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Stability

 

The development of the concept of musculoskeletal stability by Martin Krause, Dec 2006

B.Appl.Sc (Physio), M.Appl.Sc (Manip.Physio), Grad.Dip.Hlth.Sc(Ex&Sp), Grad.Cert.Hlth.Sc.Edu, Cert IV Workplace Assessment & Training.

Introduction

Absolute Stability

Dynamic Stability

Oscillating Systems

Uncontrolled Manifold Hypothesis

Inverse Dynamics

Spinal Stability

Spinal Motor Control

Spinal Sensors

Spinal Controller

Lumbo Pelvic Control

Vestibular Control

Mental Stability

Neurolinguistic Feedback

Movement Classification in Lumbar Spine

Metabolic and Immune considerations

Occulomotor Control

Clinical Stability

Effect of Pain on Motor Control

Motor Control Open & Closed Loops

Cortical Changes

Muscle Tissue Proteins and Pain

Conclusions

Summary

Clinical Example

During my last undergraduate semester at University in 1986 I had an assignment titled "Why don't our shoulders subluxate". At the time the scope of thought was that the supraspinatus was entirely responsible for that stability. Whilst surfing on Cronulla beach I reflected on my problem since I was required to write a 5000 word essay as well as present a 40 minute paper on the topic!

It certainly became clear to me that the previous simplistic dogma wasn't going to be enough to solve the problem. Luckily, we had some inspirational lecturers at the time in the form of Janet Carr and Roberta Shepard. They steered me in the direction of the Russian mathematician Nikolai Bernstein and his seminal work of the 1930's on the motor control problem over the degrees of freedom around the shoulder.

Since that time the Australian Schools of Physiotherapy have considered stability across body parts and addressed the issues of motor control and pain from several different perspectives. These have included

 

1. The absolute stability of isometric contractions

Generally speaking, this type of stability training is only useful for regions with little movement. An example is the activation of the transverse abdominis and internal oblique muscles in sitting.

Interestingly, the use of muscle energy techniques employs isometric contractions and mobilization of pelvic and spinal segments for the optimization of muscle control and symmetry across the pelvis.

 

2. The dynamic stability of rotating systems which use mathematical geometric reference points

link to Shoulder calculations

These geometric reference points were emphasized by Saha (1983) in calculations of pure rotation control. However, it was Turvey et al (1978) who proposed that it was the synergistic recruitment of the scapula and glenohumeral muscles which required a controlling mechanism. Turvey et al (1982) who emphasized the recognition of contextual settings as the most important aspect of motor control.

 

3. the dynamic stability of oscillating systems

Turvey et al (1982) suggested that the problem of motor control could be solved by considering the system moving in periodicies which were constrained around a fixed point by the resistance encountered with movement. This hypothesis moved away from peripheral proprioception feeding information back to the brain. Instead we were examining the problem in the context of 'feed forward' systems where proprioceptive feedback' was only required if our objectives weren't met.

Although the original hypothesis pertained to the region of the shoulder, analysis of muscle activity in the abdominal region during arm movements in the mid 1990's by Richardson et al led to some interesting feed forward conclusions involving the transverse abdominus and multifidus muscles.

 

 

 

4. The uncontrolled manifold hypothesis for periodicies

Yet how does learning of feed forward mechanisms occur. It was suggested that 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 (Latash et al 2002). Similarly, closed loop theory suggests that a learner acquires a reference of correctness (Schmidt & Lee 1999).

 

5. The stability of inverse dynamics

With the introduction of force and momentum into the motor control stabilization argument, the natural thing to consider is the effect of Newtons 3rd Law of Action - Reaction. When applied to accelerating body parts which have mass and hence momentum, then the balancing and counterbalancing forces can be calculated and their perturbations can be used to optimize movement. The great thing with this development is that it allows us to consider the parallel and series elastic components as springs providing recoil energy, whilst muscles provide eccentric-concentric energy capturing efficiency by opitmizing the trajectories of moving body parts. Combining these concepts of elastic potential and kinetic energy with inverse dynamics gives some resolution to the problem of control of the 'inverted pendulum' which is walking. Similar to rockets or sedge way systems the propulsive force acts up from the ground resulting in a potentially unstable mechanism. Body perturbations such as swing and pendular movements of the arms help counter these potentially destabilizing forces. Additionally sinusoidal oscillations in the soft tissue acting at a microscopic molecular level up to the level of cytoskeletal and musculoskeletal architecture probably impacting on stability through the dynamic alterations and adjustments afforded by the principles of tensegrity; whereby actin like moelcules are able to change the cellular architecture to adapt to forces developed by vibration and fluid shear.

Plyometric exercise regimes employ concepts of inverse dynamics for the optimisation of movement efficiency. More recently, these type of exercises have also been emphasized for recovery from tendonosis as it benefits both the parallel and series elastic components, as well as blood flow and more importantly the capture of transverse force energy for longitudinal muscle displacement.

 

 

Spinal Stability

During the early 1980's Bergmark described muscles based on their biomechanical characteristics dividing them into two fundamental elements - local stabilisers and global mobilisers. A decade later in the early 1990's, a fundamental development in the concept of stability was from Punjabi where he described elements of control which included the passive elements (ligaments, capsule, etc), the active elements (muscle) and the 'active controller' as an integrated system of satbility. A pain element was later added by Lund et al (1991) whereby they described the inhibition of the agonists and facilitation of the antagonists in a peripheral area of pain.However, in the trunk a different interplay of muscles was construed, whereby Hodges et al (1995) and Hides et al (1994) later suggested that this peripheral motor pattern may be represented by inhibition of the multifidus and transverse abdominis muscle in the trunk. Furthermore, Wim Dankaerts and Peter O'Sullivan (2005) further suggested that facilitation of the gobal mobilisers into stabilisers resulted in motion and/or movement impairment with excessive compression of the spinal vertebrae and their comprising elements leading to reduced postural pertubations and reduced degrees of freedom.

The complexity of spinal control in the presence of pain has lead to many clinical assumptions. Spinal stability involves the co-ordination between several muscles to prevent Euler Buckling of spinal segments. There is strong evidence to suggest that the deep fibres of lumbar multifidus controls spinal motion. Multifidus contributes to 2/3 of the stiffness at the L4/5 (Wilke et al 1995) and in vitro studies (Punjabi et al 1989, Kaigle et al 1995) demonstrate contraction of multifidus increases intervertebral stiffness at an injured lumbar segment. However, it is notable to consider that all lumbar muscles contribute to stability of the lumbar spine (Cholewicki and VanVliet 2002, McGill et al 2003). Co-contraction of the superficial flexors and extensors are required to control intervertebral motion via compression. However, it has been argued that sustained compression could be detrimental to the spine (Nachemson and Moris 1964, in MacDonald, Moseley and Hodges 2006, Manual Therapy, 11, 254-263). Muscle fibre composition has also been considered as important when considering issues of stability where type I endurance fatigue resistant fibres of deeper layered muscles are thought to contribute to tonic postural control. However, fibre composition has generally been exptrapolated from investigations into disuse atrophy and exercise induced hypertrophy and furthermore, specific muscle biopsies of the paraspinal muscles have been done on cadavers or people undergoing spinal surgery (MacDonald et al 2006). Moreover, assumptions have been made that disuse atrophy is the opposite of exercise induced hypertrophy, which may not be the case. Never-the-less, Belavy et al (2007) have demonstrated a tonic-to-phasic shift of lumbo-pelvic muscle activity during 8 weeks of bed rest and at 6 months follow-up with tonic activation of short lumbar extensors and a similar trend for thoracic extensors, with a phasic trend for internal oblique and inferior gluteus maximus (J Appl Physiol, 103, 48-54). However, these results reflected EMG activity rather than muscle biopsy results. Furthermore, the concept that deep multifidus (DMF) is tonically active is not bourne out by the literature. Instead, spatial and temporal features of DMF activation reflect the activity demands of constantly changing internal and external forces on spinal control (MacDonald et al 2006). DMF activity tends to be based on feedforward mechanisms which allows for non-direction specific activity to occur prior to the onset of movement (Moseley et al 2002, 2003). Fear of pain has been demonstrated to reduce the flexion-relaxation phenomenon of paraspinal muscles during forward bending which presumably could alter DMF activity (MacDonald et al 2006). The advantage of the DMF is that it can control shear and torsion without generating a torque and therefore doesn't require a co-contraction from an antagonist to maintain stability. Furthermore, the evidence doesn't support the need for co-contraction of Transverse Abdominis and DMF (MacDonald et al 2006). Clinically DMF atrophy can be seen on MRI in people with chronic LBP. Wallwork et al (Manual Therapy 2009, 14, 496-500) demonstrated patterns of localised MF atrophy in CLBP which also demonstrated reduced ability to voluntarily contract the atrophied muscle during real-time US. Similarly, reduced Tr Abdo activity can be seen during Real Time US, regardless of the ability to contract presumably synergistic muscles such as the pelvic floor musculature. With the burgeoning research into prolonged spaceflight, future bed rest investigations should clarify some of these paradoxes.

 

6. Vestibular and verbalisation for stability

In the 1970's, Hon.Dr Med Suzanne Klein Vogelbach took a vestibular approach to agonist - antagonist recruitment and hence 'timing' of synergy. In cats, lack of vestubular input has been shown to reduce extensor muscle tone (Magnus 1926 in Belavy et al 2007, J Appl Physiol, 103, 48-54).

Klein Vogelbach also placed a large importance on complex language constructs when assessing and administering exercise for movement dysfunction. Apart from an existential philosophical construct of reality, the manipulation of language seems to underlie concepts of verbalisation for accessing the subconscious in the development of expertise, and is also used in neurolinguistic programming as well as congitive functional therapy.

 

7. Mental stability such as sporting performance in orienteering

With the evolution of each new concept the emphasis is still placed on higher centre motor control. However, since the brain can only process one piece of information at any one instance, and can only hold 6 pieces on information in short term memory how can this control movement? Indeed for control to occur it must be processed subconsciously, thereby freeing the conscious brain for decision making when the automated processes sense inconsistencies. The most powerful access to our subconscious brain is through our ability to verbilise and visualisel our expectations. Hence, in orienteering, the athlete can read the map to analyse the upcoming terraine thereby preparing their motor system for what will be encountered. Such preparation lends itself to pacing strategies and goal oriented feedback whereby anticipated feedback act like red and green traffic lights. Self affirmation requires little conscious effort e.g. is this the correct track and there is the rock followed by a spur and a clearing with a small gully to my right. If these features don't fit the terraine being scanned by the visual cortext then the greater mental effort of conscious correction and decision making needs to be employed.

link to motor learning in orienteering

Acquisition of motor control requires context specific variability. 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.

 

8 Neuro-linguistic feedback stability

From Switzerland, the Hon Dr Med Prof Klein Vogelbach (Functional Learning Theory {FBL = Funktionelle Bewegungs Lernen}) used powerful linguistic analysis of visual and tactile inputs to force physiotherapists to communicate their thinking with their clients. Hereby, a 2 way discussion ensued which could be argued lead to a stabilizing relationship between the therapist and their client and with the client and their own condition. This narrative reasoning has been propagated by Mark Jones in Adelaide. More-over the semantics of language and the power of words have been used to ascertain peoples fears and beliefs as they pertain to movement. In fact, Peter O'Sullivan has encouraged therapists not to use the term 'instability' as it may elicit fear-avoidance movement behaviour in people.

 

Peter O'Sullivan LBP movement classification disorder

Peter O'Sullivan further classified Pelvic Disorders into excessive/lack of force closure or poor form closure. Excessive force closure involves increased muscle activity across the pelvis leading to compression of the SIJ. Lack of force closure results in excessive movement around the SIJ and pubic symphasis which can lead to poor form closure whereby the opposing complimentary irregular surfaces of the ilium and sacrum move into positions of reduced stability such as 'counter-nutation'.

 

9. Stability through occulomotor reflexes

This form of stability has gained a lot attention through the work on Whiplash injuries by Michelle Stirling and Gwen Jull at the University of Queensland. They advocate the use of powerful visual reflexes to optimise both static stability as well as tracking stability. Additionally, they use pointer devices beamed from peoples heads onto a target on a wall to test and train peoples correctional ability after the eyes are shut, or when the body is turned whilst trying to keep the head stable. This is in line with their revolutionary regime of training deep neck flexors, improving scapula control, reducing muscle spasms and over-activity to improve functional stability.

 

10. Metabolic and Immune stability

Exercise for musculoskeletal disability has been advocated for both acute and chronic musculoskeletal conditions, yet it involves the paradox of the balance between anabolic and catabolic stressor states which can have profound effects on our immune systems. Over-reaching in daily life and over-training to balance cognitive stressors may be creating more harm than good

Altered biomechnical conditions are a result of misuse, disuse, abuse whose damage causes a reciprocating viscious cycle of muscle-tendon atrophy, degenerative changes, and immune-metabolic dysfunction. At Back in Business Physiotherapy we use a combination of 'hands-on' therapy, exercise and nutritional supplementation to optimise the rehabilitative process. Moreover, endurance is tantamount to musculoskeletal health, as the deeper slow twitch postural muscles are the stabilisers of the body. In contrast the multi-joint superficial muscles are the mobilisers - ballistic muscles of the body. Good training involves building a physiological endurance base with graduated progressive and periodised training regimes.

Immunological factors as a result of disuse

A biphasic stress response has been described in muscles during 'reloading' after a period of 'unloading'. Mechanical unloading as a result of disuse results in substantial muscle atrophy. This atrophy is a result of both increased protein degradation and reduced protein synthesis. Signaling pathways leading to this, include oxidative stress, proinflammatory signaling, reduced stress response, including heat shock proteins (HSP) and insulin-like growth factor (IGF-1). Insufficient HSP and antioxidant enzymes elicits oxidative damage of proteins and lipids (Lawler et al 2003, Free Radic Biol Med, 35, 9-16). Hence, unloading elevates oxidative stress. Paradoxically, loading also elevates oxidative stress. Nuclear Factor kB (NF-kB) has been implicated in both processes. During unloading it is thought to induce numerous pro-inflammatory genes including nitirc oxide synthase, cytokines, ubiquitin pathway ligases as a result of withdrawal of the stress - response including HSP25, HSP70, IGF1/Akt pathway (Lawler et al 2006, Muscle Nerve, 33, 200-207). The early portion of reloading, after a period of immobilisation is characterised by muscle damage and inflammation which requires a cognitive approach using a realistic time-frame for recovery to take place. although, muscle recovery after 7-10 days of unlaoding is rapid (7 - 9 days), prolonged immobilisation greater than 17 days exhibits impaired recovery of muscle mass (Kasper 1995, J Appl Physiol, 79, 607-614). Reloading of muscles have been shown to result in a large up-regulation of NF-kB DNA-binding activity (Lawler et al 2012, Med Sci Sp Ex, 44, 4, 600-609). HSP25 phosphorylation decreased during prolonged unloading but returned to normal after 28 days of reloading. HSP70 and IGF-1 remained depressed during short term reloading but returned to normal levels as muscle mass improved, whereas in contrast Akt phosphorylation was greater in short term reloading but returned to normal by day 28 (Lawler et al 2012).

Muscle mass is considered fundamental for the production of force and hence power. I submitted a paper for publication in 2003 which outlined the importance of muscle mass to immune, hormonal and metabolic function. From this paper, the concept of total body stability and allostasis was born, which I presented in Rome in October 2005.

  • Muscle mass has been traditionally associated as an organ of movement, however it is an organ of survival and hence allostasis, as it represents 90% of protein in the body and is an important site of both local and systemic immune - inflammatory reactions
  • Progressive resistance training (PRT) associated with goal oriented cognitive behavioural therapy (CBT) represents a credible method of mediating the risks of developing sarcopenia and metabolic syndrome as well as improving immune responses to stress and inflammation.
  • Periodisation of training represents a credible method of stressing rather than straining the system. Additionally, specific plyometric exercise regimes have the potential to enhance the myofibrillar architecture thereby reducing the amount of trauma and inflammation occurring during weight bearing eccentric exercise regimes
  • Nutritional supplementation and adequate time for recuperation will enhance immune responses
  • Goal oriented specific task demands within given time frames and associated with appropriately timed feedback (both internal and external cues) will enhance allostasis and hence improve the immune response.

Rome presentation

11. Emotional stability

Since the central nervous system and resting muscle tone are particularly important aspects of motor control, then emotional stability is of paramount importance for optimal performance. Extreme examples of mal-adpative behaviour to emotionally labile states are situations which lead to 'fear - avoidance' of activity. Optimisation of the emotional state can lead to the feeling of control over the environment rather than the reverse, "master of their own destiny". Such scenarios also result in large amounts of energy being available which if constrained through 'pacing' can result in athletic success but if unchecked can cause euphoria which ultimately leads to a "crash and burn" phenomenon.

link to Allostasis

It could be argued that the term 'instability' could lead to 'fear avoidance' behaviour with inappropriate sympathetic nervous system activity. Hence, the concept of allostasis and neuro-immune behavioural mechanisms need to be considered here. Allostasis represents the ability to go beyond ones comfort zone and to adapt postively to the 'stressor' over time.

Negative emotions such as rumination can be ascertained on questioning the client about the intial precipitating incident. Additionally peoples attitude towards them, in the working/sporting, home and social environment may have an impact on the persons 'emotional stability' as well as their ability to cope actively.

12. Clinical stability

Clearly, the gaining of sporting expertise (such as pitching in baseball) can only be obtained through repitition of movement (practice), whilst avoiding injury. Furthermore, when injuries do take place appropriate recovery from injury should occur. Generally, people consider recovery to be synonymous with being painfree. However, over the years we have learned that motor dysfunction can continue in the absence of pain, thus leaving a person vulnerable to further injury.

Clinically, the Maitland edition of Peripheral Manipulation from the early 1990's emphasized the concepts of stage, severity,irritability and stability. Unfortunately, these concepts were thought only to apply to joints, which at the time was considered a 'passive structure' (e.g. passive accessory and passive physiological). Yet the concept of 'stability' suggested a clinical past history of questioning the frequency of recurrences. 'Irritability' was emphasized and considered the ease of exacerbation of pain and the time required for it to subside, yet it was meaningless if considered outside the concept of stability. The 'stage' of the problem explained whether a condition was getting better/worse or staying the same, but was only meaningful if the 'severity' of the condition was considered. By examining 'severity' the authors were actually considering today what we would describe as 'avoidance behaviour'. Hence, it was important to know what the person was and wasn't doing. They may appear stable and non - irritable but what had been eliminated out of their activities of daily living? Addressing 'easing factors' can give an indication of whether the person copes 'actively' or 'passively'. Such cognitive evaluation by the client's higher centres is now considered an integral part of the examination and treatment process when determining the motor control issues affecting their musculoskeletal system.

Even despite the knowledge that pain could cause reflexogenic inhibition and excitation of muscle activity, pain was clearly a missing ingredient in many models of motor learning. By 1993, at the Parisian IASP world congress, French researchers had mapped descending noradrenergic modulating pain pathways in rats (Proudfit, H.K. (1992). The behavioural pharmacology of the noradrenergic descending system. In : Besson, J.M. & Guilbaud, G. (Eds.)(1992). Towards the use of Noradrenergic Agonists for the Treatment of Pain (1st ed.). Amsterdam : Elsevier Science Publishers B.V.), whilst the first MRI and PET imaging started to become available and affordable to general patient populations (IASP world congress, Vancouver 1996).

