Thursday, August 30, 2007

(Post # 20) Nerve Mobility and Sports Injuries

Can some our sports injuries be associated with the ability of the nervous system to move properly?

Can achilles tendonitis or a hamstring tear be caused by the inability of the sciatic nerve to move and glide freely?

Think for a moment how our brain is connected to the spinal cord and how the spinal cord is connected to the lumbar nerve roots; such as the sciatic nerve.
The sciatic nerve travels near the hamstring, behind the knee, all the way to the toes innervating all of these muscles. To test the sciatic nerve to see if a spinal disc is compressing it and not letting it glide, a clinician would perform a test which would put our leg in a position very similar to many sports moves therefore put our nerve roots under tension.
If there are restrictions in the lower spine the nerve roots may give the wrong information to those muscles not to relax on time, or not to relax at all.

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(Post # 19) What is the Difference Between Balance and Stability?

What is the difference between balance and stability?

Balance is how well you are able to control your body without movement against gravity.

Stability is how well you are able to control your body during movement.

So one is static and the other is dynamic.

They are both important, but if you are going to fall, think which one will protect you more?

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(Post # 18) What is the Most Vulnerable Part of Healing

What is the most vulnerable part of healing?

The most vulnerable part of healing is when we feel better and we forget about lifting properly, keeping a good posture, changing postures every 20-30 minutes of sitting, walking as a therapy for 20-30 minutes, and doing the work that got us better and we fall in the trap of I am too busy, I don't have enough time, etc.

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(Post #17) Uncertainty

Uncertainty is uncomfortable,

Certainty is ridiculous.

Wednesday, August 29, 2007

(Post # 16) Challenging Traditional Physical Rehabilitation and Training

Physical Rehabilitation and Training:

Lets keep it Functional-- multi-directional, three dimentional, against gravity, free from any artificial stability.

Lets keep it Simple-- no fancy exercises, try to train as close to real life and/or sports requirements as you can.

Lets keep it Effective-- train to fulfill a need and train with a purpose.

Lets keep it Efficient-- engage most amount of movement patterns and body parts with each repetition.

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Tuesday, August 28, 2007

(Post # 15) Factors that can Influence Pain and Dysfunction

Physical activity
  • Misuse--often mistaken for overuse. All tissues respond to load; not only will they get damaged if the load is too much or weakened if the load is too small, but become dysfunctional if there is not enough rest in between engagements.
  • Disuse or lack of use will atrophy most tissues in the body including bones, cartilage, ligaments, muscles and tendons.


  • Dissatisfaction with job and/or lifestyle.
  • Patient consciously or subconsciously uses physical pain to distract his/her mind from emotional pain
  • Patient involved in toxic relationship
  • Poor diet or nutritional deficient. The lack of needed nutrients, vitamins, minerals and enzymes in the body can contribute to conditions such as weak bones (osteoporosis), weak cartilage, weak ligaments, weak tendons, etc.
  • Lack of adequate nourishment inhibits the body's natural healing response.
  • Hormonal imbalance may weaken bones, cartilage, ligaments and tendons.
  • Hormonal imbalance can cause conditions such as systematic joint instability by making ligaments too lose.
  • Diabetes by itself, may cause conditions like tendonitis and bursitis.
  • Genetic predisposition can be the cause for diseases like rheumatoid arthritis, degenerative osteoarthritis, osteoporosis, scoliosis, etc.

(some of this factors can be backed up with science but others are just my clinical observations)

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Monday, August 27, 2007

(Post # 14) Referred Pain

What is referred pain?

Pain that is felt in an area other than the lesion.

Why is this important?

A patient is treated for thigh pain, and receives treatment for the quadriceps muscle. The reason? Pain is felt there. After endless treatments of stretching, strengthening, ultrasound, electric stimulation, etc,...etc...etc..., she gets to the right clinician who performs a functional assessment. It becomes clear that resisted knee extension (which is one of the test that test the quadriceps' contractile ability) shows negative proving that the function of the quadriceps muscle is not disturbed. Further examination, this time of the lumbar spine, shows that the patient is not able to perform lumbar extension (backward bending) without pain, and that repeated lumbar flexion (forth ward bending) increases the pain, which is referred into the thigh (L-2 dermatome). We can conclude, that the lesion lies in the lumbar spine, most likely nerve root L-2, and not in the quadriceps muscle.
Although this is just one piece of the puzzle, we can now create a plan to figure out the best treatment approach for the lower back and for the entire kinetic chain. Here is a list of some but not all of the treatment option we can explore:

  1. Trunk stability exercises.
  2. Nerve mobilisation exercises (nerve flossing).
  3. Walking 20-30 minutes.
  4. Sitting habits (finding a new neutral zone for the spine every 20-30 minutes).
  5. Lifting habits (training the legs by doing squats).

And remember to listen to the body by asking: are you better? worse? or no change?

Thank you David for your comment.

