It has been a great and even nostalgic experience thus far. I remember just a couple years ago being in this young lady’s shoes having the same successes, failures, and questions she has now.
I think working with me may have been quite a difference from the scholastic framework that she was accustomed to. This difference is because our common theme for the week was wait for it…………………………………….The Brain.
Most schools, especially in the orthopedic realm, teach about developing physical therapy diagnoses and treating various pathologies. However, we had a couple different cases in which we didn’t necessarily nail down a pathology yet got fantastic results.
The first patient we saw was a lovely middle aged woman who was classic for the biopsychoscial treatment model I espouse. She comes into seeing us with chronic low back pain over the past 3 years, has had several TIAs, been diagnosed with an eating disorder, and generally lives a stressful life. Our comparable sign for the day was flexion which was at 50% range and painful (or DP for you functional movement folks out there).
We discuss what we think is going on and the first words out of my intern’s mouth: Central Sensitization. Music to my ears, I think she will do just fine.
Our next patient was a middle aged man coming to us for medial knee pain that began while playing volleyball. Upon observation, big findings were general hypermobility with a slight limitation in knee extension on the involved side. Our comparable sign for the day was stair negotiation.
This gentleman came in with the same frame of mind as the lady above, what is wrong with me, what structure is making me painful. His complaints were very vague and difficult to reproduce except for stairs. We perform a similar treatment to above–Explain pain, breathing exercises combined with some hip activation–and guess what happens? Knee extension mobility returns to full and decreased symptoms with stairs.
Once we finished with this patient, my intern asked me what I think was wrong. My answer: It could be a thalamus problem.
In both of these cases above, I could not pinpoint an exact “structure at fault” as we both were often taught in school, yet both patients improved. I am inclined to believe that more and more that the structure at fault is and always will be the brain.
If you look at most of the research regarding anatomical correlates and pain, it is not so good. Depending on who you look at, 30-80% of asymptomatic individuals have abnormal MRI findings. Pain and structure do not always go hand in hand, and moreover, we are not very good at determining a structure. The most recent editorial in JOSPT by Paula Ludewig and a friend of mine Becky Lawrence discusses this problem, and it is definitely a step in the right direction.
Since we are not so good at finding and probably treating pathologies, I propose instead that we start treating people; people who are undergoing a pain experience that is compounded by multiple factors. That neck pain that fits a closing pattern may not have hurt if they did not undergo a stressful event a week prior. Even though we are always operating under some degree of uncertainty, the way we approach treatment ought to follow a similar step-by-step process:
Rule out any potential red flags. Make sure they are someone you can help.
The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain.
Tool 1: Education
Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery.
Here are some important concepts to be known about explaining pain.
Anyone can understand pain physiology.
Learning about pain physiology reduces pain’s threat value.
Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life.
Tool 2: Hurt ≠ Harm
It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay.
Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take drastic measure to prevent re-injury. Therefore, the best option is to gradually increase activity levels without pressing past the nervous system’s threshold.
Tool 3: Pacing & Graded Exposure
All the body tissues are designed for movement, therefore this is how we will increase activity. Here are the steps to pacing and graded exposure.
Select an activity you want to do more of.
Find your baseline – The amount of activity you can do that you know will not cause a flare-up. A flare-up is an increase in pain that leaves you debilitated for hours to days.
Plan your progressions.
Don’t flare up, but don’t freak out if you do.
It is a lifestyle change, requiring a little bit more planning.
Take walking for example. Suppose you know you could walk for 5 minutes, but if you did 7 you would pay for it over the next couple days. You might walk for 5 the first day, then 5:15. Eventually, you would work up to past 7 minutes, then so on and so forth.
Access the Virtual Body
Just like the body, the virtual body can be exercised as well. Ways to work on the virtual body are as follows:
Mistake Recovery – Training to recover from worst case scenarios.
Here were Lee’s recommendations for program design.
Skill acquisition – The ability to control desired movements. This portion can be trained by either skill components (3-4 exercises), skill itself (1-3 exercises), or linking skills (shuffle to sprint).
Force application – Performing the desired movement patterns with increased force or resistance.
Random reactive training – Challenge movements under a random setting, but make sure the above 2 components are rock solid first.
Here were Lee’s recommendations to progress to reactive training
Acceleration → deceleration → Change of direction →One direction reaction → Multi-direction reaction.
