Stay Tuned…Over the last few weeks of 2014 we will be giving gifts of knowledge in regards to health, wellness and pain free functional mobility, we hope that these gifts not only provide components of education but also inspire you to make positive changes towards a better 2015 version of you. Happy Holidays Everyone!
I work very hard, and I play very hard. I’m grateful for life.
And I live it – I believe life loves the liver of it.
I live it.Maya Angelou
As the holiday season approaches there are many things to be thankful for. I am thankful for my wife, my daughter, my family and my friends. I am thankful for my health and my ability to help people everyday. Regardless if you celebrate the Thanksgiving holiday, this time of year presents opportunities to spend time with friends, family, and loved ones. As a physical therapist and human mechanic my patients constantly remind me to be grateful everyday… my encounters with each person usually consists of painful histories, complex injuries, and devastating changes in lifestyles. I am blessed to have the ability to actively listen to people’s stories, to objectively change someone’s mobility, to assess and prescribe proper movements in order to return people to pain free function. I have a job where I am welcomed into people’s lives … and I am given the chance to positively affect their lifestyles.
I’ve had the opportunity to work with 4-week-old twin babies who were diagnosed with functional torticollis, and a 102-year-old patient who told me his only wish was to be able to attend his great grandchild’s wedding. I have worked with thousands of high school athletes who dream of being the next big superstar, and I have worked with many professional athletes whose drive is to get back to work so that they can keep inspiring the youth. I have worked with many sick patients with terminal illnesses but yet they still find inspiration within themselves to keep trying, to keep moving. I have helped many military and first responders to eliminate aches and pains from their daily routines or to recover from traumatic surgeries. I have worked with numerous weekend warriors who struggle with the battle to find a balance between work, family and recreation. I am thankful for all of my patients, past, present and future. They are part of who I am and who I want to be. I am thankful that I have a job I love and that I have a support system that believes in me. Happy Thanksgiving from Therapydia Portland and I hope you all have a safe and healthy end to 2014.
Curbing the astronomical costs of workers compensation costs has proven to be an incredibly challenging task. It is estimated that works compensation costs have reached nearly $250 Billion, that’s Billion, with a B! That means that workplace illness and injury costs has exceeded that of cancer, diabetes, and strokes. While these are staggering numbers there are multiple factors that go into health, illness, and the associated costs. One factor that is often discussed is work place ergonomics. Ergonomics is actually the study of people’s efficiency in their work place, but is often talked about regarding sitting positions, desk height, etc. Following along those same lines, I think there are three effective ways that work place health can be improved and efficiency increased.
Annual individualized movement assessments
We are all familiar with going to the doctor’s office for a physical. Typically this involves checking body weight, blood pressure, heart rate, listening to you breath, and a conversation about lifestyle choices that may be impacting your health. All of these are helpful metrics for placing you into a category of “health.” But shouldn’t we also regularly check our ability to move and the quality in which we engage in our environment? Many of the injuries I see in the clinic are related to issues with movement, either too much or not enough, and the loads that the body is experiencing. We shouldn’t just focus on the ability for you to move well but the capacity to continue to move well throughout the day, week, month as various levels of stress and fatigue set in. To best identify how well your body is prepared to meet the demands of life and your job it is helpful to have a movement assessment performed.
Individualized exercise, daily stretching/movement in the work place
We’ve all seen the charts that highlight stretching routines for office workers or low back stretching for manual labor workers. While the charts often have good content to them, they are produced in the thousands and have no specificity to them. The individual worker needs an individualized work station program. This would be based up their assessment, their physical capacity, and the individual demands of the work environment. Not all office jobs are the same nor are all physical labor jobs the same. Plus people move differently for a variety of reasons so I wouldn’t want to generalize an exercise routine for a group of people that do similar tasks.
Allocate time for exercise
Whoa, wait, pay people to exercise? Yup! I’m not suggesting 2 hours a day for a paid exercise break, but providing individuals with the opportunity to work on their individualized programs is a perfect way to ensure they have the time to do it. For most people they will want to, and likely need to, spend more time out of work addressing their individual health and wellness goals, but an opportunity each day to break, move, and improve their general wellness is an excellent way keep a workforce happy, healthy, and productive.
