Patient

On: The basics

Posted by

As practitioners of any form, the more experienced we get, the more tempting it is to forget the basics, and yet, most problems can be resolved with techniques we learned when we were first studying.

Hopefully, we can apply them with more finesse, and refined judgement, but generally, the basics remain true.

  • Structure and function are reciprocal and related
  • We are the product of our environment
  • The body has the capacity to heal itself, given the correct inputs
  • The body wants to maintain a stable state
  • Movement is a hierarchy

If we, as practitioners, reflect and apply these to every patient we see, we can know whether to treat or refer, where to focus our attentions, and if the person is following the recovery path that we would expect, given what we know.

And then, we will have an outcome that, if not what the client expects, is more likely to be what they need at that point.

You are what you do.

Posted by

They presented with a long history of shoulder and back pain, with occasional headaches, particularly in the evening. No other significant complaints, simply a tight and painful upper back, and shoulders, with a stiff neck.

After taking a thorough history and checking pertinent red flags, I carried out a suitable examination, looking at how they used their body, how it wanted to respond passively and actively.

And the thing was, other than the presenting complaint, there wasn’t much to be found. An anteriorised head posture and slightly kyphotic thoracic spine, but nothing much more than you might expect for a modern lifestyle. They exercised frequently, were not obese and tried to optimise their working posture when at a desk.

I treated what I found, and we addressed a few issues, but I was unhappy with their progress, as the complaint didn’t feel like it was resolving along the curve I expected.

Then it clicked. Whenever I went through to reception to collect them, they were playing with their phone. Head slumped forwards on the chest, looking down at the tiny screen and typing or scrolling away.

The problem is, modern expectations are that we are constantly connected, with rewards and punishments meted out by both the device and other people if we do not respond to its electronic siren call. I am as guilty as the next person, at instinctively checking and wasting hours.

It was this small, but frequent behaviour that was causing, in this case, the shoulder pain. Looking down was loading the back of their neck, the shoulders were coming in to support the arms holding close and everything matched when I mimicked them.

However, other than taking the phone away from them, there wasn’t a direct intervention I could do, so instead we discussed possible mitigation strategies, to reduce the automatic reaction, shorten the time spent interacting and change the posture, things that have been shown to work.

Following the rules of three, I suggested:

  • Switching on greyscale. This, interestingly, makes the device far less stimulating, but still allows you to work effectively. It also helps increase battery life on some devices.
  • Clean up the home screen and put apps that distract in a folder so you don’t see them first
  • Turn off notifications for social media applications

The point was simply to create a brain pause that allowed for a moment more reflection before the action, rather than create a wholesale change that would more likely fail.

Having created this awareness and put in some simple measures, we were both very happy to see that the treatment was then far more effective and the presenting issues resolved.

After they had left, I reflected in how the simple actions we do can have profound impacts and that, as practitioners of every discipline, we need to continue to look at the whole person, not just the complaint.

The basics of positive mental health

Posted by

Firstly, if you reached this via a random search on the internet and are feeling stuck, buried under unmanageable pressure, in a corner or suicidal, breathe.

If that is you now, if you have a plan, if you’re looking for ways to end your life, if it’s so dark that the relief of knowing how is a comfort, stop. Please. Call a mate, phone Samaritans, if you think you’re going to OD or have, get yourself to A&E.

If you need to self harm to relieve the pain, to give you something to focus on, try ice cubes. Squeeze them in your hand and feel the burning cold. Put down the sharp blade and open a window.

When we, as professionals, talk to people who’ve cut or attempted suicide after we’ve stabilised them, they almost all regret it. Most attempts are a cry for help, to get attention, to put down the enormous burden, to ask someone to take over, just for a while, to deal with the crap life has handed you.

If this is you, I’m sorry. I have no idea what demons you’re fighting but I do know that so many have been there before you and there is a solution, somehow. But the never ending darkness is not it. There are charities who are there to support you, pathways in place to show you that, however dark it is now, there is a way forward.