Some great cues that Lee used
Stay in the tunnel.
Arms long and strong.
Tear the paper – Get in the athletic position, load the big toes, and try to rip the floor apart.
Stop in front of a person.
Here were my favorite Lee quotes.
“The biggest component of developing multi-directional speed is being able to re-accelerate.”
“Do the most important things often.”
“We don’t teach pivoting. Open hips and retreat.”
Reactive Agility – Nick Winkelman
The first thing Nick did in his presentation is define agility, which he says is the ability to change direction and react; the ability to quickly make a decision. Both of these qualities therefore must be tested.
To test change of direction, many of your traditional tests such as 5-10-5, T test, L acceleration, can be utilized. The important thing to understand is that you only need to utilize one of these tests because they are all looking at the same thing. You want to pick one that best captures the movement you are looking for.
Before testing reactive agility, we must first discuss reaction time’s two phases. First is the latency phase, which is the time between receiving stimulus and the appearance of EMG in relevant muscles. The second key and trainable phase is response phase, which is the time from EMG appearance to motor action. The response phase is predominantly what we test, and the ability of one to respond to relevant cues is what separates the good from the great.
The big test that Nick used was the reactive agility test (RAT), which I will demonstrate in this video below.
What is nice about the RAT unlike your traditional agility tests is that we can look at asymmetries in both movement, decision-making, and accuracy. Moreover, he presented a lot of good research in support of the test.
With the RAT, you can also group athletes into how fast one moves and reacts based on ability to change direction and react. This bucketing allows you to train athletes based on necessary qualities. Here are the categories:
Fast Change of direction
Slow change of direction
Fast mover/thinker (elite)
Fast thinker/slow mover
Fast mover/slow thinker
Nick showed us several different drills utilizing the Fusion Sports Smartspeed light system to train these qualities. For most, this system is likely not in the cards to utilize. But as long as you apply the above principles, you can add a reactive component to most any activity.
Here were some other interesting tidbits from this presentation.
Human delay before you become aware of things is 300-500 ms.
Reaction time is subconscious
We react fastest to auditory cues, next to tactile, slowest to visual.
Post-injury strength returns in 6 months, whereas rate of force development takes up to 1 year.
The Science of Coaching: Applying Theory in Practice – Nick Winkelman
First, Nick talked about the classic Fitts and Posner three stages of motor learning, which are as follows:
Coginitive → associative → autonomy
Each stage requires different coaching styles. Generally, earlier stages require more feedback than later stages. You also want to transition toward having the athlete/patient describe what was done right in an activity.
It is also important to maximize context, as this helps facilitate better memory. The athlete retains and progresses more when they know rational why, how the activity felt, and what needs to be done next. Telling stories and using sticky phrases is also very helpful.
Nick also discussed attention regarding how it is the filter for all information. Understand that we all have similar attention span, it is just that some activities require more attention than others. This is most evident comparing a novice and expert performing the same activity. The activity is old hat for the expert, thus requiring less focus to perform. The novice, on the other hand, is just learning the activity and must pay greater attention when performing.
Transitioning these principles to coaching, Nick designed a framework for coaching that involved practice design at the foundation, followed by instruction and feedback.
First, let’s discuss practice design. The goal of practice design is to optimize learning and retention. The way this goal occurs is by both varying movements and context as well as interfering with the context. You want to have your athletes struggle and have bad days in practice. If this part does not occur, then we go into autopilot and learning is not facilitated.
Contextual interference also occurs by performing practice in either a blocked, serial, or random fashion. Many people tend to think that random is the way to go for motor learning, but it really depends on multiple factors:
Generally, the younger the age, the lower one’s skill, and the more complex the activity, the more block practice should be utilize. As these qualities hit the other end of the spectrum, random practice becomes more desirable.
The biggest takeaway from this portion was that most people over-coach. Generally 1-2 positive focus cues are needed at the most to build awareness. You also want to start and finish instructions with what you want versus don’t want.
When it comes to cueing, externals are key. By external cues, I mean that attention should be focused on the desired outcome as opposed to the internal process. Let’s take a pushup for example. An internal cue might be “pull your shoulder blades together, and then straighten your arms.” Whereas an external cue might be “rip the ground apart, then push the ground away from you.” When utilizing external cues, less attention span for the cue itself is required, therefore allowing for automatic motor processes to occur.
