Osteopathy

Power, paths and chains

Posted by

I have been thinking about simplifying stretching processes around exercise. Not when trying to repair or prevent injury but as a general mobilisation. Out of this, it is possible to spot a couple of patterns that are easy to follow, cover all the major muscle groups in the body and allow us to achieve the most benefit from our stretching time.

The body has an anterior and posterior chain (originally and well described in the work of Tom Myers), as well as the basic or prime moves.

By combining the basic requirements for movement (flex / extend / rotate) in all joints together with chain connections (it is possible to open up and stretch the whole body very smoothly.

Starting with the spine, we need to create flexion, extension, rotation and sidebending, focused on the articulation of the intravertebral joints rather than faking apparent range of motion with the peripheral limb movements. Hands on opposite shoulders (crossed in front of chest) and turn spine left and right, then flex forward (from the diaphagm) and arch back. Finally sidebending both directions to finish the moves.

For the front chain, step into a open lunge, keep the pelvis neutral (most important), extend the opposite arm as though stretching the chest and turn the upper body in the same direction. You should feel a gentle tension across the whole line. If you are unable to sustain this, it can be split into sections but needs to be considered part of the whole. The sections being kneeling lunge for upper body to pelvis and quad stretch for lower body. Repeat both sides, of course.

For the back line, a sitting figure 4 stretch (foot into opposite knee and lean into straight leg) covers most of the groups.

Finally, lie on your back, pull your knees up so knees and hips are comfortably angled, then let them drop to one side so that the glutes are stretched, together with the back chain. This can be amplified by putting the opposite arm out and stabilising the upper body.

Of course, these are best demonstrated in a clinical situation, so that they can be tuned to your body, however by paying attention to both your attention and intention, then good results can be acheived.

Anatomy is not everything

Posted by

Anatomy is important.

Anatomy describes how one bit connects to another and what it’s called. It lays out the typical positions of the components of the body and, with physiology, tells us how it all works.

But anatomy does not say how you move. One could not look at a supine body and say with any certainty whether they had back pain, felt stiff in the mornings or found running difficult. Dissection and a pathological examination indicate areas where the soft tissues and skeleton have changed over time, but since almost 50% of the adult population have dysfunctional spinal discs, yet not all of them present with neurological symptoms, this would be only indicative that there might be a problem not a definite diagnosis. Even then, that does not describe where they would potentially experience that pain or how it would present clinically.

All of that must be discovered through the case history and observation. Observation in all senses, including what they’re not saying or doing, how they feel, how they respond to palpation and so forth. And, as we exist within a dynamic world, at least part of that assessment has to take place with the person moving in their normal position. It is impossible to see why a shoulder is hurting if it is not normally used lying down. A knee may only twinge when the patient walks down stairs and so on. Active and passive examination needs to be considered, and not rote.

Learning to observe, to see rather than just look is a vital skill that we need to learn over time, it is a root from which other elements grow. Without effective observation feeding the diagnostic sieve, we cannot know which tool in our set to apply most effectively.

Artists learn to observe by doing. They try to see the whole, consider how it fits together, the interlocking parts. Relaxed, open, non judgemental. As practitioners, our process flow often inhibits this gentle scanning. We have probably talked to the person, taken the case history, formulated ideas, theories, considered current models of diagnosis. And through that filter attempt to see the problem in front of us. But what if we turned it around? Asked what that person experiences, why they’re with you today and then, non-judgementally asked them to move? Once we’ve observed them, then you can start the therapeutic journey.

Step away from the anatomy, the collection of organs, muscles, nerves, fascia and bones that sits in front of you and look.

3 dietary changes that could save you

Posted by

2

Clinically, we all ask the endocrine questions during our case history taking. Are you sleeping ok? Do you feel tired all the time? Have you noticed any untoward changes in your hair, your skin, your weight? Are you feeling much more thirsty? Are you feeling too hot, too cold? These cover many different symptoms and pathologies and if any of them don’t add up, we know to refer to other medical professionals for further investigation and treatment.

But what of those subclinical ones, changes that are sitting in the background, induced by life patterns. Borderline type 2 diabetic, adrenal fatigue, chronic overtraining. Is there any advice we can safely give that could help that person and make sure they don’t fall over the edge and need medical intervention?