I know there are quite a few organizations that provide great opportunities for the employees in an effort to promote a strong health and wellness work culture. What I’ve outlined are just a few different variables that can continue to promote a health work force. It is also important to remember that an individual plan is a great opportunity to empower people to be proactive in their approach to health and wellness. Where most people can feel overwhelmed and often lost, simple steps can be implemented to help give everyone the tools they need to succeed.
Building your savings account
The idea behind a monetary savings account is that it gives you a little “wiggle room” financially in case something comes up. The physical savings account can give us that same wiggle room for the day-to-day demands we experience. Over the course of these past several posts we have talked about a few of the components on how to create a stronger, healthier, and more resilient body. But our list is not an exhaustive one by any means. Plus every individual is very unique and will require different focus on their greatest needs. That is why it is important that you find a skilled clinician or clinicians to help you understand this individualized process much better. Your entourage can consist of physical therapist, chiropractors, massage therapists, acupuncturists, naturopaths, coaches, MDs, and spiritual leaders. These individuals will be able to help you better understand what your potential physical shortcomings may be and how to best address them. Regardless of whom you work with, whether it is one or many, it is vital that you are taught, not told, how to address your needs. Based upon the nature and stage of someone’s condition, a clinician may need to be much more hands on and apply most of the treatment. However, even during those times it is important that you know you are a vital component of the process and should be learning about the condition, the treatment being applied, and how to self manage the issue. Progressively the patient centered treatment will empower you as an individual to be able to take control and effectively manage things, PLUS it will teach you the how’s and why’s so that you can do your best to prevent this from happening again. And if you are not in pain the time spent with the clinician can be used to address some of your physical issues and help to keep your body working as optimally as possible. All of this to say, you are in control, you have the ability to make a huge impact in your overall wellness and health, and you should make sure you surround yourself with individuals that view you the same way and that look to support you on your journey!
Savings accounts don’t get built up without some level of planning, so take the time to figure out where you needs are, and be actively involved with those clinicians that will help you build your physiological saving account.
Rest & Recovery
Just make sure you get enough sleep. OK, that’s all, goodnight. Not hardly! Sleep is vital yes, but even if you are sleeping 8-10 hours a day but then going out and over loading your body and nervous system (see there’s that pesky nervous system again) you will likely never truly experience rest. This is individual specific, meaning that each person has a certain level or ability to adapt to the physiological stress they are exposed to. Some can recover in a matter of hours, while others may require several days. Remember how I mentioned that most issues people have physically are related to load, either too much or two little? This is where rest has a vital component to that equation. The rest we provide our bodies will allow for repair, regeneration, and the physical adaptations to occur. Rest does not mean lying flat on your back, cold drink in hand while watching an entire season of the Walking Dead. Sure taking time off to fully rest is helpful and necessary at times. The other type of rest we can utilize is relative rest. This is a way to let adequate recovery to take place without having to shut everything down. Something as simple as an easy bike ride, a mild hike or even stretching and mobility work can be useful.
Another interesting thing about rest & recovery that I’m not sure everyone recognizes is how involved the nervous system is. Recovery is not just about letting muscles heal or your energy stores be replenished, it also a period of time to let the nervous system take a break and get your body back into a state that is most optimal for individual performance. The nervous system is broken up into several groups, one of which is called the autonomic nervous system (it’s not going to get nerdy I promise). This system consists of three major parts: the sympathetic, the parasympathetic, and the enteric nervous system. The sympathetic is our fight or flight system, while the parasympathetic is our rest and digest system. The two systems try and play nice together and keep the body in some state of harmony but the daily stressors we apply to our body can tip the scales and throw these systems out of whack. This is not an athlete specific issue either. Remember, we are all athletes in the sport of life! Stress from life and work, poor eating habits, lack of restorative sleep, and prolonged exposure to physical stress (exercise, sport, and job demands) can all place increased demands on the sympathetic nervous system. If the scale is tipped too far because of elevated levels of physiological and psychological stress can result in the body being in a heightened state of fight or, can elevate stress hormones, and place increased demands on the adrenal system (think, adrenal fatigue or exhaustion). All of which can negatively impact our daily function both at work and at play.
Mobility & Coordinated Movement
Mobility has become an incredibly hot topic as of late and I think for a lot of the right reasons. The term mobility is a bit nebulous, however. Mobility can be thought of simply as of our bodies capacity to adopt a certain position or movement. This can be broken down into the ability of an individual joint to achieve a certain range or the entire body to demonstrate a specific movement pattern. The essence of mobility is not just about a joint bending or moving a certain way, but is a coordinated effort of the nervous system in conjunction with muscles, bones, ligaments, and the vascular system. Within each of these pieces lies the ability to improve or disrupt your ability to move and move well. For that reason alone it is important that we think of mobility and movement as a more complex task and improving our ability to move can be equally complex. The idea of simply stretching a joint or massaging a muscle to gain mobility may not do the trick for several reasons.
First, when we stretch or massage tissue we impart a force that is designed to change the tissue quality, and if the tissues ability to move improves, then the idea is that our movement patterns should also improve. But with this treatment application we also impart a stimulus to the nervous system and this input alone has the ability to change mobility. Bottom line here is that there isn’t always a one-to-one relationship of “I apply a force to a tissue, movement changes, then the tissue must be at fault.”
Secondly, quality movement is not just contingent on the ability of a joint to express a specific amount of range of motion, regardless of active or passive motion. Effective movement is an orchestrated event that requires multiple systems to be in tune, on time, and well rehearsed. And who is the conductor of this coordinated effort? The nervous system. Because of this it is important to think of coordinated movement/mobility as more then just an issue with stiffness. The approach to addressing movement errors will require a detailed understanding of what system or systems appear to involved and then piecing together an approach to address each individually and then collectively. If the ankle joint is stiff and that’s why you have difficulty walking down the stairs, the ankle stiffness will need to be addressed. BUT then you must go back and retrain the movement to some degree. With new found range comes new requirements that the body is not accustomed to having, so the movement pattern will also be trained.
Finally, strength issues can be a limiting factor for movement. In a previous post I discussed aspects of strength in a more general sense. Here is where the concept of strength has to be addressed to provide a stable, controlled system to allow movement to occur. Midline, or “core,” strength provides the foundation for us to move from. The stronger our midline, the stronger the rest of the body can be. Remember, we need proximal stability for distal mobility. From there it is also important that the individual joint systems have ample strength to control and support the desired movement. This can also have an impact on remote areas. For example, hip weakness can lead to faulty movement patterns of the knee and possibly pain. Our body moves based upon a series of stable and mobile parts and if one area is dysfunctional this can impact a remote site.
What? I need to be strong? But I’m not an athlete. Oh really?! The SPORT OF LIFE requires us to demonstrate the ability to move, balance, lift, carry, and coordinate movement in a variety of environments, and we need to demonstrate this consistently and with high levels of competency and capacity. I’m not asking anyone to run out and become a power lifter or enter a strong man competition but I want people to recognize that the vast majority of issues we see can be related to the fact that the body was not adequately prepared to meet the demands of the activity. This can be as simple as bending over to pick up something off of the floor or lifting a carryon out of the overhead bin on a plane. I feel that much of the physical pain we experience can be related to load. Either we experience too much of it and exceeded our bodies capacity, a.k.a. over train, OR we don’t experience enough of it and our system becomes undertrained and poorly prepared to meet the demands of life. The concept of strength is relative to the individual and their unique physical demands. The capacity to squat is different for the Olympic weight lifter during his training then it is from my grandfather when he is getting up from a chair, but the necessity is the same, as they both need to be strong in the squat to accomplish their goals. But with strength comes precision; the ability to accurately and consistently perform the desired movement or posture. Tomorrow’s post will cover components of movement patterns but keep in mind that being strong doesn’t ensure efficiency in movement and that we need to practice how to move for our strength to be truly expressed.
