Change The Context: 3 Tools to Treat Neck Pain

Basket Case Study

The other day I woke up with some right-sided neck pain. I had some discomfort and slight limitations rotating or sidebending right.

Now I’ve already completed many systemic-oriented treatments, and don’t really have a go-to non-manual for the occasional crick in the neck. I was unable to get any manual therapy, nor were self-mobilizations effective.

What’s a guy to do? Continue reading “Change The Context: 3 Tools to Treat Neck Pain”

How to Design Your Learning Program

Thanks Buddy

The other day I was texting with a friend and writer I respect dearly, Seth Oberst, and he asked me an excellent question regarding the reading process:

How do you determine what you read next though? ~Seth Oberst

I answered him then, though it felt brief and inadequate. His question inspired me to reflect on how I design my learning process.

Though I’ve mentioned my learning philosophy, it may be fruitful to delve into the details. Seth, I hope I don’t let you down. Continue reading “How to Design Your Learning Program”

Starting from the Bottom (Now We Here): When General Physical Preparation Matters

Professional Nihilism?

After wiping the tears and coming to the stark realization of our (ir)relevance in performance, we must ask where do we fit in? Do we matter?

TheRockPoint
IT DOESN’T MATTER IF WE MATTER!

I’ve asked myself this question many times. It is hard to answer when tactical over-utilization begets repetitive stress injuries; a poor night’s sleep, Slurpies, and donuts make someone ill; or a contact play ends a career. What could I have done differently? What was my role?

Though these questions have required skill development in special physical preparedness, sports science, and stress management; improving general qualities is pertinent in certain scenarios. It is these times in which rehab and training is of utmost importance, and we regain our relevance.

When GPP Matters

Our skills shine in the following instances: Continue reading “Starting from the Bottom (Now We Here): When General Physical Preparation Matters”

Movement Chapter 7: SFMA Introduction and Top-Tier Tests

This is a chapter 7 summary of the book “Movement” by Gray Cook.

Intro

The SFMA’s goal is to assess functional capabilities. This system is based on Cyriax differentiation and grading principles. Instead of describing things as strong, weak, painful, or painless; the following descriptors are utilized:

  • Functional nonpainful (FN): Unlimited movement and able to complete a breath cycle at end-range. Called the dead end.
  • Functional painful (FP): Called the marker, reassessed.
  • Dysfunctional nonpainful (DN): Limited, restricted, impaired mobility, stability, or symmetry. Labored breathing with movement also implicates this choice. Called the pathway, where treatment occurs.
  • Dysfunctional painful (DP): Called the logical beehive because we do not know if pain is causing poor movement or vice versa. It is an unreliable place to work unless acute situations.
Cee Lo is still pushing for the FU to get recognized in the SFMA.

SFMA corrective and manual therapy lie in treating the FP’s and DN’s. The order at which things are treated also matters, so the order listed below for the top tier tests is also typically where treatments should hierarchically begin.

  • Cervical spine patterns (CSP)
  • Upper extremity patterns (UEP)
  • Multi-segmental flexion (MSF)
  • Multi-segmental extension (MSE)
  • Multi-segmental rotation (MSR)
  • Single leg stance (SLS)
  • Overhead deep squat (ODS)

We then operate the SFMA in the following fashion:

Movement Chapter 4: Movement Screening

This is a chapter 4 summary of the book “Movement” by Gray Cook.

What Be the Goal?

Movement screening’s goal is to manage risk by finding limitations and asymmetries via two strategies;

1)      Movement-pattern problems: Decreased mobility and stability in basic movements.

2)      Athletic-performance problems: Decreased fitness.

But movement ain’t one.

The FMS razor, akin to Occam’s razor, is to determine a minimum movement pattern quality before movement quantity and capacity are targeted.

Movement patterns are lost by the following mechanisms:

Ideally, the FMS would be part of the basic tests performed when one is looking to participate in sport. Prior to any athletic engagement, a medical exam is performed to clear someone to participate. This exam is often followed by performance and skills tests. Gray feels that the FMS belongs between these two tests, as there is an obvious gap from basic medical screening to high performance.

Oh gosh that hurdle step is going to be awful after this.

It is not to say that we must only train movement patterns. Rather, all the above qualities can be trained in parallel. The real goal is to manage minimums at each level and make sure improving one does not sacrifice quality at the others.

Movement Chapter 3: Understanding Movement

This is a chapter 3 summary of the book “Movement” by Gray Cook.

You Down with SOP?