It is also beneficial to watch others perform activities. This change occurs due to mirror neurons which are present in the brain’s motor cortices. Benefits can be achieved by watching both experts and novices; experts by seeing the activity done correctly, novices for improving problem solving.
Nick listed two types of feedback.
Knowledge of results – Information about the outcome (quantitative) [E.g. You ran 4.5 in the 40.]
Knowledge of performance – Information about movement characteristics that led to the outcome (qualitative). [E.g. drive your knees more during the first 5 yds.]
In terms of feedback quantity, it can be detrimental to give too much feedback unless that feedback is external. The problems with too much feedback include coach dependence, less self-independnece, people becoming practice champions because there is no retainment, and paralysis by analysis. If we relate quantity to motor learning stages, less feedback should be given the further along they are. Research demonstrates that cognitive stages should get feedback 100% of the time, and associative stages 33% of the time. Research also states that athletes want feedback only 8-10% of the time and only if it was the right movement/activity.
My favorite lines from this presentation:
Art is when we don’t understand how something is.
Movement efficiency is the opposite of learning. It is okay to make errors.
Shoot for 60-70% success and 30-40% failure.
Visual memories last better.
“Movement needs a goal” [On external cues]
Don’t tell athletes things they already know.
Use noises to reinforce movements (BOOM, SNAP).
Overall, the course was excellent and one of my favorites for the year. Learn as much from these guys as possible.
There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain.
Here are some general guidelines for someone dealing with pain.
Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination.
Make sure any prescribed help makes sense and adds to your understanding of the problem.
Get all your questions answered.
Avoid total dependence on any practitioner.
Make sure your goals are understood by you and the clinician.
The clinician’s ultimate job is to assist you in mastering your situation.
Models of Engagement
There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain.
The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro.
Fear-based models – Fear of pain and reinjury are major forces behind the development and maintenance of chronic pain.
An evolutionary model – Pain protects the tissues in order to ensure species survival.
A clinician decision-making model – Pain is very personal, and therefore a plan of care should be developed exclusively for that person.
When working with a healthcare provider, they should be able to answer the following questions:
What is happening in my body?
How long will it take to get better?
What are all the options for management?
What can I do for it?
What can you do for it?
Is there anything that requires special attention?
What do my physical findings really mean?
Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology. There are various ways coping can be done, with some better than others. Generally, active copers manage pain and other health issues better than passive copers.
There are several patterns in which we react to pain.
Hurts don’t do it – Pain kicks in at a certain amount of activity, then we stop once it starts. Over time we can perform less and less activity before pain occurs, leading to disability, disuse, and likely depression.
Boom-bust – Pain comes on but you push through it and ignore it until suddenly the pain becomes unbearable. Here, your nervous system busts. A cascade of danger chemicals floods the nervous system leaving you completely wiped out for days to weeks.
The commonality between these two patterns is that both lead to eventual activity limitation. We want to be somewhere in the middle.
Whew, I recently finished (and still trying to process) the B level DNS course from the folks at The Prague School. Instructors were Martina Jeszkova and Dr. David Jeurhing. There were a lot of things covered during this 4 day course and I definitely learned a few things. Here are the highlights.
The focal point of DNS is the concept of joint centration, a static and dynamic maximal joint surface approximation. When joint surfaces achieve optimal bony congruency, the muscles surrounding the joint achieve optimal activation and highest mechanical advantage. The reverse is also true. If muscles coactivate properly, then joint centration occurs.
Conversely, if optimal joint centration is not achieved then muscle imbalances occur. The reverse is also true. This change becomes very problematic, as decentration at one joint effects centration at all the other joints. This may lead to decreased performance at best and at worst increased wear on joint surfaces.
Take lower crossed syndrome (or open scissors if you are a DNS fan) for example. Let’s say we had a problem with our lower back. In order to cope with this trouble, we increase lumbar lordosis and decentrate the lumbar spine. See how it affects the surrounding structures. The pelvis anteriorly tilts, which affects length tension relationships to glutes, hamstrings, and hip flexors. Thoracic kyphosis increases as well, affecting the shoulder girdle and cervical muscles. Basically, play with one body region or joint position and see how it affects the others, and you can develop a decent understanding of joint centration’s implications.
No optical contact due to holokinetic movements, which basically means movement due to lack of stability.
Mass extensor pattern in supine.
Mass flexor pattern in prone.
Able to turn head, but cannot lift head off of table.
Optic fixation is constant.
Begins sagittal plane stabilization.
Can begin feeling with arms.
Able to lift the head.
Able to stabilize in sagittal plane.
Functional joint centration of all joints.
Rotates head 30 degrees each direction independent of other spinal movement.
Grasp as far as midline.
Active grasp across the midline occurs, which leads to turning from supine to sidelying.
Chest breathing combined with abdominal/diaphragmatic activation.
Turn from supine to prone.
Can oblique sit onto forearm.
High oblique sit.
Independent steps between surfaces.
Here are a couple vids of the developmental process.
The Integrating Stabilizing System of the Spine
Much of where joint centration begins at the spinal level, and involves the following functional muscle unit activating in a feed-forward subconscious fashion:
Short intersegmental spinal muscles.
Deep neck flexors
Developing proper function of this group is what allows for movement. However, if one of these muscles becomes dysfunctional, the entire complex becomes dysfunctional. Stability is then achieved by substituting with other muscles groups and/or passive structures.
Stabilizing system function is very important as we develop, as lack of this mechanism may lead to abnormal bone structuring. Examples of this would be anterior pelvic tilt, femoral anteversion, spinal kyphosis, etc. These would be deemed utilizing passive structures to increase stability for function.
There are 3 reasons for which stability becomes disturbed.
These patterns are results of poor punctum fixums, which are fixed points to which muscles pull. For example, with supine cervical flexion the fixed point would be T4. If mobile, you may see excessive movement there, hence poor centration. The tests themselves unfortunately require a lot of subjective interpretation in terms of what you see, so I will not give you a demonstration. Here is a brief description of each.
Diaphragm test – seated breathing.
IAP pressure test – Supine breathing.
Trunk & head flexion test – max flexion of cervical spine in supine.
Arm elevation test – Shoulder elevation in supine.
Extension test – Prone head lift.
Oblique trunk flexion – Somewhat cross between an armbar and get-up.
Quadruped rock forward – Watching for winging.
Squat – Duh.
Low kneeling – See below exercise.
Bear position – See below exercise.
Three Level of Motor control
The three levels of motor control are as follows:
1) Spinal/brain stem – neonatal. Think primitive reflexes that we see in babies such as rooting, moro, etc.
2) Subcortical – The first year of life.
3) Cortical – 2-4 years of age.
I will not go into details regarding all the different reflexes; much of these are what you learned in school. This section was one I had some qualms with after recent discussion (i.e. me listening in awe) with Bill Hartman. I do not know that science agrees with maturation in the first year of life being subcortical and reflexive. In order for movement to occur, motor learning and motivation are required. These two are both cortical phenomena. If there were reflexive changes, then should not all babies develop optimally?
Then we went over the “voodoo” aspect of DNS—reflex locomotion (RL). What occurs with this technique is evoking partial motor patterns via afferent stimulations (i.e. pressure) at specific points. These specific points correlate to the support zones that occur throughout the developmental cycle. By pressing on these points, joint centration can be established allowing for motion.
Typically these movements occur more readily with younger children and babies, and sensitivity differs amongst adults. Here are some of the changes typically looked for in RL.
Partial/whole movement patterns
Realize that RL is not a learning/training process and does not teach normal movement. RL achieves muscle activation, stereognosis, and body awareness—prerequisites for movement.
Here are some videos of the positions that I learned in the course from someone who is obviously way better at this modality than I am.
Reflex Turning 1
Reflex Turning 2
The group at my course was generally very reactive and elicited some movements. Even I had a reaction elicited in reflex turning 2. However, it is important to understand that everyone in the course knew what was to be expected; hence I wonder if there is some “Ouija boarding” occurring when we perform these activities.
We did have a couple kiddos come in for treatment as well who had neurological problems. Some “responses” got elicited, though these were very minor and I could not tell very well if these were responses or if the kids were just fidgety. Now, seeing pre and post gait everyone thought there were improvements. Of course, I try to battle confirmation bias somewhat (but it is so damn hard), I had some of my PT colleagues check out the videos. They could neither see a difference nor could they tell which were the pre and post videos. Moreover, it does not help when much of the testing had subjective interpretation. We have to be mindful seeing changes that may not be there, or else you starting looking like the video below.