Please note that this is not about mental illness. This is not about PD, psychosis, mania or depression. These are the kind that leaves you debilitated and requiring professional assistance. For those who have such things, it is important that the rest of us do not stigmatise them, help support them in any way and be conscious that we are all a few steps and some genes away from their situation.

For the rest of us, who live every day with our own mental health, it is thankfully starting to become more commonly talked about in recent years. The typical English attitude of stiff upper lip and crack on is slowly becoming more less expected, but the underlying causes of poor mental health is less commonly discussed.

Positive mental health is much more of a holistic approach, a way of recognising that body and mind are inextricably linked, that we can influence those around us and by intercepting negative trends, and that we may be able to prevent or minimise darker times.

The sketch above shows the basic pyramid of mental health.

Positive health choices are obvious in retrospect. Avoiding drugs that effect mental state (alcohol, cannabis, tobacco, illicit chemicals), taking regular exercise, maintaining a healthy weight, getting sufficient rest.

Regular life patterns play a more subtle role. We all have a circadian clock, a biological rhythm that governs eating, sleeping, and even more complex processes. But we also have a human need for regularity. For work, for seeing friends, for doing things we enjoy. If we neglect this, or it is removed from us, we soon notice its absence.

Positive relationships make more sense. We have all had relationships that drag us down, that make us feel less than we like to be. These can be personal, romantic or work, but their effect is pernicious and corrosive.

We can tolerate shifts in any one of the points for a period of time, for example poor health choices by eating too much, drinking too much or not resting enough, but if we also have a few unsupportive or negative relationships and no regular life pattern then we are in a slippery slope to poor mental health.

Mental health is a gift to be nurtured, shared and to be grateful for.

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.

T4 / Rib 4 Problems

Posted by

1

I have recently been thinking about the connections between the ribcage and shoulder pain. From this, I have noticed a couple of connections.
The main one is dysfunction around rib 4 either side leading to pain in the same side shoulder and arm. This has typically presented as pain next to the scapula, tension in trapezius and radiating pain down the triceps into the forearm. The patient typically has a history of desk based work or driving, with the pain often coming on waking or after coughing / sneezing. Examination shows restricted thoracic spine and tenderness on the ribs, both sternally and on the spine. Having tried to research this, I struggled to uncover much that enlightened me, other than a chiropractic diagnosis of T4 syndrome, which doesn’t really match and often seems rather vague.
My view is that the symptoms are actually caused by fascial tension and pain related muscular spasm, so fascial release, gentle manipulation and soft tissue treatment can have an apparently miraculous effects on some people. I also do some cranial / functional work anteriorly to re-centre and balance the ribs / fascia.
From this, it has been useful to be able to rapidly assess the motion of the spine. Although a detailed examination is always important, it is useful to be able to have a rough guide as to where you should be looking.

Supine, where the patient lies passively and you use their bent knee to create rotation in the spine, blocking at the pelvis, ribs and shoulder to isolate the main sectors. This is following a simple standing active examination, where the patient attempts the main spinal movements of flexion, rotation and sidebending.As an extension of that, I started getting patients to attempt “monkey”. This is an Alexander technique standing posture, which is meant to demonstrate balance within the spine (my perspective). The most important thing to know about Alexander technique (other than it is really rather good and a couple of lessons from a good teacher is worthwhile, I recommend a number of patients to my local teacher) is that it is all about intention and the mind being in charge of the body, so speed is always controlled.To move into a version of monkey posture ask the patient to do the following:

1) Get them to stand comfortably, feet parallel (check, lots externally rotate to minimise loading in the glutes)
2) Bend the knees slightly
3) Bend forward at the waist, spine straight
4) Let the arms hang loose
This is a german video of a man sitting down, but if you stop half way, its monkey.
What I noticed is that most cannot bend solely at the hips without looking down and treating any thoracic restrictions allows them to move much better.
The reason for all of this is to demonstrate treatment further away from the area of complaint and to look for other areas of compromise in their movement patterns. They may also find cervical and lower limb problems start to surface. Once this has been physically demonstrated, it is easier to achieve compliance in terms of future treatments, exercise pescription and general understanding of their body.
And for a positive patient outcome, this can be used as part of their ongoing exercise plan.