Unlike many other areas, movement does not have a standard operating procedure and is thus very subjective. Since movement is the foundation for all activity, it is important that we develop some type of standard for good movement.

Good thing we haven’t heard this point before.

Changing Compensations

Movement compensations are often unconscious, thereby making these patterns difficult to be cued away.  It may be the case that less threatening movements and corrective exercise could be utilized to change undesired patterns.

When designing exercise, it is important to make them challenging as opposed to difficult. Difficulty implies struggling, whereas challenges are what test one’s abilities. Anyone can make something difficult, but not all can challenge.

Function of the FMS and SFMA

The goals of the functional movement systems are as follows:

1)      Demonstrate if movement patterns produce pain within accepted ranges of movement.

2)      Identify those without pain that are at high injury risk.

3)      Identify specific exercises and activities to avoid until achieving the required movement competency.

4)      Identify the best corrective exercise to restore movement competency.

5)      Create a baseline of standardized movement patterns for future reference.

The difference between the FMS and SFMA is that the FMS assesses risk whereas the SFMA diagnoses movement problems.

No treaties for crappy movement. Puns through the roof today.

The FMS operates in the following manner:

1)      Rates and ranks nonpainful movements based on limits and asymmetries.

2)      Identifies pain.

3)      Identifies lowest ranking or most asymmetrical patterns; most primitive pattern if greater than one.

4)      Find activities that may perpetuate the problem and take a temporary break from said activities.

5)      Start a corrective strategy.

6)      Reassess the test.

7)      If improved keep strategy, if not recheck FMS.

8)      Check exercise performance.

9)      Use effective and properly paced progressions.

10)   If changes occurs, retest FMS to establish norms and change corrections.

Whereas the SFMA operates as such:

1)      Find dysfunctional nonpainful (DN) movements (the path) and functional painful movements (FP), which are the markers. Work on DN before FP.

2)      Don’t breakdown functional nonpainful movements (FN).

3)      Only breakout dysfunctional painful movements (DP) if other breakouts can’t be performed.

4)      DN’s should show mobility or stability impairments that need to be addressed.

5)      Check these impairments.

6)      Check FP’s in loaded and unloaded positions; noting the lowest level in which pain is present.

7)      Form working diagnoses based on info from DN’s.

8)      Check for functional activities that could perpetuate the current complaint.

9)      Treat.

10)   Reassess impairments.

11)   Reassess pain breakouts. If changes occur at the lowest level, move up through the breakouts.

12)   Reassess dysfunctional breakouts.

13)   If baseline changes positively, keep chosen strategy.

Once the SFMA is clear, FMS at or near discharge.

Explain Pain Section 4: Altered Central Nervous System Alarms

This is a summary of section 4 of “Explain Pain” by David Butler and Lorimer Moseley.

CNS Alarms

While much of talk in rehab deals with tissue injury and tissue pain, realize that the brain always makes the final decision as to whether or not you should feel pain. No brain, no pain.

This sentiment does not mean that pain is not real. All pain is real. However, pain is a construct that the brain creates in order to ensure your survival.

Spinal Cord Alarms

When an injury occurs and the DRG receives impulses from peripheral structures or the brain, the spinal cord neurons must adapt to better uptake all these signals. In essence, the DRG becomes better at sending danger messages up to the brain. This change leads to short term increases in sensitivity to excitatory chemicals. Those stimuli that didn’t hurt before now do (allodynia) and those that used to hurt now hurt more (hyperalgesia).

In persistent pain, this change continues occurring to the point where neurons that do not carry danger messages start growing into space where danger messages are taking place. Now innocuous stimuli such as grazing the skin begin hurting. The pain may be normal, but the underlying processes become abnormal.

When these spinal cord alarm systems become unhealthy, the brain no longer receives an accurate message of what is going on. The alarms become magnified and distorted.  The brain is told there is more damage in the tissues than is actually present.

What is good is that this increased sensitivity can change once damaged structures are under control and/or the underlying physiological processes are understood by the person in pain.

The Animals may have been onto something.

Smudging

Another change that happens in the brain is termed smudging, in which brain areas devoted to body parts or functions begin overlapping. This process is why some body parts may become difficult to use or other areas become sensitive compared to the injured area.

Fortunately, since the brain homunculus frequently changes, these effects are reversible. The homunculus must be trained just like any other muscle or skill.

Thoughts

It is now understood that thoughts are powerful enough to maintain a pain state, known as thought viruses. These viruses are known to cause and enhance a low back pain experience, and likely have an effect at the whole body. Here are some examples of thought viruses.