Although the concepts of motor learning, skill acquisition and stability have seemed like a parallel phenomenon to the traditional approach to physiotherapy, this shouldn't be taken for granted. The Swiss physiotherapist and founder of Functional Movement Learning, Honorary Doctor Medicine Klein Vogelbach, used concepts out of neurology, in the 1970's, such as training with Swiss balls and brought them across to musculoskeletal physiotherapy. Other watersheds included, the McConnell technique of 'patella taping' which was actually developed at Sydney University in the mid 1980's and had a strong stabilising motor control emphasis drawing on the works of the Americans Gentile and Sahrmann. By the mid 1990's Hodges, Richardson, Jull et al at the University of Queensland placed emphasis on the stability from the transverse abdominal and multifidus muscles in treating low back pain. Interestingly, Klein Vogelbach had already incorporated small spinal rotational movement training into her Functional Movement Learning (FBL) regime at least a decade previously, presumably to stimulate the small intraspinal muscles. By the late 1990's, Lorrimer Mosely was using techniques out of rehabilitation in Neurology, such as reverse mirrors, to take a revolutionary perspective on motor control and neuropathic pain. Similarly, Peter O'Sullivan from Western Australia drew on work in Neurology and Psychology (CBT) to determine and validate a new classification for the treatment of chronic low back pain which has been termed Cognitivel Movement Therapy.

Inconsistent findings on the effects of pain on motor control has made it important to conceptualize a theoretical framework of adaptation in the sensorimotor system in the person with pain. A simplistic approach would be to say that the person will use the redundancy in the system to protect the perceived vulnerability to further injury. Such redundancy takes the form of employing synergistic muscles to perform the task and/or adapting the task to reduce loading. In the acute phase of an injury, such simple strategies may be useful, however adapatation can be very rapid and permanant. If the adaptation is suboptimal for the intended goal, then secondary injuries may occur. These may take the form of disuse atrophy, reduced sensorimotor (proprioceptive and feed-forward) input from the 'unloaded' part, whilst overloading the compensatory muscles and the body parts which they influence. Therefore, both the primary and secondary consequences of the movement dysfunction must be evaluated and treated. Henry Tsao at the University of Queensland has quite clearly shown alterations in cortical processing regions (motor maps) in the brain in people with chronic low back pain. Adaptation strategies vary between people with both increases and decreases in muscle activity occuring in various parts of the body. Thus it becomes imperative that the person is examined in a systematic way in order to specifically taylor treatment management strategies.

Levin et al (2008) mapped the gene expression of pain which in the case of muscle tissue proteins and neural tissue probably has an influence on motor control.

Conclusion

In the 2 decades since surfing in Cronulla, the approach to musculoskeletal disorders and the concept and scientific verification of stability has undergone significant and fundamental changes due to the dedicated work of physiotherapist researchers validating clinicians insights and practice. Unlike 1986, by 2009 a 5000 word paper and a 40 minute presentation on the topic of 'Why our shoulders don't subluxate' would be pretty easy to fill.

Clinically, the examination process must ascertain the affect of pain and injury on attention and stress and its affects on the interpretation of task demands and hence motor planning. The effects of cortical inhibition, delayed central transmission, reflexogenic motoneuron inhibition on motor planning can lead to an altered internal model of body dynamics. Clinically this may manifest as reduced range of motion, altered reflexes and muscle strength, as well as changed movement goals to protect the body part. The clients perception of their problem is a vital part of a 'top down' approach to assessment and treatment. A 'bottom up' approach views the adaptive mechanisms in terms of altered proprioceptive input resulting in inaccurate motor planning. For this reason combination therapy, using passive modalities such as joint mobilizations, taping, dry needling, soft tissue massage, etc must be accompanied by meaningful and well integrated exercise prescription which takes into account the values and beliefs of the client. Moreover, in some cases the use of 'real' and/or virtual exercise regimes may mean that passive modalities are either unwarranted or contraindicated. Cognitive Behavioral/Movement Therapy may be required to address aspects of 'attention orientation' and 'stress'. Regardless, of the approach taken, the goal should be to educate the client on their condition and how treatment interventions can meet their (positive or negative) expectations.

