http-equiv='refresh'/> Global Therapies: 2011

Thursday, 29 December 2011

December Reading - Shirley Sahrmann

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For my December reading I was slightly inspired by Lynne going to see Shirley Sahrmann in Manchester, and raving about the experience and everything that she learnt. We have had her book, Diagnosis and Treatment of Movement Impairment Syndromes for quite a while, and while I have dipped into it from time to time, I haven't really got to grips with the meat of the book.

It's quite a tome, and heavy going if you try to read the whole thing. Considering it is more like a reference/text book, I decided to take only one section of the book in order to give myself something to get into and understand as comprehensively as possible, rather than spread myself out across the whole thing, and only really get a general understanding of the general content.

In the past few months I have been seeing more and more people with various issues and pain patterns with the Shoulder Complex. Rotator Cuff Syndrome, bicipital tendonitis/tendonosus, painful shoulder syndrome, call it what you will, there are a large number of issues that could well impact on the whole area. My decision was based upon this, and so I chose to look at the introductory chapter, to get the general concepts behind the book, and also the final chapter, about the Shoulder and various Movement Impairment Syndromes that can be seen, diagnosed and corrected.

Having skipped through the chapters in the past, in a fairly cursory manner, the deep and specific reading that I was doing threw up a number of very interesting and exciting things about various muscles, syndromes, and issues that affect the shoulder.

I will not go into more specific detail here, but suffice to say, since reading this part of the book, my knowledge of the musculature, how the whole joint fits together, what can, and indeed does go wrong, and how to identify potential issues has gone through the roof. I thought I knew a fair bit about the shoulder, having had a few injuries in the past, (climbing and snowboarding have that effect...) but this is a whole new level. I have a lot more confidence now, speaking with clients about their shoulders and what may or may not be wrong with them, and am much more specific in terms of looking at particular points of the musculature and how it affects the shoulder, and also the body, as a whole.

Although this book is titles "Diagnosis....." I am under no illusions that I am now able to diagnose. As a Massage Therapist I can have an idea of what may be wrong, and just by reading and understanding a text such as this, it does not change that stand point.

I suspect that in the next few months I will be going back to this resource time and again to refresh my memory. Also, I will definitely be using the other chapters as specific reading material later on this year.
This is an excellent book for all types of manual therapists and PT's alike. It can be a little difficult to get into if you are not academically minded, but persevere and your knowledge of movement and impairment of movement will be transformed.

Wednesday, 28 December 2011

Last race report of the year

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Sorry, there are no pictures on this one, but Lynne was running... not taking pictures, might have to get used to that in the next year... unless I manage to work out how to run and shoot at the same time... Instead, you can have a link to my Garmin track

The Map
Its been a while since I did a race report, mainly because I haven't been racing since September/October. (For various reasons including, but not limited to, minor injuries to toes, heels, and other less important running parts, not being in the right place at the right time, and generally there not being a whole lot of races in the area to jump in on).
However, the last race of the year, the Peak "O" trial is just in our back garden, starting from the Grouse Inn, just up the hill, and organised by the indefatigable Des of Wormstones and Chunal race route fame. The new thing about this race is that Lynne was also running it, and has just finished her report which is on her blog here.

We got up to the Grouse in plenty of time, registered and stood around for a bit. I realised that I hadn't brought full body cover, so jumped in the car for a quick journey home to pick up some trousers.... and also a whistle that I had neglected to switch from one bumbag to the other, and straight back up the hill again. Once again ensconced in the pub, Lynne was chatting with Andy from Pennine, and admiring his rather impressive scar on his knee- caused by falling off a bike onto a metal gridded bridge - not a pretty sight - think bone, and we generally chatted with a number of people who wandered in.
Good to see Nick (baba) there, I'm sure he has something on his blog, so I'll link to that one too, Julien, Mark Ollerenshaw, Ian, Carl and Beryl were there from Glossopdale, also great to see our wandering companion Carl Bedson back from Africa and Dave, and Rory who I haven't seen in ages. And of course Andy A turned up pretty much as he was due to start. Perfect timing. (or not, depending on your perspective).

It was an Orienteering/ timetrial format, so a number of people got their maps and left in 2 minute intervals. There were 2 routes, Long Score, with 7 checkpoints and Short Score, with 5, missing out the 2 checkpoints furthest South on the Long Score.
I lined up at 1022, got the map and had the 2 minute mantadory map looking time, deciding the best direction to take, attack points and general information before heading off into the countryside. All too soon we were told GO! and we ran off up the road. I had had enough time to take in the general gist of the map, what was going to be up and down, the direction of the wind, and how that was going to affect the direction of travel (not too much fun running into the wind in the second half of the race), and what it would be like at the end. (either a slight downward run, or an uphill slog) I decided on the uphill slog at the end. Why not? Everyone else was going to be tired at that point, and maybe I could use that to my advantage if it came to a "sprint" finish.

Off to Monks road and then up and over into access land to get to the first checkpoint, there were a lot of people milling around making unsuccessful forays into places where the dibber might have been, and a few running around like headless chickens, while others seemingly stood around waiting for others to work out where it was. I wandered around for a short while, looking for the obvious, and while doing that, Nick, who started out 2 mins after me, caught up. Damn.
Another minute of idiocy - I blatently hadn't got my attack points sorted out in the slightest, I orientated myself and where the point was most likely to be, over a fence, and pretty much straight on to it. That took far too long.
Next stop, Lantern Pike, I know my way there from various races, and also a bit of Mountain Biking in the area, so I hammered away, taking care not to overdo the pace, watching Nick become further and further away - he's got a bit good recently. As I got most of the way up to the top of the hill, he came bounding down past me, but I thought I had a better line from there to the next Check point, we'll have to see how it goes. Although in Orienteering you shouldn't really compare yourself to someone else, it was nice to get to the top of the hill before another couple of people who started climbing it before me. Clip the dibber (by now I had decided that I REALLY couldnt be bothered to take the map out of the plastic I had brought with me when clipping, too much faff taking off gloves and trying to get it back in the right way round etc.) so I just clipped it straight through the plastic. Boom.
Off on a slightly different line to Nick, and within the next couple of km I had gained a fair amount of time and distance on him, passing another runner, and getting to the next point in Rowarth before 2 others that I recognised from earlier on in the race.

We had a little bit of trouble finding the dibber at the pub, it wasn't exactly where it was meant to be- round the corner and down the way a bit, but after a brief look, all was fine and we dibbed in. Nick shot off, and I doggedly carried on. From here to the next point was a part of the Coombs tor race, and also I had run a portion of this in the Rowarth O event back in the summer, so navigation wasn't too much of an issue. Up the hill and over for a decent few km, pulling back a couple of other runners, and seeing a couple of navigational mistakes by others which helped me pull more time back. Over to the plantation and I passed Ian from Glossopdale in his BRIGHT luminous top. He was running into the sun and didn't see me.
Clipped the point, over the fence and along the top of Cown Edge rocks, Nick was disappearing from view, and the wind was buffetting strongly from the West - thankfully blowing us runners away from the edge, not towards. Along and down, down, down, the next point was in a Quarry, and I figured going all the way down, and in from the road. I noted a couple of runners heading off toward the top of the quarry, wondered what they were doing, and, in the best O spirit, I thought "ignore the others, stick to the plan". Ran to the bottom and a local bloke, washing his car (or some such thing) commented that you couldn't get into the quarry that way, you need to go back up the track and in over the wall...


Back up the hill, find a small divot in the wall, through and into the quarry. The people I was catching up with, all done, been and gone. Dammit. Nothing to do but run down into the quarry, clip, up and out.
Next- choices... do I go straight to the road and up it, Monks Road, cycled up that... its a bit damn steep. Or, up the path I've just come from, and through the path at the top. The path wins out, and as I churn up the path, overtaking 2 who caught up with me, I catch sight of Carl, storming down the path- impressive considering he appeared to be wearing road shoes!
Up the hill, retracing steps to the top, with the wind blowing in my right ear... the buff got taken off my arm and pulled firmly down over my ears - a welcome relief from potential earache... then, at the top a guy in a bright orange top is gains on me quite significantly. I paused on the crest as I decide that the original line to the next control that I had in mind - a direct bash following fence lines, probably isn't going to be as expedient as going down the hill a little way and using the path across to the Nab and he takes the opportunity to run ahead.
Down to the path, and overtaking the same guy as he stops to check his map. Down past the farm, and a choice of going left or right around the trees. I go left, and overtake another person, and then a delightful horrendously steep descent down the top part of the Nab over rough and broken ground with all kinds of craziness. Just my kind of terrain. I shot down to the control, dibbed my bit of paper and back off up the hill. From here, its just a reverse Wormstones race route home, I'll only need the map for dibbing. The guy ahead of me is walking. My legs are burning, but, he is walking. That means, if I run, I can catch him up. Right, faster feet, and run. Up the hill, I can see the optimal line across to the next gate, he goes too high, still plodding away, I break off, still maintaining my stride (if you can call it a stride), and over to the gate. I don't stop to look back, I know that there are now at least 3 in relatively close pursuit.

Up and up, over the top and I can see the Grouse. It's on the other side of a not inconsiderable valley that I have to go down and up to finish. Still, I need that final check point before I can consider that. Below me I see another runner, contouring around, I have the altitude advantage and use it well, charging down the hill to the corner where the checkpoint is. Hang on, am I in the right place? I look at the shape of the hill, and realise that I've come down just a bit too early, run along the wall, ah, here it is, the hill on the other side drops away almost like a precipice, over the fence, and there is a runner coming up behind. So this is going to be the final run off then. I dib, and launch down the ridiculously steep hill, 3 steps, slide, fall, slide on my bum, up again, and repeat until at the bottom. Not even mudclaws were gripping on part of that descent, but no time to think of that now, up and across the river, and up the other side.
The hill was over in a surprisingly short time, though I have no idea what was going on behind me, up, through a gate, again up, and through a gate to the road, and the final 400metres against the wind, traffic inches from my feet, and up to the pub.
Lynne with her winnings
Finish in 1:46:58 by my watch. 16.93km.

Soup, rolls, cake, scones and drinks were laid on by the Grouse, and very much appreciated by all who ran, there was some good sharing of knowledge around open fires, and great conversation. Congrats to Nick who came in Second, and Mark Ollerenshaw who was Third by the smallest of margins. Lynne did herself well and won the Ladies Short Score event, so we at least have a bottle of wine to celebrate with.
Thanks again to Des who organised the whole thing, and to Gordon who printed the maps and was a route advisor - or some such thing.
A great turn out for a last race of the year, good to see you all out.

Tuesday, 13 December 2011

Benefits of Sport & Remedial Massage: an overview

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Benefits of Sport & Remedial Massage
  • Injury prevention
  • Enhanced training
  • Greater energy
  • Pain reduction & management
  • Faster recovery
  • Increased flexibility & agility
  • Improved mobility & range of movement
  • Functional muscle balance
  • Normalised fluid movement (blood & lymph)
  • Emotional relaxation and stimulation
  • Increased body stamina
  • Reduced soft tissue tension & binding
  • Improved physical & mental performances

Benefits for systems of the body:
  • Skeletal system: reduced thickening of connective tissue, restore range of movement, decrease stress on joints and bones, improve muscle tone balance 
  • Muscular system: release tension, decrease stiffness, decrease spasms, decrease restrictions, decrease adhesions, normalise scar tissue, improve tissue functionality 
  • Cardiovascular system: increase blood flow, increase oxygen and nutrient uptake, remove of toxins and waste products 
  • Nervous system: increase endorphin production, stimulate and soothe sensory receptors (decrease pain), proprioceptive balance restoration, deactivate trigger points 
  • Digestive system: improve peristalis and fluid movement 
  • Lymphatic system: increase white blood count & lymph movement

Tuesday, 6 December 2011

Rockover Growl 2

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On Saturday I went over to Rock Over Climbing wall to help out with their second GROWL competition. After the success of the first one, which I blogged about here, I was really looking forward to seeing some interesting route setting, good climbing, and a lot of people having fun.

Lynne and I provided free arm and shoulder massages at the last one, so I knew there would be some demand for us there again. Unfortunately Lynne couldn't be there this time, so it was just me holding the fort. I got there nice and early, watching the first competitors float through the door, from the cold outside to the not every so much warmer inside, filling out their forms and taking in the look of the problems on the walls.
The guys had excelled themselves in terms of routes, and the very obvious amusement was "the Death Star", or, alternatively known as "Simons dangly bits". A hanging sphere of plastic volume between 2 walls. According to Simon, getting onto and across was the easy part of the problem. Excellent.
The "death star"
As more and more climbers came in, I set up the table and talked with a lot of the guys and girls wandering around. The temperature slowly began to rise, and at 11am the competition was kicked off.

As ever, the first hour or so was spent talking to the injured climbers, looking at injuries and giving advice on what to do, and, more often than not, what not to do. Then, as things began to get swinging (as it were) there was an influx of competitors for massage and de-pumps.

The general consensus from the guys I was talking to was that it was a bit harder than last time, but just as enjoyable. I certainly had a good time, and I'm looking forward to trying out a load of the problems on my next visit.

Sunday, 4 December 2011

December Book of the Month

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This month sees us reading the following books:

Tim's choice: focusing on shoulders after seeing a sudden increase in rotator cuff injuries

Lynne's choice - more depth being added to her knowledge of fascia

Thursday, 1 December 2011

Reciprocal Inhibition - or - why your muscles don't work

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Reciprocal Inhibition. What a title for a post. I can barely say it at this time in the morning, but its quite an important concept for people with tight muscles.

What is it?
Reciprocal Inhibition (RI) is what happens to antagonistic muscles - i.e. muscles that work in opposite directions on the same joint. For ease of imagination/demonstration think about the arm and bending your elbow. When you flex your arm at the elbow joint (your hand travels toward your shoulder) you are contracting your Biceps brachii - at the same time, the Triceps - on the back of the arm - are relaxing. (this isn't EXACTLY what happens by the way - its just a simplified version in order to get the general concept across).

Now, when you extend the arm - (the hand moves away from you) the triceps are
contracting, and at the same time the Biceps are relaxing.
Right. This is simple inhibition. As in the example above, the Biceps contract and the triceps relax. As your brain turns on the neural "path" to the Biceps telling it to contract, at the same time, there is another signal that goes to the Triceps telling it NOT to contract - it must relax - it INHIBITS the triceps. In fact, it reciprocally inhibits the muscle.
In the same way, as the Triceps contracts, there is a neurological signal to the Biceps to NOT contract - it must relax.

This works with all antagonistic muscles - quads/hamstrings, adductors/abductors, internal and external rotators, hip flexors/ hip extensors. You name it, it works.