  • Pain means something harmful is happening to my body.
  • Stopping social activity because of pain.
  • It is bad if no one can find out what is wrong with me.
  • Pain scares me.
  • Refusing to move until all pain is gone.
Given many medical treatments, I can see why.

Central Sensitization

Central Sensitization is when the brain and spinal cord become overly sensitive to processes. This change occurs in chronic pain states.  Diagnoses such as fibromyalgia, chronic fatigue syndrome, and non-specific low back pain are often given out. The diagnosis given often depends on where you live and which health professional you have seen. Here are the characteristics of central sensitization.

  • Pain persists past normal healing times.
  • Pain spreads.
  • Pain is worsening.
  • Lots of movements hurt. Even imagining movement can hurt.
  • Pain becomes unpredictable.
  • There are other past, present, and future problems in life.

The Autonomic Nervous System

The sympathetic nervous system helps us cope and stay protected from threat. It does so by sending adrenaline to all the tissues among many other processes.

In chronic pain states, there are increased levels of adrenaline, though in some cases adrenaline can become depleted. Adrenaline does not itself cause pain, but does increase alarm system sensitivity.

On the other hand, the parasympathetic nervous system is what slows us down and helps shift us out of a sympathetic state. This system is why relaxation and meditation can help with the healing process.

Bonus points if you meditate in a cave…and go bald

The Endocrine System

Chronic pain states are often associated with high levels are cortisol as well. Cortisol often gets a bad rap despite its role as a protector. What cortisol does is slow down unnecessary body processes which are not needed for immediate protection and enhances those which are.

The Immune System

The immune system has a major link to the autonomic and endocrine systems. The immune system works by releasing pro-inflammatory cytokines, which can create lethargy, loss of appetite, sensitive movements, etc. Even old pains can come back because of cytokines. Here are some fun immune system facts.

  • Immune system becomes more involved in serious or chronic states.
  • Immune system responses can become learnt.
  • Long-term stress and pain can lead to altered activity which leads to more cytokine production.
  • Immune stressors can be major or multiple minor events.
  • The immune system may underpin pain states such as mirror pain and loss of fine sensibility.
  • The immune system can be activated by the brain.

There are also several ways you can boost your immune system to counteract pain causing behaviors.

  • Improve your quality of life.
  • Be in control of life and treatment options.
  • Have strong family and medical support.
  • Have strong belief systems.
  • Humor.
  • Exercise.
I just boosted your immune system. You’re welcome….Unless you don’t like kids.

Movement (Not Gray Cook, that’s coming later)

In threatening states, big mover muscles become primed. This change occurs evolutionarily so your body can escape potential threats. In injured states, prime movers can act as splints.  If this state occurs for the long term, muscles can start to feel stiff and achy. Even if pain is gone, sometimes these muscles do not return to their normal activity levels.

Really big splints.

Explain Pain Section 3: The Damaged and Deconditioned Body

This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley.

Tissue Injury 101

When a body is damaged, pain is often the best guide to promote optimal healing. Sometimes it is good for us to rest, other times it is better to move.

A similar healing process occurs for all tissue injuries. First, inflammation floods the injured area with immune and rebuilding cells. This reason is why inflammation is a good thing in early injury stages.

A scar forms once the inflammatory process is over. The tissue then remodels to attempt to become as good as the original. Blood supply and tissue requirements determine how fast the healing process occurs. For example, ligaments heal much slower than skin because the former has a lower blood supply than the latter. This may also be a reason why aerobic exercise may speed up the healing process.

If present, pain usually diminishes as the tissues heal. However, pain may persist if the nervous system still feels under threat.

Acid and Inflammation

The alarm sensors described here constantly work and often get us to move. Movement keeps our system flushed. When we don’t move or a physical obstruction is present (e.g. sitting), acid and by-products build up in the body tissues. Oftentimes we will start to feel aches and pains when we stay in a prolonged position, which is our body’s way of saying “get up and move.”

Much like the alarm system, inflammation is a primitive way for our body to continue the healing process. Inflammation is designed to hurt so the injured area has time to heal. There is no need to fret when swelling, redness, and pain are present; our internal systems are merely repairing us.

Not so bad after all!

We call swelling and its corresponding cells the “inflammatory soup.” This soup is a by-product of blood and chemical transportation, and sets off our body’s alarm system to increase sensitivity. All of these changes are essential to facilitating a healing environment.

Muscles

Everybody be hatin’ on muscles nowadays as the source of our aches and pains. However, the authors put muscles in perspective for us with the following points.