Now, is there some efficacy in RL? I don’t know. I haven’t seen enough of it to say either way, nor am I good enough at it to elicit regular responses. There is also the time factor that is required to elicit changes, which I have many other techniques that may be just as effective at faster rates. I think the selling point for me will be if I can see nice changes in people with marked neurological deficits. So if anyone has stories, please comment below.
To the instructor’s credit, they state that you will use the active exerciseway more than RL. This is good because this is where I think the DNS bread and butter lies. The exercises have been an excellent adjunct in my practice. Here are the big principles regarding exercise that DNS advocates.
Develop sufficient body awareness by feeling correct and incorrect movement.
Quality over quantity
Perform movements slow and pay attention to how one is moving.
Keep centration throughout.
The exercises utilize correspond with the various developmental positions, so here are some examples that I have been utilizing and playing with.
4.5 month breathing with band pulldown courtesy of my man Bill Hartman with the wonderful Eric Oetter.
3 month prone with head turns
4.5 month reach
6 month supine breathing
7 month low oblique sit with press
Roll to 8 month oblique sit.
Low kneeling plank
Tripod to bear to squat
TRX sit to ½ kneel
We also learned a great way to cue squats to increase pelvic floor activation, which I describe in the video below.
We also had some off-topic discussion with quadruped foot versus tripod/short foot, which I outline in the below video.
Now I realize that there were some DNS concepts that I knocked, however I will say that the exercise portion of things is very good. Our nervous system is looking for novel input, and I feel the exercises are a great way to provide this. We all developed too, so neurologically these positions are somewhat familiar albeit challenging at time. What is more, DNS exercise does an excellent job of integrating all the body segments into moving as one unit as opposed to training/rehabbing specific body segments. I can appreciate that the folks at the Prague School have taken many different concepts and tied them together into one unit.
So should you take their courses? I say yes. I still learned a great deal in both A and B despite my gripes, and I plan on taking C this fall. So check out the Prague school and learn some good skills.
I also would like to shout out my good friend/fellow mentor PT/cameraman/all around good guy Scott Passman for taking some of these videos, as he put in great effort to make them look good.
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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
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.
LAFTs never slip.
LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
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.
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.
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.
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.
Here are the common symptoms associated with peripheral nerve pain.
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.
Our body’s alarm system alerts us to danger or potential danger. This alarm system is composed of sensors throughout the body, the eyes, nose, and ears. It is these sensors that are our first line of defense against harm. If one sensor fails the others take over.
Most of these sensors are located in the brain and respond to various stimuli. Some to mechanical movement, some to temperature change; the sensors in the brain particularly respond to chemical activity.
What is important to know with sensors is that they have a very short life expectancy of a few days. This cycling means our body’s sensitivity is constantly changing. It is with these life cycles that there is hope for those with chronic pain.
Moreover, the rate at which sensors are made is normally stable but can change very quickly in regards to a particular stimulus. So if we take for example one with persistent pain, the rate at which pain sensitivity occurs can be changed.
We lack pain receptors in our bodies. Instead, the various tissues have special neurons that respond to different stimuli. These receptors are called nociceptors, which translates into “danger receptors.” Nociception is occurring all the time, but only sometimes will it end in pain.
Nociception is neither necessary nor sufficient for pain.
The sensors correspond to particular neurons. In order for these neurons to become excited and send signals to the brain, an action potential must occur. An action potential is a spike in which nerves relay messages. These spikes require a certain amount of stimulation to go over a certain threshold. Think of it the same as if someone were doing many things to make you mad. Eventually, that person will cross the line and may cause you to get very angry. Action potentials act very much the same way.
These nociceptors can become very active very quickly depending on resting stimulation. If at rest these sensors are stimulated high enough, then small changes could cause the action potential threshold to more quickly be reached. This happens in acute injuries for example. Suppose you scrape your leg. The skin sensors along the scrape have increased sensitivity. This change may lead to even a slight touch to the injured area creating a nociceptive response.
Notice that above I have been neglecting to say pain. This is because the brain and spinal cord have to analyze the incoming nociceptive information prior to pain being felt. This processing is why not all nociceptive responses are painful.