(Don't worry about the mechanism for the moment, if you really want to know how it does it, drop me a line and I'll see about writing a more in depth post).

So why are you talking about this and how does it affect me?
Ah, well.
Lets talk for a moment about resting muscle tone- which is very pertinent to this issue. Lets take the same example of the biceps and triceps, (we'll expand on it in a moment). Imagine, if you will, that your Biceps is permanently high in tone - it is permanently "switched on". Not to a level that means your hand is constantly by your shoulder, but to the point that your arm is constantly half bent.
If the biceps is CONSTANTLY switched half on and you find it difficult to relax it, the triceps are always going to be switched off - they will always be Reciprocally Inhibited. Even when you try to use the triceps, because it is used to being switched off, the action that it produces is weakened, and it cannot do everything it is meant to do.

So a high resting tone in one muscle reciprocally inhibits the antagonist - causing it to be in a weakened state at rest. This means that the weakened muscle is going to be weakened in contraction as well - so it is a muscle that is being held weak, and contracts weakly - which obviously can't help you in what you are meant to be doing.

Hope you followed that. If not, tell me and I'll try and explain it better.

Saturday, 26 November 2011

Update on ITBS

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Thanks to whoever the Anonymous poster on the ITBS post was saying you should NEVER foam roller your ITB... an interesting point which I shall get to in a bit. I'm glad that they commented, because the post does need a little bit of updating.
I somewhat arrogantly stated that THE reason for ITBS is lack of musculature/ strength in the deep 6 rotators. Now this is indeed true, but it is not the ONLY reason for friction to occur down on the knee.

First of all, lets clear something up.
Illiotibial Band (Friction) Syndrome is actually caused by the LENGTHENING of the ITB. Yes, I wrote that correctly. Generally, the Tensor Fascia Latae- as mentioned in the previous post- the muscle that attaches to the ITB- and tensions it, becomes shortened- and as that becomes shortened, it pulls on the ITB - making it LONGER and causing it to become tighter along its whole length - but the key is that it is long and tight.

This is where the anonymous post comes in - if your ITB is already Long and Tight, why would you even consider lengthening it by rolling on it? Exactly. You wouldn't want to lengthen it any more. Its plainly not a good idea.
As for NEVER foam rollering it - I'm not so sure - if you are rollering your Vastus Lateralis - the quad on the far outside of the leg - which I often have cause to do - where exactly does the Vastus Lat stop and the ITB start? You can't really say - simply because the structures exist in 3 dimensions and in order to get to the whole of the tissue I am trying to roll out, I have to roll on the ITB.

So. There is a reason for not rollering your ITB if you have friction syndrome, but its pretty naive to say you should NEVER roll on the ITB.

I say, if it gives you a little relief, by all means go for it, but you should really be focusing on strengthening other structures around the hip which will stop you getting pain from the dreaded ITBS.

As already mentioned, it could be weak lateral rotators.
It could be (and is more likely to be) weakness in the Glutes (glute max and med)
It could be that your adductors (muscles on the inside of the leg) are too tight and are INHIBITING your Glutes- causing the tensor fascia latae to shorten.
It could be that the arch of your foot is flattening more than is optimal (some people might call this over-pronating) which is causing the tibia to torsion medially (rotate inward) causing the ITB to lengthen and create friction around the knee.
It could be that a nerve root in your spine is trapped and is inhibiting nervous signals to the glutes, bringing you back to the shortened tensor fascia latae.
It could be that the hips (innominate and sacrum) are slightly out of alignment and this is causing a biomechanical imbalance, the weak point being your knee - and thus causing pain.

It could be any number of things.
The vast majority of people I have seen with ITB friction syndrome have issues with deep rotators and glutes that don't fire properly.
Don't run on only half the muscles in your legs- practice firing those glutes- clench your butt! More to come on that later.

Friday, 25 November 2011

Trigger Point Therapy for Myofascial Pain

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My book of the month was Trigger Point Therapy for Myofascial Pain by Donna Finando and Steven Finando. It is actually more of a manual than a book to read from cover to cover, a guide to common trigger points in the body and their referral patterns.

A quick explanation of trigger points - in case you don't know what they are - is that they are specific points in muscles which are hyperirritable, found in taut bands of muscle fibre and frequently refer pain to a different area of the body. People often refer to them as 'knots' or 'lumps', and indeed they can often be easily felt within muscles.

The book divides the body into regions, further split into separate muscles. For each muscle included there is a standard format including information on how to locate the muscle, pain referral patterns, causative factors, affected organs, stretch and strengthening exercises plus a few other bits. Each muscle is accompanied by a diagram showing where, in the experience of the authors, they've found to be the most likely areas for trigger points to develop, and another showing pain referral areas. This is the useful part because a therapist can easily look at where pain is felt by the client and then go to a specific muscle to potentially find a trigger point. In practice it doesn't work this way - unless a whole treatment is set up purely to look for trigger points it is more usual to locate the trigger point within a dysfunctional muscle when we palpate it during the course of a treatment. By applying compression on the trigger point we can often replicate the pain a client feels, and with treatment erradicate them.

The introductory chapters are very useful for us as therapists to read and refresh our knowledge. Chapter 1, The Nature of Muscles and Trigger Points, has some good information on phasic and postural muscles. It talks a lot about dysfunction and the reasons that may come about due to postural stresses and physical activities which involve repeated movements. This leads on to areas prone to trigger points because of increased mechanical strain and decreased circulation.  "Our ability to operate in a physiologically optimal manner are all affected by holding patterns of muscular constriction.".

Chapter 2, Qi, Movement and Health, explores the Eastern and Western ways of treating trigger points. There are two points that stand out in this chapter. Firstly is that Eastern and Western therapists would both benefit from studying the others way of viewing the body. However each treats, we do so by seeking to remove constrictions that cause pain and trigger points. Importantly, we both do so by affecting the body on a physical level through movement and the release of contrictions. So, Finando & Finando suggest that Eastern practitioners would benefit from studying myofascial and muscular structures, and Western therapists by studying meridians.

The second point I take away from reading this chapter is related to movement. "Health requires movement, when movement ceases, life ceases." That may seem like a dramatic sentence to highlight, but it has stuck in my mind. Ultimately, without movement comes death. On a less dramatic, but very significant level, without movement your muscles become dysfunctional, pain affects your body and constrictions occur (and thus trigger points).  When the constrictions are released by a therapist the muscle can return to function and this will lead (directly and indirectly) to freedom thoughout the body, at both superficial and deeper levels. The chapter also talks about fascial lines, quoting Dr Paula Scariati on trauma or fascial changes:

Moving on, Chapter 3, Informed Touch, was a good reminder to me as a therapist about the process and thought that goes behind palpation. It's not just about hands on the client, there is so much more thought that goes into the process - from both a physical and emotional point of view. Key point from this chapter is to have a mental image of what your are palpating; know what to expect, then you can see whether there is dysfunction present. Good knowledge of anatomy is vital.

The final chapter, Diagnosis and Treatment gives an overview of what a therapist should be doing - observing the client, evolving palpation skills, listening closely, treating with precision and attention, extending treatment beyond the clinic (i.e. homecare), and allowing feedback from palpation to guide the treatment.

Although a short read, this book (or should I say manual) was good to review. I'll certainly be showing the diagrams to clients more often so they can visualise pain referral patterns, and why when they say the pain is felt in one area I might look to treat elsewhere.

Wednesday, 23 November 2011

F.I.T.T. Principle

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Ever heard of the F.I.T.T. Principle?
If not, read on - it's important to anyone wanting to progress in their chosen sport.

