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.

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 6^th 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.