When nociceptive fibers activate, a signal is sent to the spinal cord. Here at the cord, chemicals are released to activate surrounding neurons. The various neurons are built to respond to particular chemicals and not to others. This is called the Lock and Key Principle.
From the spinal cord, neuronal messages are relayed to the brain. In the brain, all relevant stimuli are processed and sorted out to determine the best course of action. There is not one part of the brain, but several, that deal with pain. These areas are called “ignition nodes.”
The response that can occur from the brain can affect multiple body systems in order to get us out of trouble. Here are the different effects that can occur with an injury.
Sympathetic nervous system – Increase heart rate and vigilance, mobilize energy stores, sweat.
Motor system – Run away, fight, protect damaged area.
Endocrine system – Mobilize energy stores, reduce gut and reproductive activity.
Pain production system – Motivate to escape and seek help, attract attention.
Immune system – Occurs later post-injury, but cleans up injured area, increases sensitivity, produces fever, makes one sleepy.
Parasympathetic system – Occurs later post-injury, but promotes healing.
3) Improve the nerve tract’s ability to absorb traction forces.
4) Assess and improve the nerve to container relationship.
5) Assess/modify any adverse ergonomic or environmental factors.
Carpal Tunnel Syndrome
Tests to perform.
ULNT1 & reverse.
ULNT2 (median) & reverse.
Compression (can add ULNT).
Phalens and reverse Phalens.
Phalens + ULNT.
There are several options to treat carpal tunnel syndrome. Mobilizing not only the median nerve, but radial and ulnar is beneficial because the nerves are closely connected. Movement is critical because nerve inflammation and swelling does not leave the carpal tunnel easily. This problem is because there are minimal lymphatic channels in the tunnel.
Nerve Root Complex
Nerve root issues often have corresponding postural adaptations.
Cervical – forward head posture.
Lumbar – Flat lumbar spine with knees flexed, positioned toward the injured sign. In acute instance, it may be okay to let the patient rest in these antalgic postures until AIGS settle.
Other presentations indicative of nerve root complex pathology include numbness/tingling down the extremities. Other possibilities include coldness, shooting, tiredness. Pain rarely goes into the extremities.
Double crush is a phenomenon where two AIGS or compressive locations are present on a single nerve. Currently, the literature is mixed on its existence. However, Butler feels that the second pain that occurs with this phenomenon is likely an old problem showing itself.
The Foot & Neurodynamics
The biggest take home point here was regarding heel spurs. With these pathologies, there is evidence of concomitant peripheral neuropathic pain. The likely involved nerves include the lateral plantar nerve or medial calcaneal nerve. With these, it is important to check eversion and implement this movement into the straight leg raise.
Neurodynamics and the Thorax
A couple suggested treatments include sliders and tensioners in the slump long sit, as well as Anterior to posterior glides of the thoracic spine. Butler feels these lead to more thoracic spine movement.
Rapid changes can frequently occur with these conditions, and often this speed is due to patients altering the way they think and feel about the problems.
15) Assess how injury affects creative outlets and assist the patient with regaining creativity and discovering new creative outlets.
There are several ways to incorporate neurodynamics into the patient’s plan of care which will be outlined below.
Posture and ergonomics.
There are many evaluation protocols that warrant constant reassessment after applying an intervention. Be it a comparable sign or audit, neurodynamic tests can be utilized well within these systems.
A word of caution with instant reassessment, as quick changes could merely be playing with impulses in a healing environment. The real sense of improvement is through improved function.
When working with Peripheral neuropathic pain (PNP), it is important to educate patients on normal responses. Many may find it weird that neck movements can change sensations at the wrist, but patients must realize that the nervous system is a continuous structure. Providing stimulus at one point of the structure can lead to responses at other ends of the same structure.
In central sensitization, the language provided must be spoken tactfully. The following points are important to hit home:
1) Acknowledge the specific dysfunction, but say it has had time to heal.
2) Real processes within the central nervous system occur that magnify inputs.
3) There are several reasons why this increased sensitivity occurs, including biopsychosocial inputs.
4) The nervous system produces chemicals that keep it sensitive.
Regardless of how we communicate with patients, the most important thing is to not be frightened by pain. If we are frightened of pain and do not understand it, this will be carried to the patient.
First some ground rule concepts.
1) Reject the notion of neural stretches and crude assessments.