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Sunday, August 26, 2007

(Post # 13) The X-ray, a doubtful assistance?

Can an X-ray be a substitute for functional assessment?

No, a characteristic shared by the moving soft tissues is their radio-translucency (their ability not to be seen in a x-ray). The tissues that I am talking about are joint capsules, ligaments, fasciae, muscles, tenons, bursae, spinal discs, dura mater, dural sheaths, and nerve roots. Any of these structures can cause pain. None of them inflame or other wise, can be diagnose on the x-ray. If a soft tissue causes pain, the x-ray can show only one of two things. First, it may reveal the bones are normal; therefore it allows the patient to be open to a misplace diagnosis of neurosis or psychogenic pain (pain caused by the mind). On the other hand the x-ray may disclose some symptomless abnormalities or natural degenerative changes which is then incorrectly regarded as the source of the pain. In this case the x-ray is positively misleading.
So be skeptical of those clinicians that will give you a diagnosis, without giving you a thorough functional assessment first.

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Saturday, August 25, 2007

(Post # 12) Dr Cyriax the Father of Orthopedic Medicine

My biggest hero Dr James Cyriax MD once said

"All pain has a source"

"All treatment must reach the source"

"All treatment must benefit the lesion"

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(Post # 11) To Treat or Not to Treat

Needless to say, there can be no justification for physical treatment unless that treatment is known to accelerate the natural history of the condition or to assist in the recovery of function. I believe that all patients are entitle to comprehensive guidance and education in the appropriate strategies to assist in the healing process and to regain normal painless function.

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Friday, August 24, 2007

(Post # 10) 11 Factors that can Inhibit Healing

Factors that can Inhibit Healing

1. Poor blood supply – especially tendon lesions where intrinsic blood supply may be poor.

2. Lack of initial protection and reduction of swelling (first few days).

3. Lack or not enough early mobilization – gentle natural mobilization encourages good quality repair (starting within the first week post-injury).

4. Prolonged inflammation: anything that prolongs or re-triggers this phase will cause poor healing – for instance infection, a hematoma, or excessive premature mobilization.

5. Inadequate use of steroid medication – decreases tensile strength of healing lesions, slows the rate of wound closure and vascularisation.

6. Nutrition – lack of nourishment inhibits the body’s response to injury and healing.

7. Diabetes – mechanical problems and metabolic defect impairs wound healing.

8. Increased or too much deposit of collagen or scar tissue.

9. The grade of mobilization or physical activity must be appropriated for the stage of healing. If too aggressive too early, or not enough stresses are applied to repair tissue, the end result can be the same – poor wound healing and function.

10. Inappropriate behavior in dealing with pain and its consequence--letting fear of pain paralyze your lifestyle, leading to fear-avoidance beliefs and behaviors such as: lack of movement, becoming inactive, low self-efficacy, low self-reliance, anxiety and depression.

11. Inappropriate behaviors on the part of the health care practitioner – encouraging patient to adopt sick-roles, obtain sick leave, and offering passive, clinician-led treatment strategies, which help to maintain low self-efficacy and clinician dependency.

I know I got a bit technical with this one, but for some of you it can be very useful.

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(Post # 9) Three Stages of Healing

From my perspective here is why its important to keep the nervous system moving, so it does not become adhered and dysfunctional when injury and healing goes through the three progressive phases:

Inflammatory phase....prepares tissue for repair....we need to protect tissue.

Repair phase....rebuilds the structure....we need to gently move tissue.

Remodeling phase....provides the final form for the structure....we need to move tissue to its end-range.

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Wednesday, August 22, 2007

(Post # 8 ) The Sensitive Nervous System

In my opinion, one of the most comprehensive textbooks on the assessment and treatment of pain and dysfunction is The Sensitive Nervous System by David Butler. One of the many great points I got from this book is the need to encourage those in pain to stay active and to keep the fear of pain from paralyzing their lives. To do this effectively, first establish a comfortable level of activity or a functional baseline. Then gradually increase the activity level whether it is five minutes walking, swimming, or riding a stationary bike, even if five minutes does not seem like much, it will keep the nervous system moving and healthy while the surrounding tissues repair and heal.

Tuesday, August 21, 2007

(Post # 7) Myth and the Problems they Cause

Myth #2: Posture must be completely straight all the time!!!

I am the first to admit that at the beginning of my career I also bought into this theory.
It was frustrating for me as a therapist but specially frustrating for my patients. They had the best intentions of maintaining a straight posture but would give in after just a few minutes because of lack of muscle endurance or because they would get distracted by the computer or book they were reading and would go right back to old habits.

So I asked myself...

Is a sustained straight posture good for the spinal disc?

Is asking patients to sustain a good posture on will alone a reasonable approach?

Is there a better approach?