So you have a training programme but are you following the F.I.T.T. Principle? Well you should be. It's a guideline that will help you get the best out of your training and it stands for

Frequency: how often you train

Intensity: the level of effort you put into each session

Type: the activity you are doing

Time: the duration of a session

Lets expand on those a bit, so you know what you're doing and why this principle is something everyone should adopt. With a word of caution, these are general principles - there's always going to be some people who do things differently, overloading or just beasting themselves!

How often you train for a particular activity is important. There are different frequencies for different things, think about weight training and aerobic training. With weights you really shouldn't train the same muscle groups every day. Neither would you want to do a hard hill session daily. It's all about balance and making sure you give yourself and the muscles worked time to recover adequately between sessions. Muscles get damaged when we use them, even without injuring them so you'd notice, and it's this microtrauma you need to give time to repair sufficiently so that your muscles stay strong and can perform optimally.

How hard you train in a session and how much energy is expended. I'm not going to go into max heart rates, zones and percentages of max - but it's all this stuff you need to factor into your training to get the most out of a session. Work out what you're trying to achieve - is it the 100m sprint record or an ultra-marathon? Training intensity needs to reflect your goals. You need balance here - sufficient intensity to tax your body but not too much so you end up injured or you're overtraining.

Cardio, weights, mixed sessions (circuits). Are you running, swimming, lifting weights, walking, doing strength and conditioning, circuits, yoga, boxercise classes? Regardless of your overall aim, be it a top 10 finish in a fell race or to beat your PB, you need to mix up your training.  This ensures all muscle groups are being worked, you won't get bored of simply counting down the mileage, and your body becomes stronger by being constantly challenged.

The duration of your training session will vary, depending on the activity and your goals. If you're working on improving fitness by walking you wouldn't get very far if you did 2 minutes walk, 1 minute rest and repeating 5 times. But for a hill session running these times up a 20% incline would be appropriate. In general, the higher the intensity, the less time you spend training.

Essentially what all this boils down to is that you have to be sensible about your training. No sudden increases in what you're doing. If you're a new runner, don't expect to be able to run 5 miles at marathon pace after only a few training sessions. Build up slowly - use the 10% rule - keep all increases to no more than 10%.  This might seem overly cautious, but it ensures your body adapts to changes and helps to prevent injury.

Friday, 18 November 2011

Guest blog at Combat Sports Clinic

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In October we were asked by Rosi Sexton if we wanted to contribute an article for the Combat Sports Clinic blog. Of course we jumped at the chance - Rosi, in her own words... " the founder of Combat Sports Clinic and is a registered osteopath and sports massage therapist. She is also a professional MMA fighter, and is currently ranked amongst the top 10 female fighters in the world."

The topic for our article is the Physiological Benefits of Sports Massage for Athletes it was published in two parts. Enjoy the read of both Part 1 and Part 2 - and as always, let us know if you have any comments.

Thursday, 17 November 2011

Advanced Therapy Course

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I was down in Oxford this weekend just gone doing an Advanced Therapy Course with John Gibbons, who has more letters after his name than in it, and is involved in more world class sports teams than I could actually name. (I know he has a new website being made, so when I know where it is I'll link to it).

The idea of doing this course was to get some new ideas, new techniques and get some insights into the structural world of the body. I am mostly concerned with muscles and soft tissue, John comes from an osteopathic background, so to see his take on things was very useful.

Some of the things that stick in my mind - especially now I have had the time to look at and write up my notes are the differences in Spinal mechanics, both in neutral and non-neutral positions, and, perhaps more importantly, how to identify and recognise them. We went through the mechanics and motion of the innominate and sacrum (pelvis) and how to identify and fix dysfunction through various methods.

There was an excellent re-cap on muscle firing patterns, which, although I know, and have been taught, was a welcome reminder, and gave me a few more ideas as to WHY firing dysfunctions may happen, and also more ideas on how to re-fire, and re-educate muscles into correct patterns.

There was more, much more, but I don't have time or space to go into it all now.
I can't wait to put the things I've learned into practice, rest assured they will be tested out and refined on Lynne first before being unleashed on other people!

If there are other therapists who have heard about the Advanced Therapy Course, or even if you haven't, I'd suggest going on it. It was very educational, thoroughly worth the money, and I will be constantly learning from my notes for the foreseeable future. It'll be great when it has all been assimilated into my head, and even better when it is in my style.

Tuesday, 15 November 2011

November Book of the Month

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In our continual search to improve our skills and knowledge we are reading a new book each. In November our books are:
Tim's choice is Spinal Manipulation Made Simple, A Manual of Soft Tissue Techniques by Jeffrey Maitland
Lynne's choice is Trigger Point Therapy for Myofascial Pain, The Practice of Informed Touch by Donna & Steven Finando
Just because you have books on your shelf doesn't mean you are learning: you need to read them!!

Rehab exercises for ankle sprains

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We've already written about ankle sprains and how to possibly prevent them through strengthening and proprioceptive training. I recently came across some rehabilitation exercises which can also help.

Make sure you are past the acute stage of injury and can fully weight the injured ankle before undertaking these exercises. Do the exercises in bare feet to start with, and on flat, even, ground. Start with stepping in the configurations shown and build up to hopping.

Continue with the direction and step configuration for 1-2 minutes on each leg
Using the different change of directions places multiple stresses on various structures of the ankle, thereby providing all round strengthening. Ensure you do each configuration starting on each foot.

It's hard to say do these for X number of days or X times. Only you know when your ankle feels stronger, and in addition people heal at different rates. Don't rush your rehabilitation - it's better to be conservative, reducing the risk of re-injury. Saying that, you have to put in some hard work and integrate rehab exercises into your daily training (and rest) programme.

Once you are ready to move on you can start to introduce changes in terrain (e.g. grass, sand) and then do drills with running in a circle, figure of eights, plus hill work and different cambers. Finally, remember the hedgehog for proprioceptive training - see the other blog linked at the top if you need a reminder!

Saturday, 12 November 2011

Lower back and hip pain - Professor Shirley Sahrmann

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I was privileged to be able to hear Professor Shirley Sahrmann speak in Manchester on Sunday 6th November 2011. For those who don't know her, she is a highly regarded expert on muscle and movement imbalances. Her book, Diagnosis and Treatment of Movement Impairment Syndromes, is an absolute must read for any therapist working with the body, regardless of modality.

Prof. Sahrmann is based at Washington University, USA, so to catch her on a flying visit to the UK was an opportunity not to be missed.

So what was I there to learn? The official title of the course was Differentiation and Effective Management of Lumbar Spine and Hip Pain using the Movement System Syndromes Approach. A bit of a mouthful I think you'll agree.

Issues covered:
  • Kinesiology of the lumbar spine, pelvis and hip.
  • The concept of relative flexibility and it's presentation in the lumbar spine and hip
  • Current knowledge of the structural variations in the hip including cam and pincer.
  • Movement systems syndromes of the lumbar spine and hip joint, and contributing factors.
  • Clinical and research evidence of the interactions between the lumbar spine and hip.
  • Practical application of the movement system syndromes including screening and clinical reasoning.
  • Rehab exercises to correct movement faults.
The objectives of the day were to enhance our treatment strategy when a client presents with back and hip pain, learn how to effectively manage those conditions and have a more systematical way to examine those clients.

