which deconstructs the problem, before constructing a map reading strategy using familiar features (eg compass bearing, contours), in order to arrive at the destination of unfamiliar new terraine. Hereby, the orienteer lays down new long term memories of successful navigational strategies (cognitive templates), to use at a later date, for a new but familiar terraine. In chess the laying down of sufficient 'cognitive templates' to attaine expertise takes around 10 years of consistent congnitive effort.

Motor Learning in Orienteering

Mind maps and clinical reasoning

Instructional Design and Cognitive Processing

World Orienteering Championships, Vuokatti, Finland 2013

During the second week of July 2013, the world orienteering championships took place in the middle of Finland. This is a particularly important place for me, as it is where I started my professional orienteering physiotherapist - trainer career back in 1989. The following are a snap shot of maps with route choices and errors which occured amongst the worlds best.

2013WOCLongW 2

 

2013WOCLongW 4

 

2013WOCLongW 5

 

2013WOCLongW 6

 

2013WOCLongW 7

 

2013WOCLongW 8

 

2013WOCLongW 9

 

2013WOCLongW 10

 

2013WOCLongW 11

Errors, route choices and times lost

averagetimelossperleg-590x314

 

errorfrequency-590x310

Comparison of route choices between competitors

W1-2

 

W2-3-590x487

 

W3-4b-590x486

 

W6-7b

 

W6-7c

 

W6-7d

 

w10-11b-590x470

 

w10-11c-590x423

 

w10-11d

 

women10-11-new-590x546

The longer the leg, the greater the number of choices correlates with the greater the variability of success. Clinically, the longer the story, the greater or more complex the clinical picture, the greater the possibilities of intervention. However, similar to orienteering, the speedier the intervention, the more structured the cognitive processing, the sooner the improvements in signs and symptoms, the better the rate of success.

Uploaded 31 December 2006

Updated 18 July 2013

based on Orienteering exercises with OLG Chur and the Swiss National Team 1988 - 1993

WOC Vuokatti, Finland 2013


 

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    Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasent sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreoever, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existant inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional coonectivity strength.  further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. ndividuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036)   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stumilation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand athritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of aquired skilled movement map plasticity is supported by a reorganisation of cortical microcircuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns aquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepness nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year abscence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into finctional improvement. Further explainations for my expereience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibiton occurs by the contralaleral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishement of motor drive to the affected side is important. In terms of tendon rehabilitation, external audtory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manouvers, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected.limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitatation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 18 October 2017 Read More
  • Thu 03 Aug 2017

    Sickle Cell Trait and Acute Low Back Pain

    Researchers believe that lumbar paraspinal myonecrosis (LPSMN) may contribute to the uncommon paraspinal compartment syndrome and that sickle cell trait (SCT) may play a role. Sustained, intense exertion of these lumbar paraspinal muscles can acutely increase muscle size and compartment pressure and so decrease arterial perfusion pressure. This same exertion can evoke diverse metabolic forces that in concert can lead to sickling in SCT that can compromise perfusion in the microvasculature of working muscles. In this manner, they believe that SCT may represent an additional risk factor for LPSMN. Accordingly, they presented six cases of LPSMN in elite African American football players with SCT. See link below http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Acute_Lumbar_Paraspinal_Myonecrosis_in_Football.1.aspx Read More
  • Thu 03 Aug 2017

    Ibuprofen, Resistance Training, Bone Density

    Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Effects_of_Ibuprofen_and_Resistance_Training_on.2.aspx Read More
  • Tue 11 Jul 2017

    Mitochondrial Health and Sarcopenia

    The aging process (AKA 30 years of age onwards), in the presence of high ROS (reactive oxygen species) and/or damaged mitochondrial DNA, can induce widespred mitochondrial dysfunction. In the healthy cell, mitophagy results in the removal of dysfunctional mitochondria and related material. In the abscence of functional removal of unwanted mitochondrial material, a retrograde and anterograde signalling process is potentially instigated, which results in both motor neuronal and muscle fibre apoptosis (death) (Alway, Mohamed, Myers 2017, Ex Sp Sc Rev, 45, 2, 58-69). This process is irreversible. Investigations in healthy populations, have shown that regular exercise improves the ability to cope with regular oxidative stress by the buffering and 'mopping up' of ROS agents which are induced as a result of exercise. It is plausible and highly probable that regular exercise throughout life can mitigate against muscle fibre death (Sarcopenia). Importantly, this process of muscle fibre death can commence in the 4th decade of life. and be as much as 1% per year. Reduction of muscle mass can result in immune and metabolic compromise, including subclinical inflammation, type II diabetes as well as the obvious reduction in functional capacity for activities of daily living. Published 11 July 2017 Read More
  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 17 October 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected