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Motor Learning

Cognition and injury prevention through motor learning during the development of elite Orienteering performance

by Martin Krause, May 2002

Master of Manipulative Physiotherapy, Graduate Diploma Health Science (Exercise & Sport), Graduate Certificate Health Science Education

 

Content

- Introduction

- How does the expert determine relevant information

- Expert & Exceptional Performance

- Learning (acquisition of skill)

- Fundamental requirements for co-ordination

- Differentiation for new skill acquisition

- Three stages of learning

- Motor variability (repetition without repetition)

- Uncontrolled manifold hypothesis

- Anticipatory ability

- Burnout

- Psychic Energy

- Psychological Stress (boredom versus anxiety)

- Strategic automatization and imagery

- Goal Implementation

- Optimal Zone

- Nociceptive interference to perception

- Injury Prevention

- Fixation and spatial ability

- Psychophysical Domain and risk taking

- Concentration

- Mental training and imagery

- Conclusion

- References

- Links

"The ultimate goal of a training programme is to attain optimization of mobilizing and stabilizing forces through the engagement of feed-forward CNS efficiency"

Orienteering is a sport, which requires an athlete to run through terrain with a map and compass. At an elite level the winning times are between 70 and 90 minutes. Central to orienteering is the requirement to manage attention from three sources of information: the map, the environment, and run through the terrain (Eccles, Walsh, Ingledew 2002). During the development of elite orienteering skills the management of these sources of information needs to be refined through experiential learning (Aeschlimann 1997). Additionally, the avoidance of injury may influence the development of expertise in orienteering. Moreover, the development of expertise suggests the specific development of all musculoskeletal structures (excluding bone length but including width) required for the agility, speed, co-ordination, endurance and power for orienteering.

How does an elite athlete perceive the most relevant information?

motor

 

Expert & exceptional performance

Expertise is gained through experience of and practice in a domain (Ericsson, Krampe, Tesch-Romer 1993). Knowledge has been proposed as the mediator between practice and skill (Gilhooly 1990). Vast, well-organized and domain specific knowledge appears fundamental to expertise (Williams 2000). Experts are therefore knowledge driven whereas novices are search driven during problem solving (Gilhooly 1990). These adaptations make the expert efficient by reducing processing demands on the less adaptable, limited capacity, basic visual and neural systems (Ericsson & Lehmann 1996). Anticipation, allows experts to prepare their actions thereby circumventing the need for rapid immediate reactions (Ericsson & Lehmenn 1996). In orienteering the novice attends to the start first thereby working forward with their problem solving whereas the expert attends to the control site, thereby working backwards (Eccles, Walsh, Ingledew 2002). Importantly, the experienced orienteer is able to read the map without a loss of running performance (Eccles et al 2000). Therefore, the experienced orienteer will make use of the map for an automated analysis of the running conditions to decide which, is the fastest and safest route.

 

Learning (acquisition of skill)

The ability to learn defines the requirement to be able to acquire and stabilize new motor programmes. Without the ability to learn, to lay down new motor programmes and to recall motor programmes when required, it becomes impossible to gain the motor control necessary to compete in an adaptable manner to an ever changing environment (figure 1) (Aeschlimann 1997). This adaptability is critical as the orienteer is often confronted with varying terrain. Reaction time involves proprioception as well as feed-forward visual reflexes which become more developed with experience.

Figure 1 Correlation between the fundamental requirements for co-ordination

Differentiation refers to the ability to adjust each body part to maximize the efficiency of movement of the entire system. Initially, the learner may use a 'freezing-freeing' process, which reduces the number of active biomechanical degrees of freedom to be managed (Magill). The second strategy consists of introducing rigid couplings between the oscillators building the system. Therefore, learning implies the dissolution of initial couplings and the emergence of new, more task specific couplings. This was demonstrated by a new organization of the trunk during the acquisition of a complex balancing task (Caillou, Nourrit, Lauriot, Delingnieres 2002). Conceivably, such learning would impart the ability to co-ordinate various body parts quickly to varying demands of the terrain

Fitts and Posner proposed a three stage model. The cognitive stage is marked by large amounts of variable performance and error. The second stage is the associative stage where the learner is refining their skills, and they are now able to detect some of their own sources of error in performing the task. The final stage is the autonomous stage where the skill is automatic or habitual (Magill).

One of the most commonly seen features in orienteering is motor variability. Bernstein (1967) used an expression "repetition without repetition" whereby each repetition of an act involved unique, nonrepetitive neural and motor patterns. Synergies have been proposed to accommodate this motor learning problem of controlling for infinite degrees of freedom. Synergies are defined as a structural unit organized in a task specific manner, where if an element introduces an error into the common output, other elements change their contributions to minimize the original error, and no corrective action is required by the controller (Latash, Scholz, Schoener 2002). Releasing and reorganizing degrees of freedom are processes that accompany practice (Schmidt & Lee 1999). Recently an "uncontrolled manifold hypothesis" was proposed which assumes that when a controller of a multi-element system wants to stabilize a particular value of a performance variable, it selects a particular subspace where the desired variable is held constant. Simultaneously, other elements can show a high degree of variability so long as they do not affect the essential variable (figure 2) (Latash et al 2002). Similarly, closed loop theory suggests that a learner acquires a reference of correctness (Schmidt & Lee 1999). Variability is particularly important in orienteering as each course is unique and different. Without variability, injury and/or sub-optimal performance is likely to occur.

Figure 2: the uncontrolled manifold hypothesis for oscillatory movements

The ability to anticipate the changing environment and the ability to predict the outcome of a given motor strategy allows time for analysis and selection of alternative movement patterns (Eccles et al 2002). By anticipating the environment from the map, and by simplifying the information required to navigate, expert orienteers can circumvent processing limitations (Eccles et al 2002). From a dynamic control perspective, long sequences of movement are generated based upon prediction (Schmidt & Lee 1999). This would entail anticipation of upcoming terrain difficulty, since efficient use of energy is paramount for optimal performance (Aeschlimann 1997; Eccles 2002). Gentile (1972) proposed the need for diversification when learning such 'open skills'.

 

Variable Reality

Orienteering involves the use of maps. These maps have standardised symboles to represent terraine (eg contours, creeks, rocks, cliffs, etc). However, their depiction is an interpretation by the maper. Additionally, geographic variation may dicatate that rocks of a certain size are mapped as contours rather than rocks, re-entry half gullies and uneven terrain may be mapped irregularly, bare rock may be ingnored, emphasis may be placed on contours, rocks, or vegetation boundaries depending on the country you are in. Furthermore, the vegetation may vary depending on the season and hence affect runnability and/or navigability. Added to this variability of the depiction of reality, is the runners interpretation of the features and their significance to the lie of the land. My experience of analysis of elite Swiss Orienteers was that males tended to place emphasis on linear features and angles of attack, whereas females were more likely to emphasise vegetation features. Interestingly, elite orienteers were prepared to accept varaibility in interpretation and decision making by analyzing these cognitive attributes through the verbalistion of their thinking as well as requesting that verbalisation of others. Hereby, the philosophical constraints of language on reality were reduced, allowing for greater mental agility for confronting decision making tasks in new terraine which normally wouldn't have conformed to their sense of reality.

Learning facilitation therefore should come from family members, later from club training and peer interaction and from squad training (Aeschlimann 1997). This perspective is supported by the literature (McNevin, Wulf, Carlson 2000) whereby practice in larger groups allows participants to observe others performing the same task, thereby providing sensory cues of correct performance. Typically, orienteers compare their route choices after an event. Frequently, these comparisons include timed splits, reasons for making a particular route choice and strategies for overcoming errors. This is often on an informal basis. However, squad members have coaches and as well as a more experienced peer as mentor. As the expert has acquired complex encoding methods and retrieval structures that utilize the apparently limitless capacity of long term memory (Ericsson & Lehmann 1996), the novice may gain useful insights into the process of problem solving through this interaction.

 

Burnout

Burnout is defined as a breakdown in fitness (Botterrill & Wilson 2002). Recommendations for the prevention of burnout based on mental and emotional fitness include

  • understanding psychic energy
  • reassessing realistic and achievable goals, (Aeschlimann 1997)

Psychic energy is referred to as drive, activation - arousal of the mind and body (figure 3) (Martens 1987). Optimisation of arousal uses the inverted 'u' principle whereby too little arousal will result in underperformance and too much arousal will result in anxiety and deterioration in performance (Daniel Kahneman {1973} in Magill).

Figure 3: Model proposed by Martens (1987) for optimization of performance.

 

Psychological stress occurs when athletes perceive that there is a substantial imbalance between what is being demanded of them and what they are capable of doing (figure 4) (Martens 1987). Therefore learner - trainer interaction over goal setting has to be clear and concise to be realistic and achievable (Aeschlimann 1997).

 

Figure 4: Psychological stress (Martens 1987)

Implementation intentions that link anticipated critical situations to goal directed responses, using specified time frames have been shown to be effective in translating goals into action (Gollwitzer 1999). Gollwitzer (1999) argued that through 'strategic automatization', the athlete delegates control of their goal-directed actions to the environment, thereby freeing cognitive capacity to recognize alternatives. Imagery is used to state that when a specific situation arises this will be the response. Orienteers will frequently visualize complex and detailed terrain when studying maps in their lounge chair. Conversely, whilst running in terrain they will visualize the map.

Goal Implementation : strong effects of simple plans. Better performances are observed when people set themselves challenging specific goals as compared with challenging but vague goals ("do your best"). This goal specificity is based upon feedback and self-monitoring advantages. This is also true for goal proximity effect (proximal goals lead to better performances than distal goals. Goal attainment is also more likely when people frame their good intentions as learning goals (to learn how to perform a given task) rather than performance goals (to find out through task performance how capable one is). Similarly, when they frame their intentions as promotional goals (focus on the presence or absence of positive outcomes) rather than prevention goals (focusing on the presence or absence of negative outcomes) better results are obtained (Gollwitzer 1999).

To know oneself and be at peace with oneself . The optimal zone has been described when athletes have

  • awareness of their actions but are not aware of the awareness
  • attention focused completely on the activity
  • loss of self-consciousness or egos
  • control of their actions

Only then can the activity providing clear and unambiguous feedback.

Sporting expertise is gained through reptition of movement and avoidance of (appropriate recovery from) injury

Nociceptive processing in the human brain of task relevant and task irrelevant noxious stimuli

Recently, investigators have demonstrated that various attentional operations can modulate nociceptive processing at different times, and pain perception probably depends upon a balance between those modulations (Legrain, Bruyer, Guerit, Plaghki 2003). Therefore, confirmation of an attentional priority to pain hypothesis would predict a lower threshold in triggering attentional orientation for nociception than for other sensory modalities. Hence, in the presence of pain motor performance would deteriorate due to reduced perception of other sensory stimuli.

 

Injury Prevention

In orienteering, common areas of pain occur due to injuries of the ankle, knee and back. Since short term memory are considered the 'work space' in which information from short term sensory store and long term memory are processed to produce movements, stimulus identification, response selection and response programming may all be affected by the presence of pain. Cognitive processes such as anticipation from visual feed-forward mechanisms have been shown to prevent knee injuries in athletes (Besier, Lloyd, Ackland and Cochrane 2001). Similar cognitive processes are plausible for the prevention of ongoing back pain and ankle injuries. However, disc herniation related back pain impairs feed-forward control of paraspinal muscles (Leinonen, Kankaanpaa, Luukkonen, Hanninen, Airaksinen, Taimela 2001). Once pain is present it may modify an individual's ability to focus attention (Villemurre & Bushnell 2002). Additionally, people with a fear of pain have an attentional bias toward pain related information (Keogh, Ellery, Hunt, Hannent 2001). Since the short term memory has only limited processing capacity this would lead to a reduction in performance (Luoto et al 1999). Interestingly, higher centers of the CNS are thought to be able to modulate, synaptically, these pain processes at the spinal cord level (Petrovic & Ingvar 2002; Ren & Dubner 2002). Furthermore, adequate training of cognitive mechanisms may optimize the CNS and musculoskeletal interaction for stabilizing the region of injury (McGill 2001). Motor imagery may be useful to provide quasi-kinaesthetic experiences (Annet 1995). Additionally, EMG biofeedback, pressure biofeedback, textured soles and video have been proposed to provide feedback for optimization of musculoskeletal retraining (Babyar 1995, McNevin, Wulf, Carlson 2000; Waddington & Adams 2003)

It has been suggested that bones, lgaments, muscles, etc will adapt their structure to specifically meet the demands of the sport (Ericsson & Lehrman 1996). Therefore, it may be expected that orienteers have particularly large bone structures around the ankles to adapt to the large loads produced from running on uneven ground.

Fixation refers to the movement pattern developed in the first stage of learning so that this pattern can be created at will (Gentile 1973). Such closed skills require a practice structure as similar as possible to orienteering. An example of this may be the use of a wobble board for training ankle proprioception and plyometrics for developing tendon-muscle reflexes. Later in learning the 'open skill' (Gentile 1972) of spatial ability can be trained in ever increasingly demanding terrain. Spatial ability includes the extroceptive awareness of the entire body movement in relation to the terrain. Balance entails the ability to maintain forward propulsion in uneven terrain using both extroceptive visual cues (occulomotor reflexes), vestibular reflexes as well as interoceptive senses such as kinesthesia from tendon, muscle and ligament proprioception. Additionally, functional tape is used by orienteers to gain feedback from skin sensation (Aeschlimann 1997).

Importantly, for the elite athlete, their team therapist needs to be in tune with the philosophical state of their athletes, the coaches, the manages, the families, the supporters, the press, the nation, the officials and themselves in order to attain exceptional performance.

The psychophysical domain proposed by Aeschlimann (1997) involves 'determination' and 'risk taking'. Determination is defined as the conscious selection of direction, with the strength of resolve when making decisions where multiple possibilities are present (Singer 2002). The quality of determination can be made by training physical ability in various terrain and mental agility with various maps.

Risk taking when making route decisions has been found to be a particularly important aspect of skill acquisition when the orienteer is at the brink of being elite (Aerschlimann 1997). Although such an orienteer has a lot of experience and a large repertoire of automated motor processes, they may be reluctant to try something new, as errors may arise. Yet, the athlete can learn from these errors (Hanin, Korjus, Jouste, Baxter 2002). The performance goal is to free oneself from fear of making mistakes in execution or outcome and has been termed 'training for trust' (Moore & Stevenson 1994).

A strategy suggested was to practice risk taking at less important events. However, intrinsic to less important events are lesser amounts of psychological stress. Another strategy is to practice the limitation through the use of 'blind compass', map memory or contour map training tasks. Concentration (figure 5), high motivation, good self confidence and high frustration tolerance would aid in overcoming fear of risk taking (Aeschlimann 1997; Singer 2002). Using meta-cognition and a constructivist approach to learning, expectation of 'success probability' reinforces the new way (Hanin et al 2002). Thus the athlete can continue to lay down new decision making and motor patterns (Moore & Stevenson 1994).

Figure 5 : Concentration has been divided into 4 domains in the Swiss Orienteering Federation (SOLV) mental training manual

 

Mental Training (Annett 1995)

Uses of imagery include the ability to see success, that is to formulate performance goals and to motivate the attainment of those goals, to familiarize oneself with the environment, as a reminder of key elements of performance that require attention, to facilitate warm up and general preparedness and to perfect skills of mental practice. Mental practice is "the symbolic rehearsal of a physical activity in the absence of any gross muscular movements" used for the purpose of acquiring or maintaining a skill. Novices benefit more from practice on cognitive tasks, whereas experienced athletes benefit equally, consistent with the notion that novices may still be in the cognitive stage of learning. "Bereitschaftspotential" or global preparedness for action using the intentional processes through the action-language bridge of the motor and verbal systems allows the development of implicit procedural knowledge through the use of explicit declarative knowledge. Therefore, when experienced orienteers explain their route choice and decision making to another orienteer they are training their higher center cognitive processes.

 

Cognitive Behavioural Therapy in relation to injury

Conclusion : Orienteering rated in the context of motor learning theory

The body of evidence in motor learning supports orienteering development and training as proposed by SOLV. Experiential learning through practice is divided into orienteering task constraints, which include physical training, mental training and technical training. Mental training includes cognitive and psychophysical aspects of training. Technical training aims at maximizing the ability to anticipate various situations encountered throughout the race as well as perform error analysis and correction during and after the race (ESSM Magglingen J+S Leiterbuch 1993). Finally, for the high levels of physical and mental demands to occur during elite sporting endeavour, the athlete is required to either avoid injury, through measured analysis of risk taking relevant to their capacity, as well as learning the appropriate responses and processes for the rapid and complete recovery from injury.

Footnote: Uli Aeschlimann has been the coach of the Swiss and Austrian Orienteering teams since 1989. He is credited for being one of the most successful orienteering coaches of recent times. The Swiss Orienteering federation underwent a considerable metamorphosis during the 1990's, gaining A class world status during this time. Switzerland is still the only country outside of Scandinavia to have such a status.

Examples of map reading exercises for enhanced cognition


 

 

MotorLearning

 

References

Aeschlimman U (1997) Diplomprojekt Orienteerungslauf: Auf der Treppe and die Spitze. Schweizerischer Orienteerungslauf Verband (SOLV), Schweizerischer Olympischer Verband (SOV), Eidgenoessische Sportschule Magglingen (ESSM) Chapters 2 and 3

Annettt J (1995) Motor imagery: perception or action? Neuropsychologia , 33 , 11, 1395 to 1417

Babyar SR (1995) Excessive scapular motion in individuals recovering from painful and stiff shoulders: causes and treatment strategies. Physical Therapy , 76 , 3, 228 to 237

Bernstein NA (1967) The coordination and regulation of movements . Oxford , Pergamon Press.

Besier TF, Lloyd DG, Ackland TR, Cochrane JL (2001) Anticipatory effects on knee joint loading during running and cutting maneuvers. Medicine & Science & Sports & Exercise , 33 , 7, 1176 to 1181.

Botterill C, Wilson C (2002) Overtraining: Emotional and interdisciplinary dimensions. In Kellman M (ed) Enhancing recovery: preventing underperformance in athletes , Champaign , Illinois , Human Kinetics, pp 143 to 159

Caillou N, Nourrit D, Deschamps T, Lauriot B, Delignieres D (2002). Overcoming spontaneous patterns of coordination during the acquisition of a complex balancing task. Canadian Journal of Experimental Psychology , 56 , 4, 283-293

Eccles DW, Walsh SE, Ingledew DK (2000) Visual attention in orienteers with different amounts of experience. Journal of Sports Sciences , 29 , 72 to 73

Eccles DW, Walsh SE, Ingledew DK (2002) A grounded theory of expert cognition in orienteering. A grounded theory of expert cognition in orienteering. Journal of Sports Sciences , 24 , 68 to 88

Eccles DW, Walsh SE, Ingledew DK (2002) The use of heuristics during route planning by expert and novice orienteers. Journal of Sports Sciences , 20 , 327-337

Eidgenoessische Sportschule Magglingen (ESSM) Magglingen (1993) OL trainieren: Broschuere zum Leiterhandbuch Form. 30.60.500d. Jugend und Sport Leiterhandbuch

Ericsson KA, Krampe RT, Tesch-Romer C (1993) The role of deliberate practice in the acquisition of expert performance. Psychological Review , 100 , 363 to 406

Ericsson KA, Lehmann AC (1996) Expert and Exceptional Performance: evidence of maximal adaptation to task constraints. Annu.Rev.Psychol , 47 , 273 to 305.

Gilhooly KJ (1990) Cognitive psychology and medical diagnosis. Applied Cognitive Psychology , 4 , 261 to 272

Gollwitzer PM (1999) Implementation Intentions : strong effects of simple plans. American Psychologist , 54 , 7, 493 to 503.

Hanin Y, Korjus T, Jouste P, Baxter P (2002) Rapid technique correction using old wat/new way: two case studies with Olympic athletes. The Sport Psychologist , 16 , 79 to 99

Keogh E, Ellery D, Hunt C, Hannent I (2001) Selective attentional bias for pain related stimuli amongst pain fearful individuals. Pain , 91 , 91 to 100

Latash L, Scholz JP, Schoener G (2002) Motor control strategies revealed in the structure of motor variability. Exercise and Sport Sciences Reviews , 30 , 1, 26 to 31

Leinonen V, Kankaanpaa M, Luukkonen M, Hanninen O, Airaksinen O, Taimela S (2001) Disc herniation-related back pain impairs feed-forward control of paraspinal muscles Spine , 26 , 16,367 to 372

Legrain V, Bruyer R, Guerit J-M, Plaghki L (2003) Nociceptive processing in the human brain of infrequent task relevant and task irrelevant noxious stimuli. A study with event-related potentials evoked by CO2 laser radiant heat stimuli. Pain , 103 , 237 to 248

Luoto S, Taimela S, Hurri H, Alaranta H (1999) Mechanisms explaining the association between low back trouble and deficits in information processing: a controlled study with follow-up. Spine , 24 , 3, 255 to 261

Magill RA Motor Learning : Concepts and Applications , Madison , Brown & Benchmark

Martens R (1987) Coaches guide to sport psychology , Champagn , Illinois , Human Kinetics

McGill SM (2001) Low back stability: from formal description to issues for performance and rehabilitation. Exercise & Sports Sciences Reviews , 29 , 1, 26 to 31

McNevin NH, Wulf G, Carlson C (2000) Effects of attentional focus, self control, and dyad training on motor learing: implications for physical rehabilitation. Physical Therapy , 80 , 4, 373 to 385

Moore WE, Stevenson JR (1994) Training for trust in sports skills. The Sports Psychologist , 8 , 1 to 12

Petrovic P, Ingvar M (2002) Imaging cognitive modulation of pain processing. Pain , 95 , 1 to 5

Ren K, Dubner R (2002) Descending modulation in persistent pain: an update. Pain , 100 , 1 to 6

Schmidt R, Lee R (1999) Motor Control and Learning , Human Kinetics

SOLV (1991): Mentale Trainingsformen im Orientierungslauf . Zurich

OL (1993) Trainieren ESSM Magglingen Jugend + Sport Leiterhandbuch

Singer RN (2002) Preperformance state, routines, and automaticity: what does it take to realize expertise in self paced events? Journal of Sport & Exercise Psychology , 24 , 359 to 375

Villemure C, Bushnell MC (2002) Cognitive modulation of pain: how do attention and emotion influence pain processing Pain , 95 , 195 to 199

Waddington G, Adams R (2003) Football boot insoles and sensitivity to extent of ankle inversion movement. British Journal Sports Medicine , 37 , 170 to 175

Williams AM (2000) Perceptual skill in soccer: implications for talent identification and development. Journal of Sports Sciences , 18 , 737 to 750

Orienteering Cognition (pdf file)

 

Last update : 16 July 2009


 

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    Neck aetiology, autonomic and immune implications, exercise and diet in the musculoskeletal physiotherapy management of Post Concussion Syndrome (PCS) by Martin Krause, MAPA, Titled member Musculoskeletal Physiotherapy Association of Australia  A 14 year old boy presented to A&E, in August 2016, after receiving an impact to the head during AFL (Australian Rules Football). Although his SCAT3 scores were relatively mild, he went on to suffer severe lethergy, resulting in a lengthy abscence from school, culminating in a return to school for exams in the first week of December 2016. Even by December, even a 30 minute walk was extremely fatiguing. To place this into perspective, he had been playing elite academy grade AFL for several seasons and was an extremely fit outdoor adventurer. Confounding Variables : end of season injury and hence no follow up from the academy suffers from Hypermobile Joint Syndrome (HJS) and possibly Ehlers Danlos Syndrome (EDS), however Beighton score 4/9. suffers from food intolerances, particularly to Glutin and diary, but also some other foods. Potential IBS and autoimmune issues. had just gone through a growth spurt (190cm) Imaging : Brain MRI normal Medical Examination : Balance remained impaired to tandem walking and single leg stance. The vestibular occular motor scale showed significant accomodation deficit of 15cm and there was a mild exacerbation of symptoms. ImPACT testing revealed adequate scores and reaction time of 0.65 which is within acceptable range. History : School holidays December - January. Return to school and was placed in the lower classes. Prior to his concussion he was a top 10 student at an academically selective high school. Took up basketball and rowing as summer sports. Academic results tanked. Several Basketball injuries (Feb - April 17') as a result of what apppeared to be muscular imbalances from the relatively recent growth spurt, as well as taking on a new sport. Showed little interest in returning to AFL as no-one had followed him up during the previous year.  Current History : September 2017 showed a continued decline in academic levels. School teachers noted an inability to concentrate. Academic results still well below pre-concussion levels. Fatigue continuing to be problematic.  Literature Review : Post Concussion Syndrom (PCS) is defined as "cognitive deficits in attention or memory and at least three or more of the following symptoms: fatigue, sleep disturbances, headache, dizziness, irritability, affective disturbance, apathy, or personality change"  Further complications of PCS also appear to be an increased risk of musculoskeletal injury Nordstrom et al (2014, BMJ Sports Med, 48, 19, http://bjsm.bmj.com/content/48/19/1447) Predictors of PCS are uncertain. However, the following clinical variables are considered factors at increasing risk. These include prior history of concussion, sex (females more prominant), younger age, history of cognitive dysfunction, and affective disorders such as anxiety and depression (Leddy et al 2012, Sports Health, 4, 2, 147-154). Unlike the 'good old days' which recommended a dark room and rest for several weeks post concussion, the consensus appears to be a graded return to exercise in order to restore metabolic homeostasis. Incredibly, highly trained young individuals can find even exercises in bed extremely demanding. Kozlowski et al (2013, J Ath Train, 48, 5, 627-635) used 34 people 226 days post injury to conclude significant physiological annomalies in response to exercise which may be the result of 'diffuse cerebral swelling'. Researchers have noted lower systolic and higher diastolic blood pressure in PCS (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Due to autonomic dysfunction manifested in altered cardiovascular and pulmonary responses (Mossberg et 2007, Arch Phys Med Rehab, 88, 3, 15-320) some clinicians have recommended the use of the exercise program for POTS (Postural Orthostatic Tachycardia Syndrome). This is a 5 month program which recommends mainly exercise in the horizontal and sitting positions for 1-4 months, including recumbent bike, rowing ergometer and swimming laps or kicking laps with a kick board. Month 4 upright bike and Month 5 upright training such as a elliptical trainer or treadmill.  http://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf Other progressive exercise therapies have also included 20 minutes per day, 6 days per week, for 12 weeks of either treadmill or home gym exercises at 80% of the heart rate at which their concussion symtoms are exacerbated. Their programs were individually modified as the heart rate provoking symptoms increased. When compared to the 'control group', this intervention was shown to improve cerebral perfusion on fMRI, increase exercise tolerance at a higher heart rate, less fatigue and were showing activation patterns in areas of the brain on performing math processing test which were now normalised (Leddy et al 2010, Clin J Sports Med, 20, 1, 21-27). Graded exercises could also have included 'motor imagery' as espouse by the NOI group and the work of Lorrimer Moseley (University South Australia) when dealing with chronic pain. Ongoing Symptoms : The literature review by Leddy et al (2012) found that ongoing symptoms are either a prolonged version of concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual disturbance, or some combination of conditions. Physiotherapy Assessment : One year PCS, fatigue continued to persist. Cognitive deficits with school work were reported to becoming more apparent. Assessment using various one leg standing tests employing oscillatory movement aroud the hips and knees for kinetic limb stability and lumbopelvic stability, which had been employed 6 months previously for his Basketball injuries were exhibiting deficits, despite these being 'somewhat good' previously. Physical Examination : cervical and thoracic spine Due