Cushing syndrome describes the signs and symptoms produced due to prolonged and excessive cortisol exposure (from overstimulation of the adrenal glands due to pituitary gland issues).

These include [1,2]:

  • Centralised (around the torso) weight gain
  • Fat pads on the back of the neck and clavicle,
  • Thinning of the skin
  • Bone loss
  • Glucose insensitivity
  • Memory changes and concentration issues

Some of these symptoms may look remarkably like the effect of prolonged stress on many people who will be presenting to us as patients.

Another cause of adrenal fatigue is over training in athletes. To them, if some is good, then more is better. The flaw in this logic is that, past a certain point, more becomes destructive, with the body no longer able to deal with the training load, leading the athlete to slow down, more tired and more prone to injury and illness. So they push harder, train longer and eventually run the risk of systemic collapse. The hormonal response in this depends on the sex and makeup of the person in question but in all cases, there may be evidence of adrenal fatigue, insulin resistance and muscle metabolisation [3]

Type II diabetes, or late onset occurs when the body becomes resistant to insulin and is often caused by obesity. Typical symptoms include increased thirst, increased frequency of urination and increased hunger. The effects of diabetes in any form are multi factorial, leading to potential peripheral neuropathy, damage to the eye sight, systemic organ failure and increased healing times in the skin. This is most commonly treated through a combination of diet, exercise and medication if necessary.

The commonality between these conditions is the recommendations offered for recovery and healing. If a patient is suffering from Cushing Syndrome  they are advised to take a low carbohydrate, low calorie, high potassium diet [2]. In diabetes, the patient is told to lose weight, change their dietary patterns and reduce their carbohydrate intake significantly. In a recovering athlete, they need to reduce the stress on the body, look at their dietary patterns and ensure they have sufficient protein in their diet to allow full muscle and immune system recovery. Magnesium is also recommended as it has been shown to lower cortisol, help improve mood swings, improve glucose sensitivity and help manage blood pressure [4]. Omega 3 oils have been indicated as beneficial in helping deal with the mental effects of cortisol and as such, can help with cognitive processes in all the above cases.

The message, time and again, is that a lower carbohydrate diet is beneficial. There is little evidence we need carbohydrate to the extent that we need proteins and fat. It is a highly efficient source of fuel but one that needs to be used rapidly, otherwise it is metabolised into fat in the liver. With athletes, it is important that they receive sufficient energy to support their performance and healing but some believe that this should be achieved by increasing their fat intake. Quite how much carbohydrate is still in discussion but the consensus appears to be drifting to less than 100g for sedentary people (strict advocates would suggest lower). For athletes it is harder to factor, since they are burning so much more but they might consider fueling around training sessions and health status with fat as the dominant energy source.

Take home tactics?

  1. Magnesium supplementation (250mg per day)
  2. Significantly less carbohydrate
  3. Omega 3 oils

Simple and with reduced adrenal stimulation, very successful.

References

1: http://en.wikipedia.org/wiki/Cushing’s_syndrome

2: Pathophysiology Made Easy, Lippincott, Williams and Wilkins 2006

3: http://en.wikipedia.org/wiki/Overtraining

4: G. Paolisso, A. Scheen, F. D’Onofrio, P. Lefèbvre (1990), ‘Magnesium and glucose homeostasis’, in Diabetologia, 33: 511-514

5 easy ways to stop back pain

Posted by

1

Over 70% of adults will suffer from back pain at some point and this number is rising every year. We all use our backs every day without thinking about it until they hurt.

Whether its from acute discs to muscle spasms, trapped nerves to torn ligaments, there are lots of ways for them to go and some easy ones to prevent it, without resorting to pills and surgery. Techniques doctors don’t always have time to tell you but save you time, money and worry.