  • Muscles are loaded with sensors, so can impact the pain experience.
  • Muscles can become unhealthy and weak.
  • Muscles are very difficult to injure, they are just very responsive structures.
  • Muscles are well vascularized which allows for quick healing.
  • Muscle activity alters in response to threat and injury.
  • Muscles reflect what our brain is thinking.
Truf
Truf.

The Artist formerly known as disks – LAFTs

The reason the authors wish to change the name of these structures is because anatomically they do not resemble a disk at all. The new name is “living adaptable force transducers,” or LAFTs.

LAFTs are made up of the same material as your ear, and contain some very strong ligaments. In the medical world, we have many different treatment modalities that target the LAFT. We have McKenzie, traction, surgery, and injection to name a few. Because there are so many different treatments for these structures, it is fair to say that LAFT injuries are still not fully understood.

LAFTs also come with very strong language: slipped, bulging, herniated. Using such strong language can stop someone from moving, which is far from the ideal regarding low back pain.

Here are some LAFT facts.

  1. The LAFT outer layer has a nerve supply, so danger sensors can become activated easily. If the LAFT becomes injured, the surrounding structures will likely set off danger sensors as well. You want a lot of danger sensors if something is occurring near the spinal cord. It is kind of a big deal.
  2. LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
  3. LAFTs naturally degenerate and do not have to contribute to a pain experience. At least 30% (and potentially up to 80%) of people without low back pain have LAFTs bulging.
  4. LAFTs never slip.
  5. LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
  6. LAFTs, spinal joints, and nerves are built to withstand high forces.

Skin and Soft Tissues

Our knowledge of pain is based predominantly on the skin. The skin mirrors the nervous system’s state. Rarely is the case that skin injury leads to chronic pain however. On the flipside, painful skin zones; changes in skin health; and altered sweating or hair growth can all be indicators of damaged nerves.

How often have you seen or had your skin become increasingly sensitive to touch after an injury? This is a common phenomenon that occurs because cutaneous nerves increase sensitivity in order to protect an injured area. Here are some other skin and soft tissue facts.

  • Damaged skin heals very quickly.
  • Skin has a high danger sensor density.
  • Skin is very mobile and loves movement.
  • Fascia is a strong tissue that lies under the skin and also contains many danger sensors.
  • Massage moves tissues and sends impulses to the brain. Therefore, movement and touch are great ways to refresh the virtual and actual body.
Love skin, just not too much.

Bones and Joints

Most joints have lining known as synovium which keeps the joint contained and lubricated. This lining is loaded with danger sensors. Here are some other facts.

  • Joint pain seems to be dependent at which the speed damage occurs. Slow changes usually do not make the brain think there is danger. A dislocation however may lead to severe pain. Most people with worn joints never know about it.
  • Everyone has worn joints as we age. They are the wrinkles on the inside.
  • Joints love movement and compression.
  • Broken bones heal and are often stronger than before.
  • Joints in the back and neck can get injured, but may be too small to see on imaging. This may or may not set off the alarm bells.

Peripheral Nerves

Most of today’s neuroscientists agree that peripheral nerve problems are far more common than we think. Here are some fun facts regarding nerves.

  • Nerves have danger sensors.
  • Neurons can contribute to pain.
  • If a nerve becomes injured, it may become more sensitive to ensure you survive.
  • Nerves slide as we move. If a nerve cannot slide well, pain may occur while moving.
  • Nerves change as we age, just like everything else in our bodies.
  • Scans and nerve conduction tests cannot easily identify a damaged nerve.
  • Nerves can be injured but may not create a danger message for days to weeks.

The Dorsal Root Ganglion (DRG)

The DRG is like the brain of the peripheral nervous system. This is the first place that tissue messages are evaluated. Here are some facts for DRGs

  • Peripheral nerves have their nucleus in the DRG. It is here that sensors are made.
  • The DRG is extremely sensitive and changeable.
  • The DRG is very sensitive to blood chemicals, especially stress chemicals.
  • Sometimes the DRG fires just because. It is like your body’s car alarm. Sometimes the DRG can be hurt without having any pain too.

Backfiring Nerves

When a nerve is injured, oftentimes it will backfire. The reason for this is like a domino effect. If a nerve is stimulated at one end, it will send messages up the system to go to the other end.

Backfiring may not be an issue for the short term, but its persistence can lead to sustained inflammation. A less sensitive nervous system may lessen the amount of inflammation in the tissues.

Nerve Pain

Here are the common symptoms associated with peripheral nerve pain.