I believe good posture is a combination of different postures within a neutral zone, where ears are on top of shoulders, and shoulders on top of hips, and the spine in neutral position.
We must find a different neutral position every twenty to thirty minutes for the pressure of the spinal discs to get redistributed and evenly loaded and unloaded.
We must build strength and endurance of all muscles, specially those of the trunk, so we do not rely on will alone but also in the strength and endurance of those muscles.

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Monday, August 20, 2007

(Post # 6) Myths and the Problems they Cause # 1

Myth #1: Sit ups for lower back pain.
Although this concept has been disproved many times before, it keeps being recommended by many therapist and trainers. It is based on the assumption that all lower back pain is caused by weak abdominal muscles when in reality every back pain is different, and every back pain responds to different treatments. Different pain responds to different approaches like: stability exercises, nerve mobilization exercises, end-range stretching, strengthening of the trunk muscles, static and dynamic posture correction, gate correction, lifting techniques, and some may need a combination of all or some of them.

Saturday, August 18, 2007

(Post # 5) Help from Socrates

To help us answer the questions in the last post, I would like to follow Socrates, the father of Western philosophy, the one that taught Plato and Aristotle that through questions you have the potential to discover, learn, teach and get as close to the truth as possible, to ask the following questions:

How do you know you have pain?

How do you feel it?

How does pain travels to the brain?

Can we at least say that nerves are involved?

Which structures have the potential to compress them?

If you have pain in the shoulder and arm muscles, but can only induce the pain by moving the neck, where is the problem?

Can we say that the problem may be in the cervical spine (neck) and is only referred to the shoulder and arm?

How is it that someone who has lost an arm in an accident can still feel pain down an arm that is not longer there?

Is it possible that the cortex (sensory part of the brain) may be misinterpreting the location of the dysfunction?

Can the lack of functional understanding be the reason why most doctors, therapists, trainers and us may be confused by the cortex?

Thursday, August 16, 2007

(Post # 4) Tissue Dysfunctions

About every other year there is a tissue that comes in style.

Whaaaat? you ask. And yes, you are told that: your pain is caused by a tight psoas, No!... by a tight piriformis, No! a weak core, No!... by a disc, No! a bone out of place, No!... by a psiatic nerve, No!... by facet joints, No!... by weak abs, etc,etc,etc.
Well, what are we suppose to do with all this confusion?

Here is a description of most common dysfunctions:

Spinal Dysfunction—usually caused by disc displacement or restrictions.

Joint Dysfunction--lack of range of motion, due to displacement, instability or restriction.

Nerve Dysfunction--Inability for the nervous system to move and glide freely with movement.

Neuromuscular Dysfunction-- caused by inactivity, misuse, or wrong method of training.

Tendon Dysfunction--usually caused by joint injury, instability or misuse.

Bursa Dysfunction--usually secondary to other dysfunction such as joint instability or neuromuscular dysfunction.

(Post # 3) Physical Dysfunctions

It is crucial to identify the different types of physical dysfunctions so we don't make common mistakes such as stretching an unstable joint when the right strategy is to stabilize, or strengthen a restricted part when the right strategy is to mobilize or stretch.

Here are the four main different types of physical dysfunctions:

Instability : The inability to control a neutral position of joints or body parts during movement, therefore causing pain and dysfunction.

Displacement: Joint, spinal disc and meniscus displacement can cause disturbances in normal resting position, obstruct movement in the direction of the displacement and cause pain by compressing and/or stressing nerve tissues.

Restriction: Lack of range of motion caused by dysfunctional joints, muscles and nerve tissue.

Weakness: Neuromuscular dysfunction that is caused by lack of use, inactivity or injury.

Wednesday, August 15, 2007

(Post # 2) Understanding Pain

To treat our pain safely and effectively, we must first identify the type of pain we are dealing with.

Here are the different types of pain:

Chemical Pain
  • Pain is constant, regardlessof the position we adopt.

  • It is caused by inflammation.

  • Movement makes it worst.

  • It may be helped by anti-inflammatory medication.

  • We may need to use the RICES concept (Rest, Ice, Compress, Elevate and Stabilize).
Mechanical Pain
  • Pain is intermittent, it comes and goes depending on the position we adopt.

  • Pain will improve if we do the right type of movement or therapeutic exercise.

  • It does not respond to medication.

Tuesday, August 14, 2007

(Post # 1) Back in Motion

The purpose of this training is to teach you how to identify, treat and prevent pain, injury and dysfunction so you can safely and effectively train your body perform better and get fit. In order to do that we need to understand the following:

1. Types of Pain
2. Mechanics of Pain
3. Factors that influence pain
4. Injury and healing Phases
5. Factors that influence injury and healing
6. Physical Dysfunctions
7. Tissue Dysfunctions
8. Rehabilitation and training Principles
9. Rehabilitation and training Stages
10. Rehabilitation and training Goals
11. Rehabilitation and training Strategies
12. Rehabilitation and training Guidelines
13. Rehabilitation and Training progressions and Modifications
14. Rehabilitation and Training exercises