What have I learnt?
There were some big issues that have resounded with me since the course last weekend.
  • All Systems in the body involve Movement, be it muscle fibres contracting to produce movement via the joints and bones, gases being exchanged in the respiratory system and the circulatory system transporting those gases and nutrients to where they are needed. Any abnormality in any one of the systems affects the others, and all structures in the body. Something works less efficiently, becomes dysfunctional and pain is felt. 

  • Repeated Movements and Prolonged Postures cause deviations at joints, making them less efficient, dysfunctional and in some cases painful. The tissue changes that occur with Repeated Movements and Prolonged Postures includes neuromuscular changes. The progression of dysfunction and its associated degenerative changes is not only affected by physiological factors, but also biomechanical interactions and through an individuals lifestyle and personal movement patterns - the way that everyday activities are performed is the critical issue.
  • The body will always chose to move along the path of least resistance. With the resulting tissue changes from Repeated Movements and Prolonged Postures, relative flexibility or weakness can develop. For example, long distance runners typically have strong and dominant hamstrings, rectus femoris (one of your quadriceps) and tensor fascia lata (involved in hip flexion, medial rotation and abduction) - bending the hip, turning it in, and pushing it out whereas weakness tends to develop in the iliopsoas (hip flexors) and gluteus maximus (external hip rotation and hip extension). The joint movements can then become disrupted from the optimal, and in this case, where the hamstrings are dominant and gluteus maximus weak, the end result can be a hamstring strain. Sahrmann attributes this to the joint movement being altered because the muscles which should be working to control the precise, pain free movement of hip extension, are not doing so. I'll write more about this soon because it really is fascinating, and definitely a topic for all runners to know more about.
  • You get what you train. Quite simply, if you train a muscle to be strong, it will hypertrophy and develop more fibres, and hence be stronger. But, and this is the important point, following on from the previous point about the path of least resistance, those muscles not trained (or not as much) will be comparatively weaker.  Why is this important? Well, if you have strong quadriceps (thigh muscles) but weaker abdominals (stomach muscles) your pelvis will be pulled down at the front and this can lead to lower back pain because of an increased lumbar curve.
  • The presence of a muscle doesn't not mean it is being used appropriately. Sahrmann calls this "missing in action"- meaning that although there is physically a muscle being "worn" does not automatically mean it's working the way is should. This also contributes to the path of least resistance in movement.
  • The final message which is still ringing in my ears is this, You will continue to do what is familiar, not necessarily what is right.  It's worth reading that again to really get it in your head.
Having a good therapist (and Sahrmann is a very, very good one) test muscles for movement impairments and weaknesses is essential. It is the first step to correcting any imbalances you may have. You have, of course, got to want to make the change, as different ways of moving will need to become habit. They have to become part of your daily activities. Comfortingly, this is one message which we at Global Therapies already advise our clients. We show clients where they have movement patterns or imbalances which are sub-optimal, and then educate them on how to modify movements and strengthen specific areas to improve symptoms.

I have to say that I'm quite overwhelmed by the amount of knowledge passed on by Prof. Sahrmann. She is quite incredible, and to see her working with a client, demonstrating the tests she carries out was truly humbling. I'll be ordering her second book, there's a whole lot more for us to learn yet.

Wednesday, 9 November 2011

Pain on the heel. Plantar Fasciitis or Achilles tendonitis?

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As you may or may not know, I was in London for a week or so in the past month. Doing a slightly different job to that of my daily work, standing up on concrete all day every day, and cycling 10 miles to and 10 miles from my work everyday. Definitely not in my daily routine as a Soft Tissue Therapist, and a massive change in terms of the FITT principle.

It hardly comes as a surprise when I change the type of shoe I walk around in every day, the type of exercise I do every day and reduce the amount of rest - that something in my body decides that its not happy and goes into a bit of pain.

For clarity, I should say that I was going back to help out in Ski Show, I figured that standing around Earls Court for the best part of a week and a bit in minimalist trainers might hurt my feet quite a lot - so I should go back to a pair of trainers with some "squishiness" to help me out. That, added with cycling everyday for 2 weeks when I haven't been on a bike for a good few months, in biking shoes I haven't really got on with...

After a week of this, I began to feel a little bit of a twinge in the right heel - just on the lateral (out) side of the foot. Funnily enough, I only felt the pain (like a tearing sensation) when my leg was straight and the foot was dorsiflexed (toe pointing upward). When the leg was not straight and the foot was in the same position, the sensation wasn't there.

From that I can work out that its probably an issue with the gastrocnemius rather than the soleus - that's the muscle which goes from the achilles tendon to above the knee joint - as opposed to the one which originates below the knee.

I can happily say that its not plantar fasciitis simply because its not on the plantar (bottom) surface of my foot. Boom. It's not plantar fasciitis.

So, what can be done? Well, from the looks of things, its the gastroc which is causing the issues, so in terms of exercises, I'm not doing anything. Well, maybe a little bit of walking, but certainly not running, I might get on the Turbo at some point this week to see if there is an issue with being on the bike, but I am keeping well away from running - mainly because it involves an awful lot of dorsiflexion with a straight leg. I'd rather just stay off the hills for a few weeks and have it heal faster, rather than push it and then be out for months and months.

I'm also icing it on a regular basis - 84p peas from Tesco - (Tip - if you ever come to my house, don't eat the peas) and having massage and trigger point release on the gastroc on a relatively regular basis - just for 20 mins a day every 2-3 days. Although it doesn't hurt on a general basis, there are a ridiculous amount of trigger points and tender points all down the medial side of the muscle, and it certainly does it good to have them released, so as to relieve pressure on the achilles tendon and the bursae underneath. One other possibility is that its not tendonitis, but might be bursitis, in which case the treatment that I'm getting for it and the things I'm doing and not doing are helping the healing process, no matter.

However, as I have mentioned in other places, being injured is pretty boring. I don't think I'll do it again.

Friday, 4 November 2011


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We are bombarded by the media with messages to drink water. The volume quoted by many is 2 litres per day, but that's irrelevant here. What we're interested in is why. Why do we need to ensure our intake of water is sufficient?

To explain that, a little physiology is called for.
And a word of caution - figures quoted in different sources vary, what we have included here are estimates and averages, approximations if you like. But it is a good illustration of what the percentages are like.

Human bodies are approximately 70% water.
Just think about that for a moment.
Actually stop and look at yourself in a mirror.
Nearly three quarters of you is made up of water. How amazing is that.

Two thirds of that water in our body is intracellular - meaning it is inside a cell; the remaining third is extracellular (this includes blood plasma).

Blood is around 85-90% water.
The brain is around 80% water.
Muscles are about 75% water.
Cells are around 90% water.
Bones are about 25% water.

It's claimed that a human can survive about a month without food, but only a few days, a week at best, without water.

Best way to check you are hydrated?
If you're drinking a fair amount and going to the toilet regularly, chances are you are pretty hydrated. When you do go, take a note of the colour - the darker the colour the more dehydrated you are. The most obvious way to tell if you are more seriously dehydrated by how thirsty you feel, but on an intracellular level your body will be suffering before this symptom if felt.