  • Pins & needles.
  • Burning.
  • Night pain.

Here are potential locations

  • Skin zones supplied by the damaged nerve.
  • Small sensitive hot spots known as trigger points.

There are also some other potential qualities

  • Movement often makes it worse, so you may adopt abnormal postures for relief (upper cross, elevated shoulders).
  • Stress makes it worse.
  • Unpredictable zings may occur.
  • Movement or a sustained posture may ignite an injured nerve which keeps ringing.
  • May not hurt for a few days or weeks.
  • Skin zones may become itchy.
  • Might just feel weird.

Just because you feel these symptoms does not mean it is the end of the world. Understand that nerves are just responding to signals from the brain that tell them to increase sensitivity and improve warning capacity.

The Sensitive Nervous System Chapter XI: Neurodynamic Testing for the Spine and Lower Limb

This is a summary of Chapter XI of “The Sensitive Nervous System” by David Butler.

Intro

For today’s chapter, I have decided that the best way to learn these tests is to show you. I will write in any pertinent details you need for a good test performance.

The Straight Leg Raise (SLR)

SLR hacks.

  • Add sensitizers (dorsiflexion, plantarflexion, etc) to determine nervous system involvement.
  • Add cervical flexion or visual input to enhance responses.
  • Be mindful of symptoms before and after pain responses.
  • If this test is positive post-operation, it will likely be inflammatory in nature.
  • You can preload the system further with cervical flexion or sidebending the trunk away from the test side.

Here are some other ways to perform the SLR with sensitizers first. (I apologize for the way the camera shot in advance).

For tibial nerve-bias.

For fibular nerve bias.

For sural nerve bias.

Passive Neck Flexion (PNF)

Here is how to perform the test.

PNF Hacks.

  • Add SLR to further bias the test.
  • Be mindful of Lhermitte’s sign, which is an electric shock down the arms or spine. This is a must-refer sign as there is potential spinal cord damage.

Slump Test

Here is how to perform the slump.

Slump Knee Bend

In the book itself, Butler uses the prone knee bend as his base test. However, NOI does not teach this motion as much and now favors the slump knee bend. This movement allows for much more differentiation to be had.

And the saphenous nerve (just so you get a break from seeing me).

Final Words

Have some fun with these tests, and be mindful that you are not too aggressive.

The Sensitive Nervous System Chapter VIII: Palpation and Orientation of Peripheral Nervous System

This is a summary of Chapter VIII of  “The Sensitive Nervous System” by David Butler.

Intro

Palpation is a major component to therapeutic touch, and gives us a way to build rapport and interact with our patients. When palpating the nervous system, it is important to palpate in sensitive positions so the nervous system is placed on load. Here are some general nerve anatomical rules.

  • Where a nerve has fewer fascicles and less connective tissue, palpation will be more sensitive (ulnar nerve).
  • Where there is a lot of connective tissue, there will be a more localized and less “nervy” response.
  • Where there is increased sensitivity does not mean there is damage locally. Damage could have occurred more proximally (that whole nerves fire in both directions thing).

You must also be mindful that anatomical variations are common, especially if symptoms seem anatomically weird. Here are some of the more common ones:

  • Martin-Gruber anastomosis: Median and ulnar communicate distally.
MN - Median Nerve; UN - Ulnar nerve; CB - Communicating branch.
MN – Median Nerve; UN – Ulnar nerve; CB – Communicating branch.
  • Rieche-Cannieu anastomosis: Deep branch of ulnar and recurrent branch of median nerve.
MN - Median Nerve; UN - Ulnar nerve; CB - Communicating branch.
MN – Median Nerve; UN – Ulnar nerve; CB – Communicating branch.
  • Absent musculocutaneous nerve.

Palpation 101

Here are some basic nervous system palpation guidelines.

  • Nerves feel hard and slippery.
  • Palpate with your finger tip or thumb, and follow it proximally or distally.
  • Use sustained pressure up to 30 seconds.
  • Twang if easily accessible.
  • If using a Tinel’s, tap the nerve 4-6 times.
Do not play Stairway on the superficial fibular nerve.

Spinal Nerve Palpation

Here are the craniocervical nerves.

The Trunk

Upper Extremity Nerve Palpation

Brachial plexus

The median nerve

The Ulnar nerve

The Radial Nerve

The Musculocutaneous Nerve

Lower Extremity Nerve Palpation

First, the nerves palpated anteriorly.

And then posterior.

Last Words

Grab a partner or yourself and palpate away.