"It is the thoughts which proceed the action which count

considered thoughts, considered action

decisive thoughts, decisive action

constructed thoughts, constructed action"

Summary

 

Clinical example of muscular synergies

Alec presented with 6/12 history of 'patella tracking disorder' which was exacerbated by a 7/7 very hilly multistage Transprovance MTB race where the technical sections were so difficult that he had to walk down hill a lot. This resulted in the onset of Pains A, B and C. 2/12 ago a 'low level burning pain commenced at night in the calf's and thighs'. A few weeks prior to the onset of of this burning pain he had had a 'nasty cold'. There was also a prior history of a fractured collar bone 2 years previously as well as some I/T chronic neck and upper thoracic pain of at least 10 years duration.

Examination revealed a stiff kyphotic T/S, reduced rotation and lateral flexion. Extension of the lumbar spine produced increased adductor on the right associated with some increased distal hamstring activity as well. Otherwise ROM of the L/S and hips was within normal range. One Leg Standing (OLS) revealed increased adductor and hamstring activity during lateral weight shift as well as anterior ilial rotation on the right associated with increased ITB tension. The right leg also appeared to be longer than the left. Bilateral excessive pro-nation was present. Active SLR revealed a positive left side which improved with anterior compression of the left inferior ribs. Active leg extension (ALE) was positive on the right and left with early onset of hamstrings as well as contraction of the thoracolumbar muscles prior to the onset of thighs movement. Vastus Medialis Oblique (VMO) on the left was normal whereas on the right the Vastus Lateralis (VL) came on prior to VMO.

Hence, in terms of motor control we have the initiation of movement being dominated by global muscles such as

  • Thoracic erector spine and Hamstrings prior to gluteus maximus contraction
  • Abductors(esp right) prior to and even substituting gluteus medius contraction
  • VL prior to VMO
  • Lack of inferior-lateral and posterior expansion of the diaphragm, probably resulting in reduced eccentric Psoas Major activity.
  • Excessive superficial abdominal muscle activity resulting in reduced thoracic mobility with a consequential enhanced outer sling activity

This pain induced dysfunction or this dysfunction induced pain hypothesis was tested by giving the client a series of motor control innervation exercises whereby synergistic action of deep stabilizers such as Transverse Abdominus, Gluteus Medius and VMO were accompanied by posteriolateral left inferior Diaphragmatic chest expansion. Gluteus Maximus activation over Hamstrings was facilitated through exercises aimed at reducing low thoracic/upper lumbar spine erector spinae activity as well as further facilitating diaphragmatic activity. Exercises to reconstitute the foot arches as well as activate Gluteus Maximus and Transverse Oblique were also given.

Additionally, thoracolumbar dysfunction was addressed with mobility exercises for this region employing serratus anterior and posterior (inferior and superior) activity. The innervation of the diaphragm, as well as the serratus anterior and latissimus dorsi was addressed by providing a Deep Neck Flexor and Low Trapezius exercise, which should in turn have an effect on shoulder and lumbar spine stability.

Muscle Energy Techniques were used for the right anterior ilial rotation (counter nutation). Reduction in muscle spasms of erector spine, quadratures lumborum, and VL is achieved through throracic rib mobilizations, soft tissue massage of the thoracolumbar fascia and dry needling of trigger points. The latter has been demonstrated to act on fascia gliding as well as induce the liberation of pro and anti-inflammatory cytokines of the immune system. See link to Dry Needling for more details. Furthermore, immune considerations and recovery from competition and training took into account calorific deficits by suggesting supplementation with carbohydrate-protein powder, fish oil (EPA and DHA 1000mg), magnesium o rotate, Co Enzyme Q10 and Tumeric.

Hereby, stability is achieved through the appropriate timing and synchronization of various synergistic neuromuscular vectors as well as considering the systems physiology as a whole.

also see : chronic low back pain (central)

neurophysiology of pain (peripheral)

neuro-immune considerations in pain

neuro-immune considerations in sport

Updated : 9 August 2012


 

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    Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More
  • Thu 14 Sep 2017

    Cervical Spine implications in concussion

    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

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