Effects of dehydration
  • Chemical reactions in the body need water to function effectively. These processes will be compromised.
  • Hormones and nutrients need water to be transported around the body. These, and other substances will not reach their target areas without water.
  • Water is used in the lubrication and cushioning of joints - reduced water can lead to joint dysfunction,  restricted movement and pain.
  • Oxygen is transported around the body with the help of water. Without oxygen we simply cannot survive. Without oxygen muscles will not function.
  • Carbon dioxide is removed from body cells to lungs with the help of water.
  • Water helps to dilute toxic and waste substances and transport them to the kidneys and liver for cleaning or removal from the body.
  • Water helps to distribute heat around the body - without this help overheating will occur.
  • Balancing electrolytes is essential for athletic performance. With good hydration levels sodium, potassium and calcium can be moved from blood plasma and interstitial fluid freely. If these elements are unbalanced performance suffers and cramp is a real threat.
It is common for athletes to sweat when performing. Dehydrating only 2% of body weight can impair your physical performance:
  • increased heart rate
  • decreased cardiac output
  • drained mental sharpness
  • reduction in muscle power and endurance
  • risk of heat stroke
  • mental confusion
  • loss of coordination
  • fatigue
  • muscle weakness
  • muscle cramps
At only 10% dehydration muscle spasms, confusion, difficulty breathing and even unconsciousness can occur. Even with a modest level of dehydration the adverse effects on the body are noticeable and performance levels will be reduced.

Staying hydrated is really not very difficult. To be quite frank, we don't see why so many people seem to resist drinking water so strongly. It keeps us alive, keeps our bodies working efficiently and keeps us clean on the inside. Make sure you are hydrated, before exercise have some extra water to prevent fluid levels dropping significantly through sweat loss.

Finally, don't wait until you are thirsty before drinking some water. That goes for cold weather days too.

Wednesday, 2 November 2011

ART and STR - the differences?

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I've had a few clients come for a first treatment, and they have mentioned that during trips to the USA they received a marvellous and almost magical treatment called ART. They explained it as a stretching kind of motion which caused an almost "Chinese burn" like sensation.

Now to me as a Sports Massage Therapist, this sounded remarkably like STR (Soft Tissue Release), very much one of the standard techniques that we are taught and use on a day to day basis. When I proceeded to do STR on them, they were astounded and the remarks were generally along the lines of

"Yup- that's it, that's ART- wow, it feels MUCH better now."


So what is the difference between ART and STR? Are there any? I decided to do a little bit of delving and see what I could find. Obviously from a position where I use STR on a daily basis, most of my research was based around looking at what ART is and how (if it does at all) it differs.

My first port of call was, as ever, the internet, ART- Active Release Technique "the gold standard in soft tissue therapy" Brilliant, so I get to find out what it is. But not quite.
ART, it seems is a patented version of Soft Tissue Release. You pay your money, and go on a seminar, and learn to do ART. Which is pretty cool... but is there actually a difference between the two techniques - especially as STR certainly isn't patented. As Mel Cash says - you can patent a way to teach something, but you can't actually patent a technique.

I asked around a few therapists, and a few authors of Soft Tissue Release books, and received the somewhat underwhelming response that they thought the techniques were very similar, but weren't really sure.

Thankfully I found a colleague who has been trained in both STR and ART - and is someone I look up to as a tutor and a therapist, he was able to give a little more insight into the similarities and, more importantly, the differences between the two techniques.

It would appear that the main difference between the two techniques in terms of "hands on" palpation is that in STR we apply a lock into the tissue, creating a false insertion to the muscle - creating a restricted range of motion. The muscle is then moved through this restricted range. I suppose you could ultimately call this a "pin and stretch" technique.

ART uses more of a slide and move between components. There is no specific "lock", but more of a non-specific parallel tension - and the limb/muscle is pretty much always moved through the full range of movement. There is no movement of the contact hand- certainly no slide, but perhaps a slight proximal or distal grip.

It would appear that the technique is quite subtle and there are various releases that don't seem to be covered by STR as a rule - things like nerve entrapment releases - which sound really quite intriguing. It has been explained that the tension is used in a way to try to separate myofascia - and seems to be more precise in terms of depth, area and location.

The main massive difference is the way in which it is taught - and this is where ART and STR differ and where the patent comes in. STR is widely publicised and is very much a part of the Soft Tissue Therapists daily tool box. It requires a knowledge of how muscles and fascia work and in which direction they work in, and the subtlety comes from the practitioner. Precise techniques are developed over time and mastery is very much something that you get to from your own exploration of the technique.

From what I've been told, ART is taught in a very regimented and exacting way. Each myofascial structure, each muscle, each nerve and joint capsule has a working protocol and it is all standardised. When you learn, you learn exactly as demonstrated and you do not deviate from the way it is done by the tutor - which is the way it has been handed down from the guy who patented it.

Both versions of this myofascial release and the way in which they are taught have their benefits and their downfalls, but they both get the job done in remarkably similar ways.

As such, I will continue treating with STR, but now, when people ask about ART and the treatment they may have had elsewhere, I know where they are coming from and what they are expecting in terms of treatment. Interestingly, I often feel that STR might be a little too aggressive and choose to let the lock slide, so perhaps I'm already using some form of ART to obtain more subtle tissue changes.  I would like to actually go on an ART course in order to have hands on experience of the differences between them, but unfortunately as far as continual professional development, my time and resources have been allocated already for the moment. Hopefully next year I will get a chance to see and feel the difference. When I do, I would hope to be able to give more of an insight as to the differences, instead of just writing down what I have gleaned from other people.

Sunday, 30 October 2011

Rockover GROWL

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Today saw the first of the Rockover Climbing walls GROWL competitions. The sun was out as we went over there at about 11am as the first of the eager competitors were registering - though it was rapidly clouding over - perhaps a better day to be inside than out for a decent bit of climbing.

Tom and Simon had been busy setting up new problems for the competition, just over 40 of them ranging from V0 to about V7-8ish. Perfect for general competitions in the UK, but there were a couple of worried glances as Shauna Coxsey and Alex Puccio arrived at the door - concern that they would just flash all the problems and head out for a beer. However, it seemed that the vast majority of the climbers would be challenged by the routes.

The new walls and volumes provided an excellent challenge, and the training and circuit boards upstairs were being used to great effect.

Not only was there a general competition with a final climb off at the end, but there was a cash prize route - with anyone who climbed it getting a share of the cash. Obviously the more people that do the route, the lower the prize, so unsurprisingly, anyone who managed to get up it was being quite secretive about their beta.

We were there very much in a volunteer capacity, helping out with arm de-pumps and general advice about injury (generally referring back to the RICE protocol), though we were collecting donations for Mountain Rescue as well - which is a charity organisation close to our hearts as climbers and mountain goers.

We have already had some fantastic feedback from the guys at the wall- both the organisers and the competitors about our services, with several climbers mentioning that after a short treatment they felt like they hadn't even climbed yet. My response being - well get back on the wall then!

We were there until the end of the bouldering comp and saw a fair few people during that time, always good to make friends down at the wall - and I look forward to seeing them again, and climbing with them once my leg gets better (but that's another story for another post).

Unfortunately we were not able to stick around for the dry-tooling competition as we had a prior appointment elsewhere, but from the photos, it looked like a great time was had by all. Hopefully next time we should be able to have a go!

If you weren't there, get to the next one, good routes, good food, good company, and of course, good massage. The next one is on December 3rd. See you there!

Friday, 28 October 2011

Continual Professional Development

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What are we doing to make our services better for you?

We spend a considerable amount of time reading, researching and learning new techniques so that our clients get the very best treatments. We have an extensive library of books which are continually being pulled of the shelves, and the internet is abound with resources for us to delve into. Whenever we come across a new health condition or injury we spend a lot of time learning about it.