  1. Move regularly. Your back is often painful if you sit for too long. The muscles go weak, the ligaments holding the bones together stretch and pain is the end result. Instead, walk a bit more, sit a bit less and use those muscles. Exercise doesn’t have to be gyms and furious sweating, simple moves at home will do it.
  2. Lift Properly. Whether it is a bag of shopping, a suitcase out of the car or a small child, we often lift very heavy objects without thinking and without doing it properly. Even if you can only manage a few of these items, they will massively reduce the risk. There is a simple way to remember lifting:
    1. Stop: Stop and think about the lift. Is it too heavy, too bulky?
    2. Face: Move to face the object. Twisting, bending and using the spine is the fastest way to cause lots of damage quickly.
    3. Brace: Pull your tummy muscles in. They are orientated so that they help support the spine safely but we often neglect to use them.
    4. Legs: Bend your knees, back straight and lift by pushing your heels into the ground and driving through your bottom.
  3. Stretch. If we spend too long sitting down, all the muscles at the front of us shorten, all the muscles at the back lengthen and we develop imbalances that cause pain when we try and stand up. Simple stretches can make an enormous difference to how you stand and move.
  4. Lose weight. If you are overweight, every step you take creates excess load on all your joints, even the ones in the spine. Your back has to take more force in the wrong directions, increasing the risk of it hurting.
  5. See an Osteopath. If in doubt, see an expert. Preferably before it starts hurting and you need the emergency appointment. Osteopaths are able to see where it might go and help free you up, allowing you to enjoy life without worrying.

Try these before its too late and you’re laid up.

Pareto Principle

Posted by

Vilfredo Pareto, an Italian economist, observed that there in general, there is an 80/20 split to all things.

  • 80% of a businesses income will come from 20% of the customers
  • 80% of the commodities will be owned by 20% of the people
  • 80% of the work will take 20% of the time

Interestingly, this also seems to apply to the treatment of patients.

 

x = time, y = improvement

If we take the above plot (y = log x +2, where x = 0 to 10) we can see that, for a greater value of x, y takes proportionally longer to increase. A simplistic interpretation and a mathematician will be able to show that it never truly will be horizontal, (y will always change) but it can also be seen that the greatest increase in y happens very quickly (approximately within the first 20% of the graph).

We can therefore use this tool and curve as a multilayered example to discuss with our patients.

  • Intial improvement should be rapid, within the first few treatments. If it isn’t, are we as clinicians missing something important?
  • 80% of their improvement will take 20% of the treatment time
  • They will never reach 100% better. We are all carrying compensations from the moment we are born, there will always be niggles. Our job is also to educate the patient on when these are mild or serious.
  • Treatment is progressive and dynamic. As they pass the 80% improvement point (on the y axis) then they should be encouraged to take more responsibility for their improvement, through exercises, diet and behavioural changes.

The Pareto pricinple can also be applied to others areas of practice. We will get 20% of clients who are unusual presentations, 80% of problems will be resolved with 20% of our treatment techniques and so forth. It is that 20% that requires our focus and skill.

168 Hours

Posted by

There are 168 Hours in a week.

We sleep, on average, for 56 (8 hours a night)

We sit and work for 45 (9 hours a day, 5 days a week)

We sit and commute for 10 (1 hour each way, 5 days a week)

We sit eating, reading or watching TV for 21 (3 hours a day, 7 days a week)

That leaves 36 hours to do other things, mostly at the weekend.

That which we do the most of, we become.

An hours exercise or movement a day really doesn’t seem much to ask does it? And if you recieve treatment for half an hour a week and change nothing else, how can you expect it to work?

You can’t fix them all.

Posted by

Conversations with colleagues often produce unexpected results. One of these recently was, for me, the realisation that you can’t help everyone.

We graduate from college, ready to take on the world and  slowly the experience knocks the corners off us, we grow into our own style of practice and learn what works for us.

However, one of the hardest things to face up to is that not everyone will get better. There are, of course, the red flag patients who should be referred to medical care and those who need other forms of intervention. But in theory, the rest should be amenable to treatment, at least to some extent.

So to understand that you can’t do it all is a big leap. There will be some where  your personality clashes with theirs, those who come with high expectactions, hoping for a magic click that frees them of the chronic pain that they have had for the past 20 years, people who blame you when they don’t improve, in spite of not following your advice, patients where the problem is as much psychological as physical and many others.

The skill is in recognising this, accepting it and moving on in the most appropriate direction, whatever that may be.

For me, once I came to this conclusion, the pressure lifted and, as long as I felt I could stand by my clinical decisions, my practice improved.

Wobbly sticks and string

Posted by

Most people have seen a tensegrity model. These are clever constructions of sticks and elastic that use balanced tension and compression to created self supporting shapes.

(Image taken from http://dotensegrity.blogspot.co.uk/2011/01/make-your-own-tensegrity-model.html)

It is possible to consider the body as a tensegrity model, where the bones, muscles and ligaments all act together to support, articulate and move.

Although simplistic and missing huge elements of the effects of fascia, organs, inflammation and so forth, it is a useful analogy to hold, especially when trying to educate patients.

Recently, I have been considering the lumbar spine and the need for good abdominal support around it. The metaphor I use it that of a wobbly stick attempting to link upper and lower halves of the body. The pelvis is a fairly stable, solid object and the thoracic spine is well held with the ribs. This leaves the cervical spine (a wobbly stick with a block on top) and Lumbar spine to do a lot of work. Therefore, we need plenty of active muscles recruited to provide stability, support and movement.

So, no matter how much we may train that six pack and work to get well toned abs, if we cannot recruit them during activity, its fairly pointless.

I have 3 basic exercises I start with for every patient and, if they can do those, move to the next level. These are:

Pelvic control: The patient lies supine, slides one heel up the couch or floor, whilst attempting to maintain a level pelvis, the ASIS not deviating significantly posteriorly. Recruitment of the TA is particularly useful in this.

Cat crunches: On all 4s, the patient pulls their navel towards the spine, attempting to keep everything else still. A count of 5 and release slowly. This helps recruit deep obliques and the thoracolumbar fascia attachments.

Gluteal raises (trendelenburg drops). The patient stands sideways on a step and allows one leg to drop. They raise it back up again, using the opposite glutes, minimising recruitment of QL or lumbar erector spinae if possible.

Once they’ve got these, then the neuromuscular paths are working better and we can progress to more dynamic tests.

No more wobbly stick, less back pain.

Thoughts on taping

Posted by

2

Having recently attended a very interesting taping course, I have been thinking more about possible mechanisms of function.

If you have not worked with modern kinetic tapes, they are woven cotton strip, normally 5cm wide, with an adhesive backing. The materials used in manufacture mean that the tape has the ability to stretch, allowing it to support or follow the skin. This also means that it has less ability to support or inhibit motion, since there is less strength in the cloth.

The tape can be applied either under tension or free, which apparently gives it different functionality and there is some evidence that it is effective, not just in supporting injuries, but also in reducing eodema and bruising.

It is the method of function that interests me, as unlike the older zinc oxide white tape, which is used to immobilise and support an area, this is used to guide and improve movement.

Others are doing far better research on this, but my overall impression of this tape is that, rather than guiding a muscle or joint through the physical properties within the material, it is improving neuromuscular feedback and athletic perception of the affected area, in turn leading to better patterns. I also suspect that it is dynamically guiding the fascia, around the structures, which in turn is improving the allowed function there. And, as we know, the fascia can connect many apparently unrelated structures so again, complete examination is required to ensure the most effective placement.

With these thoughts in mind, I am considering the use of kinetic tapes more in my practice and attempting to be more creative with their application.

80:20

Posted by

1

There is an idea called the Pareto law. This says that 80% of the work takes 20% of the time. It can be used in almost any situation, from business management to problem solving, personal training to writing a book. I use it to illustrate a patients recovery plan (and will try to cover this in a post soon).
I also think it applies to our area, not just in terms of treatment processes, but in terms of techniques.Far too many people don’t use their training, expertise and experience sufficiently when working with clients. Instead they fall back on what they know works and do the same thing for everybody. (80% of problems can be solved with 20% of our skill). But every body is not the same. Each client is unique and each time we see them they have changed.

From a therapeutic perspective, this means that we need to reassess and reinterpret them each time, not just do the same thing and hope it will work.

When carrying out a fitness program, this also stands. We can draw up a framework for the series of sessions but need to be flexible enough to modify it as necessary. We should and need to concentrate on what they are saying, how they are responding and whether we are achieving their goals. In either mode, we especially need to take into consideration current research and thinking to ensure we are up to date with what the experts are doing. As with every other part of life, we need to remember the loop: observe, think, apply. Only then will we be doing the best for our clients and ourselves.