Most financial planners will advise their clients to carry a certain amount in savings to help cover the unexpected in the event of an emergency. I think all will agree this is a good idea. Now, what if we take the same concept and apply it to our health and wellness. I’m not talking about saving more money to pay for health related bills, but rather taking the human body and working on the ability for it to move better, be stronger, reduce pain, and improve endurance so that it builds a physiological savings account.
The concept of “normal” is debatable when it comes to things such as posture, movement patterns, and performance. For every one person that demonstrates “the ideal posture” and is pain free, we can find one that doesn’t demonstrate the same posture and is pain free as well. However, there are general concepts that are agreed upon regarding ways to reduce relative risk with activities such as reducing the imbalance that may occur from our right to left sides, or demonstrate a relatively neutral alignment of the lumbar spine when performing a bending and lifting task. Following these recommendations doesn’t automatically mean we are bullet proof but it does allow us to build a slight physical buffer between what is considered to be more optimal and what could potentially cause harm or increased wear and tear on the body. Over the course of this week we will break down some of the simple concepts that can be implemented to help start building your physiological savings account.
Sit up straight! Shoulders back! Belly in! Whoa, wait, are we all standing in formation here or are we working on being in a more physiologically neutral position? Some of the commands that are given can be just as detrimental to alignment as the most rounded and slouched posture could be. The idea with regards to posture correction is not to be rigid or overly corrected but to position the structures of the body into a position that is relatively more neutral, less stressful to the surrounding tissue, and aligns the joints as best as possible. When discussing the body sometimes the term length/tension relationship is used. This refers to the fact that tissue (muscles, ligaments, tendons, nerves, blood vessels, etc) will be under a certain amount of length and a certain amount of tension even when in a neutral, or more ideal, position. Things like blood vessels, nerves, and connective tissue don’t particularly like to be stressed all day long, which is exactly what happens when we sit with a round low back, rounded shoulders and forward head. If we use sitting as an example the forward head increases the demands of the neck musculature to hold the head up. It has been estimated that for every inch the head is forward it gains 10 pounds of weight, as it relates to the neck muscle stress. It would be the equivalent of you holding a bag of groceries with your hand as high as your shoulder and your arm straight. Stress, strain, and not to mention fatigue will quickly set in. In addition to increased daily stress to the body, poor posture also can influence our movement habits and abilities. I’ll talk about movement and mobility more in an upcoming post but think about the fact that if I am in a forward head, rounded low back position throughout most of my day; I am reinforcing this common movement pattern. Making it more difficult for my body to assume a more ideal body position during other tasks, which can be potentially harmful and improperly increase the demands of other parts of the body.
Too painful and stiff to move, he walked in with his head slightly off to the side and rigid. He began by telling me that something was off in his shoulder blade area, aggravated from an earlier exercise. He then pointed to the inside border of his shoulder blade and said, “ There’s a knot in my back.”
The “knot” is his back was in a familiar place as he had experienced this in the past. Something he hadn’t considered though, was that the pain in his shoulder blade might have less to do with the shoulder blade or the muscles around that area and more to do with structures further up the kinetic chain; his neck.
Pain is a unique phenomenon. All you need to do is type “Pain” or “Pain Science” in any search engine and you will get a wide variety of results. One of the unique characteristics of pain is that it has the ability to be felt in areas other then where the pain is actually originating. This is often described as referred pain, which can be confusing for those who are experiencing it. The true mechanism behind referred pain is debated but a term often used to describe this event is convergence. The idea of convergence stems from the fact that the nerves that supply information to a specific area, in this case a shoulder blade, converge at the same location in the spine as certain nerve fibers from the neck structures. The specific details of this are a little more complicated but the bottom line is, the body is essentially confused about the true location of the pain. Therefore a neck problem can be felt around the shoulder or a low back issue can be felt on the outside of the calf.
Referred pain is different than when someone is experiencing pain related to nerve irritation or compression. The term Sciatica is commonly used when discussing radiating pain down the back of the leg. Semantics aside, the term is somewhat accurate in that a nerve that travels down the back of the leg may be irritated or may be in some level of distress. The pain experience can be generated anywhere along that nerve tract, hence the confusion of why location doesn’t always give us a clear picture of what is truly going on within the body.
The concept of convergence and referred pain is just one of several reason why it is important to have a thorough examination to explore all possibilities regarding pain, discomfort, or dysfunction. Some ideas of what patients can do to help better understand their condition relates back to recognizing the behaviors and symptoms of the condition. Some conditions will have fairly consistent culprits that will either make the condition better or worse. Often times we call these easing and aggravating factors. It is also helpful to take note of how the condition feels in the morning, specifically if there were any issues with sleep and if there were any changes throughout a normal day. Collectively all of this information will assist you and the clinician in determining what truly may be at fault and how to best address it.
As for the hero of our story, he made it! We did a quick neck exam and determined that is was likely the lower part of his cervical spine referring pain to his shoulder blade. After a short bout of treatment his pain was down significantly and he left with some self at-home treatment techniques that he used to clean up the rest of the symptoms he had over the next several days.
- Bogduk, N., Innervation and pain patterns of the cervical spine, in Physical Therapy of the Cervical and Thoracic Spine, R. Grand, Editor. 202, Churchill Livingstone: New York.
- Grieve, G., Referred pain and other clinical features, in Grieve’s Modern Manual Therapy: The Verebral Column, J. Boyling and N. Palastanga, Editors. 1994, Churchill Livingstone: Edinburgh.
- Lundy-Ekman, L., Neuroscience: Fundamentals for Rehabilitation. 1998, Philadelphia: W.B. Saunders.
- Aprill, C., A. Dwyer, and N. Bogduk, Cervical zygapophyseal joint pain patterns II” a clinical evaluation. Spine, 1990. 15(6): p. 458-461.
The shoulder is one of the most versatile and complex joints in the human body. As the connection point for the upper extremity to the body it is required to provide a tremendous amount of mobility while sustaining high stress loads. This unique relationship between mobility and stability is a component of why shoulder pain and dysfunction occurs. Remote areas of the body can also impact the function of the shoulder. For instance, stiffness in our mid back or weakness in our mid line, A.K.A. the core, can also alter how the shoulder behaves. Here area a few tips on how to keep the shoulders healthy and happy.
- Always focus on quality over quantity. The quality of the movement you are trying to achieve should always trump the amount of weight, the number of repetitions, speed or duration. Once form is broken and you can’t regain the proper movement the exercise should stop or be modified.
- Not all pain in the shoulder is solely the fault of the shoulder. Stiffness in the thoracic spine can alter the movement of the shoulder leading to issues such as impingement and tendon irritation. Spending time on maintaining good mid back mobility and posture can help keep the shoulder moving more freely and efficiently.
- Address on your weaknesses. I’m not just referencing muscular weaknesses here either. If your posture is poor find time to stretch what is tight and strengthen what is weak. If you don’t have adequate shoulder range of motion find time to mobilize the joint and/or the surrounding tissue. If you have multiple areas that need to be worked on you need to devote enough time to properly address them. You may not feel like mobility work is “exercising” but helping your body move better can allow you to train harder and reduce the risk for injury.
- Build a strong foundation. You would never build a house on a foundation of sand so then why do so many try and train with a poorly organized core? Your body’s ability to stabilize and control movement originates in the core of our body. You can’t have distal mobility without proximal stability and that is why no matter the goal or injury you should always make sure you have a good foundation to work from.
- Treatment or at least a consultation as soon as possible. In the acute stages of an injury there is a cascade of events taking place to help protect the injured site as well as assist in recovery. Things such as swelling, redness, bruising, weakness and of course pain are often associated with acute trauma as well as chronic problems. It is important that we accurately and quickly provide a clinical diagnosis that will start you on an early intervention protocol. Early treatment can make the difference between a shoulder problem that takes seven days or seven weeks to recover from. Connect with a qualified health care professional such as a physical therapist, chiropractor, athletic trainer or body worker. If that person is not sure how to manage the condition, they likely have a great network of people that can get you on track and started as quickly as possible.
As an aside, these principles relate to more then just the shoulder and can be applied to any area of the body.