Being able to give each other treatments and practicing new techniques, is great. It means that when we come to provide you with a treatment our skills have been tried and tested - plus we know what it feels like.

Finally, we go on courses to learn practical skills and new knowledge from the myriad of experts in our field. The next courses we are attending are:

6 November - Lynne is attending a course in Manchester run by Professor Shirley Sahrmann: Differentiation and Effective Management of Lumbar Spine and Hip Pain using the Movement System Syndromes Approach. Lynne will be learning about "the factors that contributing to these syndromes of the lumbar spine and hip, how to correct any offending movements and as such be far better equipped in determining the regional source of back and hip pain AND, more importantly, how to successfully train and rehabilitate the person."

11-14 November - Tim will be attending an Advanced Therapy Course run by John Gibbons in Oxford. This course focuses "mainly on the treatment of postural dysfunction for the major joints" and aims to give therapists "the knowledge and practical experience to competently assess, treat and be able to identify specific dysfunction within the musculo-skeletal framework."

This is a selection of the things we do to keep our knowledge up to date with what is going on in the world. All of these modalities of study count towards our Continual Professional Development. As level 4 members of the Sports Massage Association we are bound to complete a minimum of 40 hours per year of CPD. Both of us far exceed this requirement and are always seeking new knowledge to improve our treatments for you.

Friday, 21 October 2011

Rest Days

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Knackered. Run down. Beat up. However, you still feel like you should go to the gym, go on that run, do a hang board session or go to the climbing wall.
Really? Is that going to do you much good?

Think about how many times you train during the week.
Actually, more importantly, how many days do you REST during the week? Note that this doesn't mean how many days do you not go to the gym or run if on that day you do some other activity, that's a change, not a rest.

How often do you actually take a break and let your muscles, cardiac system and nervous system rest?
Chances are it isn't very often.

One of the main reasons for getting run down, and, more importantly from a training perspective - getting injured is because an athlete does not get enough rest. This can be rest and recovery on a day to day basis, but it must also manifest itself in time away from the active stimulus of exercise.
I for one can find this a little difficult. I eat a fair amount, and I have quite a lot of excess energy, so on a day when I am resting and not getting out there to bike, run or climb, I have to think about what I'm doing so that I don't end up bouncing off the walls by the end of the day.

A rest day is a day away from hard exercise. It can include some light stuff, like a walk to the park, a leisurely cycle around a lake, a light massage something like that, or even just a day of not lifting weights.
Why? What is so important about this?

Our bodies respond to outside stimuli - muscles, nerves, brains etc. When there is a constant overload to one or more of the systems, the body releases hormones which enable the Sympathetic Nervous System to take over. This is the "fight or flight" side of the nervous system. If you are constantly in a state of tension, constantly on edge and ready to "go", it has a negative effect upon the body.

Added to this, when you exercise, you burn fuel, which breaks down muscle. With exercise your muscles suffer microtrauma. The muscle and neurological pathways then regrow and retrench themselves when you are not using them. The body needs down time to repair and regenerate itself before you put it through the next "test".

Indeed, stress from competition or trauma can lead to sympathetic dominance, and a series of potential issues such as breathing disorders, digestive upset, disrupted sleep patterns and immune system weakness against illness and disease.

If the body doesn't have enough time to regenerate, it begins to breakdown, you will feel more and more tired, more and more run down and at some point, it will break. Your body will react to the constant overload in your training programme as overtraining. The body responds to long term stress, physiological or psychological, with a general sympathetic response - a series of physiological and hormonal adjustments. I'll look at stress a little more specifically in a later blog.

A way to stop this from happening is to take adequate rest. To give yourself time to regroup and regenerate. If you don't know how often you are doing this, then try keeping a rest diary. I'm sure a number of you keep training or running diaries, you may even keep a food diary. But a rest diary is just as important. Write down what recovery practices (rest, sports massage, foam rollering) you are doing on a day to day basis, and note when you are taking a total rest day away from any type of athletic stimulus.

For everything you do, there must be an equal amount of rest or recovery. If you work too hard and don't rest enough, you will pay.
If you rest too much and don't work enough, you won't get fit.

But remember, Everything costs something. In the end, everyone must pay the price of rest for the work they do. Taking small chunks of intelligent rest throughout the months will make it far less likely that you will have to take an enforced layoff when your body tells you "that is enough" and decides to take you out of it completely, be that from injury or overtraining.

Tuesday, 18 October 2011

Stretching 5 - A summary

A while ago, in August, we wrote a series of blogs on stretching. We thought it would be helpful to give you a summary on stretching:

Warm up before you stretch.

When you stretch, don't count, just go with what feels right.

You are NOT looking for pain, you are looking for a pleasant sensation. If it's painful, its more likely that you are damaging muscles, not making them better.

Stretch gently and slowly (unless warming up for an event).


Breathe some more.

Make sure that you are stretching all the muscles that you are meant to be stretching. The most common one is stretching out one muscle in the calf and not the other one. Know what you are stretching.

Muscles have lots of different fibres. Don't just stretch in one direction, do it in multiple directions to stretch as many of the fibres as possible. Your muscles are not 2D and linear, they are 3D and work in multiple planes. Make sure they are flexible across them all.

Stretch before exercise (lightly) and, more importantly, stretch AFTER exercise.

Be aware of your limitations. This is not a competition. Every person is different, and has different things that need to be stretched. This is why there is not a stretching "routine" telling you what to stretch and for how long. It is as individual as you are. Find out what is inflexible in you, find out what the ranges of motion are meant to be, go away and gently stretch them.

Don't expect to get visible results in a day, a week, or even two weeks. You may have spent more than a decade getting tighter and tighter. You won't undo all that tension in a matter of a single stretching session. Be patient.

Its not just muscle you are stretching, but tendon and fascia.

And don't forget to DRINK WATER. Your muscles and tendons and fascia are more than 70% water. If they are dehydrated your body is like a swamp. Boggy and unresponsive. You need it to be more like a river. Trying to make dehydrated tissue flexible is like trying to make an old elastic band stretchy again. Its just going to break eventually. Luckily, unlike the elastic band, the body can regenerate. Drink water.

I hope at least some of the stuff I've written down has been of some use to someone, and I hope it hasn't totally confused you.

Once more I shall say, if you don't want to stretch, don't, but if you do, do it sensibly.

Monday, 10 October 2011

Herniated disc

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Your spine is made up of vertebrae, each separated by intervertebral discs made of fibrocartilage.  The discs are made up of inner and outer parts - a soft gel like elastic inner core called the nucleus pulposus and the tough annulus fibrosus being the outer rim of cartilage. The nucleus pulposus is there to distribute the pressure of each disc when they are put under load, i.e. they are shock absorbers. They also enable each vertebrae to glide over the other, keeping movements smooth.

What is a herniated disc?
Also called a slipped, ruptured or prolapsed disc. What happens is the soft inner nucleus pulposus herniates - it bulges through a tear or distortion in the annulus fibrosus into the vertebral canal or intervertebral foramen. The damage to the annulus fibrosus can happen because the disc is compressed beyond its normal range.

Depending on which way the bulge protrudes will determine what symptoms are felt. The disc can compress the spinal cord or nerves which can lead to reduced, or loss of function to the areas of the body served by the nerves. To you, this will feel like mild to severe back ache with or without burning, tingling, numbness or other sensations. If really severe muscle function can be affected or even paralysis. It really depends how severe the injury is, and what structures are affected.