to the Joint Hypermobility Syndrome (JHS) it was difficult to ascertain neck dysfunction based on range of movement testing. ROM were unremarkable except for lateral flexion which demonstrated altered intervertebral motion in both directions. Palpation using Australian and New Zealand manual therapy techniques such as passive accessory glides (upslopes and downslopes and traction) exhibited muscles spasms in the upper right cervical spine. In particular, the right C1/2 regions demonstrated most marked restrictions in movement. Eye - Neck proprioceptive assessment using blind folds and laser pointer also  revealed marked variance from the normal. Repositioning error using the laser pointer with rotation demonstrated marked inability to reposition accurately from the left, tending to be short and at times completely missing the bullseye. Gaze stability with body rotation was NAD. Gaze stability whilst walking displayed some difficulty. Laser pointer tracing of the alphabet was wildly inaccurate. Thoracic ring relocation testing also revealed several annomalies, which may have also accounted for some autonomic dysfunction.  Occulomotor assessment and training Upper Cervical Spine : The upper cervical spine (atlas and axis) represents approximately 50% of the available rotation. An investigation into the environmental and physiological factors affecting football head impct biomechanics found that rotational acceleration was one of the few factors approaching significance and concluded that more research should be undertaken to evaluate this (Mihalik et al 2017 Med Sc Sp Ex, 49, 10, 2093-2101). Headache : Commonly referred to as cervicogenic headaches, one in five headaches in the general population are thought to be due to the cervical spine. The Upper Cervical Spine is particularly vulnerable to trauma because it is the most mobile part of the vertebral column, with a complex proprioceptive system connecting the vestibular apparatus and visual systems. It also coincides with the lower region of the brainstem and fourth ventricle. The brainstem houses many neurones associated with autonomic responses to pain and balance. Imaging of the fourth ventricle for swelling of the 'tonsils' and Arnold Chiari malformations are recommended when symptoms persist. In particular, children and adolescents are more vulnerable to neck contusions due to the proportionately larger head and less developed musculature. Cervical vertigo and dizziness after whiplash can mimic symptoms of PCS.. Mechanoreceptor dysfunction and vertebrobasilar artery insufficiency should be part of the differential diagnosis. Mechanical instability of the Upper Cervical Spine should also not be missed. Cervicogenic Headaches Further Interventions : Neurocognitive rehabilitation of attention processes. Psychological intervention using cognitive behavioural therapy (CBT). Neuro-opthalmologist to assess and treat smooth pursuit eye tracking. Naturopath for food intolerances and dietician for the optimisation of diet. Diet :  In cases with chronic fatiguing factors, nutrition can be become a vital aspect into the reparative process. This may include energy and mineral rich foods such as bananas, green leafy vegetables for iron and magnesium (200-300mg), oranges for vitamin C (anit-oxidant and helps with the absorption of iron), anti-oxidant rich foods such as EPA/DHA (1000mg) fish oil, curcumin (tumeric), Cats Claw, Devils Claw, Chia seeds, fruits of the forest (berries), and CoQ10 with Vitamin B. Folate and Ferritin levels should also be checked. Calorific energy intake should balance with energy exependiture. However, as we are often dealing with young individuals, as in this case, some form of comfort food may be appropriate such as, nuts, legumes, homus and sushi. Protein intake prior to carbohydrate intake may help ameliorate any blood suger fluctuations due to Glycemic Index factors, however simple carbohydrates (high GI) should be avoided wherever practical. Even oats need to be soaked overnight and cooked briefly, otherwise they become a high GI food and may even affect the absorption of iron. The type of rice used can also influence GI, hence the addition of protein such as fish. Protein supplementations are generally over-used. Daily protein intake should not exceed 1.2g per kg of body weight per day. Dosage for children is less than that for adults. See Nutritional Section of this Site Conclusion  Investigations, into people with persisting PCS, demonstrated that they applied more force over time to control balance. Helmich et al (2016, Med Sc Ex Sp, 48,  12, 2362-2368) proposed that in regard to cognitive processes, the increase of cerebral activation indicates an increase of attention demanding processes during postural control in altered environments. This is relevant in so far as individuals with post concussive symptomatology have a variety of symptoms including headache, dizziness, and cognitive difficulties that usually resolve over a few days to weeks. However, a subgroup of patients can have persistent symptoms which last months and even years. Complications in differential diagnosis, can arise clinically, when neck dysfunction and altered motor control occur concurrently due to both neck and cerebral pathology. For example, Whiplash and other traumatic head and neck injuries can result in pathology to both regions, whereas, more discreet altered cognitive processing from concussion can result in altered neck motor control. Musculoskelatal Physiotherapy can play a vital part in the treatment of neck dysfunction including the re-establishment of occulomotor proprioception and managing localized strength and cardiovascular exercise regimes. A total body, multi-disciplinary approach which is well co-ordinated amongst practitioners is vital to an optimal outcome.    Uploaded : 17 November 2017 Read More
  • Thu 24 Aug 2017

    Pain in the Brain - neural plasticity

    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