Why does it happen?
For a fit and healthy person it is usually caused by sudden trauma, generally because of strenuous exertion (e.g. lifting a heavy object) or exercise (e.g. improper technique when weight lifting). Trauma can occur because of the lightest of movements, e.g. picking up a small object, and this would point to an underlying cause, or with forceful trauma to the vertebral discs such as in a fall or car accident. Poor posture can also contribute to this condition. In the healthy/young population the herniation is generally sudden and acute.
For older people the herniation can occur because of wear and tear - bone disease or degeneration, and the onset can be more progressive and chronic. That said, the onset, i.e. when you feel the pain, is usually sudden and sharp.

Can it be prevented?
Obviously accidents and traumatic occurrences are difficult to prevent. You can however ensure you perform lifting with proper technique, and keep yourself generally fit and healthy. Avoiding repetitive twisting movements is generally a good idea as this can put extra pressure on the discs. In a gym ensure your trainer shows you correct posture and technique and continues to monitor you so that you continue to do the exercises correctly. This should minimise the risks.

How to treat it?
Immediate care is rest and application of ice initially, heat can be applied after the acute stage has passed. Seeing your GP or emergency doctor may be appropriate. With medical intervention anti-inflammatory and pain medication may be prescribed.  As the injury progresses bed rest may be applicable for a period but generally normal activity should be undertaken ('active rest') to prevent muscle guarding and keep the spine mobile. If there is pain then stop what you're doing. Longer term, you should be looking to undertake strengthening and flexibility exercises with a sufficient warm up. It should go without saying that sudden or excessive heavy lifting is to be avoided to prevent re-injury. In severe cases surgery may be necessary but the majority of cases resolve with this being necessary.

Can Sports Massage help?
Yes, it can. Providing the therapist avoids treating on a day when symptoms are bad then there are no reason not to massage. Sports Massage will help to relieve muscle spasms, muscle guarding and tension which is your body's natural reaction to 'protect' the area. The intention of massage is to create space around the affected vertebrae, thereby allowing for the retreat of the herniated tissues.

Massage will also help to manage pain. A good therapist will look at the wider issues occurring in your body which might be contributing to, or a result of the disc injury. For example, postural imbalances, muscle functioning (what might be inhibited or short), firing pattern dysfunction and gait reflexes should be considered as part of the treatment. The aim is to look for the cause of the issue, as well as managing the acute area and muscles surrounding the injured disc. 

It is often appropriate with this condition for massage therapy and osteopathy treatments to be included in the overall treatment plan. This is to allow the soft tissues and bony structures to be worked in tandem, since both are involved.

Friday, 7 October 2011

Sporting Injuries and the NHS

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Talk about a can of worms.

Having spoken to a few people (fell runners) recently about nightmares with ligament ruptures and misdiagnosed breakages, I thought I might write a little something on here.
When you "do" sport, you tend to put yourself under a fair bit of risk. Some sports are more risky than others, but the vast majority have the opportunity in which to do something pretty nasty to your body, should you mess it up.

Its interesting that if you go to the doctor with hypertension, overweight, general un-wellbeing and feeling rubbish, they will tell you to get out more and lead a healthy life. Do some sport, stop sitting around being unhealthy.
However, go into a GP with muscle injuries or aches and pains from doing a sport, and if you haven't got the fortune to go to someone who has a genuine interest in Sports injuries, the chances are, you are going to be given some pain killers, some fairly generic advice and told to go away and stop doing it until it heals.

So imagine I've been out running for a good number of years, and my knee starts hurting. Ouch. Not a good thing. Right. Not to worry. I'll carry on running and see if it gets worse. Yep.
Ouch. That REALLY hurts.
An average runner (from what I've seen) will continue on with this cycle for about 6-8 months, changing terrain, running shorter and shorter distances, getting frustrated, and generally hurting more and more, until it actually starts hurting when they walk.
At this point, ooooh, now it REALLY REALLY hurts, I think I should go to the doctor. They fix bodies.

So they go to a GP and get a response of, oh, there doesn't seem to be any structural damage. Here's a prescription for some decent pain killers. Go away, stop running, and take pain killers and everything will be alright.
(I'm paraphrasing here, obviously, and different doctors will say different things).
So the idea is that you stop hurting because you are taking pain suppressants. Great. So you aren't actually NOT in pain, you are still actually in pain, its just that the pain killers are stopping you from feeling that pain. So the thing that is actually causing the pain is still there, but you can't feel it.
That's why, when you finish the course of pain killers, you go back to running (or whatever) and it STILL hurts. The original problem has not been fixed.
Other times, the GP may not even prescribe you pain killers. From personal experience, I went to one with pain in my shoulder, and was in not so many words told not to waste her time. Great. So now I have a pain in my shoulder, and the only guidance is not to do what I normally do. Yes, I could get a referral to a physio, but there is another problem associated with that.

If you are the runner that I have mentioned earlier, and have been running on the knee that hurts for 6 months, you eventually go to the GP, who refers you to a physio - that takes about 6 weeks. So now you've been waiting 7 and a half months to get an injury seen to that is going to cause compensation issues for a year or so, maybe more, down the line.

Quickly back up to personal experience again. Knee injury skiing. Bummer. However, still able to walk, but not run, in any shape or form. We suspect a meniscus tear, so we go to see the GP, who after a while agrees to refer to a knee specialist. Great. That takes 6 weeks to come through, and he recommends an x-ray. Lovely, a 5 week wait, then the x-ray, another 3 weeks until you get an appointment with the specialist again for him to say - nope, there is nothing showing up on that. Great. We request an MRI, it may have been on the cards, but we push for it anyway. Another 6 weeks waiting and finally get the scan. Then 3-4 weeks wait and see the knee specialist again who says that yes, indeed, there is a meniscus tear. Its taken THAT long, and that's going to see the GP straight away and not trying to run on it for a while before going to see anyone about it. Injury done in Feb and finally got someone to talk to us about whether or not to get an operation in about July/August. And that was in London.
Things do not run quickly.

OK, so that's a bit of an extreme case which needed an MRI, but think about other issues that don't need drugs, but do need some kind of help. Do you want someone to cursorily prod your arm/knee for 3 mins of the 7 that are allocated to you by someone who mainly deals out prescriptions to ill people. The GP is generally more concerned about giving out or withholding drugs. They are more likely than not tell you to stop what you are doing, and as a secondary thought, refer you to a physio.

Not wishing to blow my own trumpet, wouldn't it be better to go to a Soft Tissue Therapist, or a physio who can test, prod, poke, feel and understand what is going on with your injured limb/shoulder and see how the compensation patterns are distributing across the body, rather than dosing it up with excessive pain killers.
Yes, it costs money.
Yes, it may take time. But it will take an hour of your time. It won't take months of waiting, not knowing what is going on, and constant pain when you try to run.

If you get injured, get it seen to. Go to a GP if you wish, but I'd rather not waste their or my time.

GPs are great for some things. If I have a stomach upset, viral infection, or another issue that can be solved with drugs, or if something has happened that I don't understand with my digestive system etc. that is the place I will go. They are stressed people, and they should be given respect. They do a lot of things that I, and many other people cannot do.
I'm just saying that when it comes to sporting injuries, there are better places to go and get understanding of what is happening. If the therapist is not able to help, or recognises that you need a scan or to see a doctor, they will send you straight there.

At the end of the day, its your body, decide what it is worth to you. If it isn't worth much, don't waste your money on it. If it is, I'd suggest spending all you can on it. You only get one. Maintain it.