Blog

LAYERS OF COMPENSATION

Originally Published: Monday, 17 February 2014

Remember when you suffered that frustrating acute injury? That old injury most likely still affects your movement and function today. Our bodies are hardwired with an incredible ability to protect injured tissue. When the body sustains an injury a cascade of protective events begins. Pain receptors are activated sending signals to the cortex communicating that injury occurred. The cortex receives and processes these signals responding by down regulating neurological reflexes and altering muscular tone of the system. This leads to cortical asymmetry resulting in an imbalance in function between the right and left sides of the body. This leaves the individual in a compensated and under functioning neural state that may predispose them to further injury.                                       

For most of us, especially high-level athletes, we have not sustained just one injury but many. With each injury the cascade occurs, which moves the body further from optimal muscle function and support. I like to call this phenomenon “layers of compensation”. When I begin to rehabilitate an injury the patient often will note some pain from an old injury. This is due to the fact that as we begin to allow the body to support itself properly the compensation patterns developed to protect old injuries are removed. While this is positive progress towards optimal neuromuscular function it leaves old injuries vulnerable until they are also repaired. 

As we continue to resolve various layers of compensation we can help the individual return to proper recruitment patterns free of compensation.  An example from a recent case would help explain this. A patient recently came in with an acute low back disc injury. While the patient surely had damage in their low back they had a history of severe ankle sprains, and a right knee injury. The cascade in this case began with an ankle injury which led to compensation. These poor movement patterns led to another ankle injury which was followed by a knee injury. After many years of altered muscle tone and neural reflex the patient sustained a disc injury. 

To fully rehab the disc injury it was necessary to address each area of injury.  I like to compare the process of full injury recovery to the activity of putting a puzzle together. Piece by piece we take care of old injuries, and neural compensation patterns. This allows the individual to not only feel relief but to move beyond injury and reach their goals.

KEY TO INJURY PREVENTION

ORIGINALLY published on Thursday, 09 February 2012

Preventing injury and reducing injury potential is among one of the most valuable concepts I can share with my patients.  We tend to think regular exercise; strengthening our core; wearing proper footwear; and consistent stretching are secrets to not getting injured.  Interestingly to me, these popular ideas of injury prevention seem to have very little bearing on the prevalence of injury.  In fact, some of them can cause injury, but that is for another time.

Musculoskeletal injury occurs when the body cannot absorb a particular force.  As force enters our body, it is the job of the muscle to absorb force. In order for a muscle to absorb force properly it must be able to turn on at the exact moment force enters into our body. It must also be able to turn on strong enough to absorb the amount of force entering the area. The ability of a muscle to turn on is controlled by the signals coming from the brain. If the signals from the brain are slow or weak it will cause the muscle to respond late and with less strength. This results in some of the force not being absorbed properly. The unabsorbed force will start to transfer to other areas of the body that were not designed to absorb it. These areas are tendons, ligaments, meniscus, labrum, cartilage, bone, bursa, fascia, and other muscles. Because these structures are not designed to absorb force they start to stretch, fray, tear, degenerate, and become inflamed and injured. Very often the cause of injury to tissues is force transferring into the area because of the loss of ability to absorb the force properly by the muscle.

This concept goes against what is often thought by patients and practitioners alike, that the problem lies in the injured tissue itself. Therefore treatment is designed and applied to the injured area alone. One example is when an athlete tears an anterior cruciate ligament (ACL) in the knee. It is the thought of the athlete, the surgeon, and the physical therapist, that the problem is with the ACL. Through the eyes of functional neurology we can see the problem is a force absorption issue which resulted in an ACL tear. 

In short, the ability to maintain appropriate force absorption is directly related to your ability to remain injury free.  This concept is very new, but, drives the rapid results that we see clinically at PPC.  Simply put, patients and athletes that can fire their muscle with accurate and rapid reaction to stimuli are fast, strong and very rarely get injured.  This ability can be easily be determined with a brief neurological assessment of your upper and lower extremity muscle tissue.   

Feel free to contact me for questions or comments.

EXPERIENCING MUSCLE FATIGUE?

ORIGINALLY published on Monday, 19 March 2012

Understanding how to prevent muscle fatigue is an extraordinarily powerful tool for our athletes. Muscles are designed to work together.  When they don't work together, fatigue begins. Fatigue can be defined as the process of the muscle shortening.  When full shortening occurs the muscle has achieved full fatigue.  By training a muscle eccentrically we can increase the time before fatigue.   The longer the starting position the longer it takes for the muscle to reach its shortened state. 

As the biceps contracts the triceps should relax to the same degree.  Think of contraction as shortening and relaxing as lengthening.  When the triceps contracts the biceps should relax and lengthen to the same degree.  Traditional athletic training does not teach the body to contract and relax.  Typically, as in the biceps curl, the biceps pulls the load up and then the biceps lowers the load back to the starting position.  In normal movement, elbow extension should be controlled by triceps contraction.  However, we tend to train the biceps to contract with both movements.  This training will transfer over into athletics.  We can see that by contracting the biceps with flexion and extension, it never gets a chance to relax and lengthen. Thus, it is shortening with elbow flexion and not lengthening with elbow extension.  The biceps only gets shorter and shorter, until it finally becomes fully shortened with maximum fatigue.   

Another problem with training a muscle this way is the elbow movement becomes very inefficient, slow and will cause a reduced ability to absorb force.  Please refer to . . . to learn the negatives of poor force absorption.  Training a muscle slowly will also only allow it to move at the same speed during athletics.  In order to move fast we must train fast.  The faster the contraction occurs the more stimulation is applied to the antagonistic relaxation.  With slow contraction the normal reflex loops will not be able to cause enough relaxation of the antagonist muscle to allow relaxation. 

When our athletes train the elbow flexion to be a violent contraction of the biceps we will get reflexive violent relaxation of the triceps.  And with the following movement a violent contraction of the triceps to extend the elbow we will also have a violent reflex to inhibit the biceps and allow it to relax and lengthen.  In the first case we are strengthening both neurologic pathways of relaxation.  In the first case we are only strengthening one neurologic pathway.  In the second case the biceps will be allowed to lengthen with each movement of elbow extension.  Because the contractions are very violent the stimulation to relax is strong enough to allow the muscle to relax and lengthen.  There will also be no fatigue of the muscle because each muscle has the chance to lengthen back to its starting position, away from shortening.  In training at high intensity using the proper muscles to move the joint will allow an athlete to compete indefinitely without fatigue of the muscle.  Fatigue will only occur when the antagonistic relationship only goes one-way.   

Continual training with proper movements over an extreme period of time will also allow for development of the proper energy delivery systems.  As the systems become stimulated at a high rate they will become more efficient, eventually to the point an athlete would never run out of energy.  They would only rotate to different energy systems, thus allowing the previous energy system to recover.  At this point fatigue would never affect an athlete.   

This is very valuable for our athletic community permitting freer, more powerful movement. Longer muscles are capable of creating up to 10x more force than that of the same muscle in a shortened state.  More force will equal a greater athletic performance.  And, due to the violent contraction the athlete will be able to move much faster.  Remember, you can only move as fast as you train!

ARGUMENT FOR DISC INJURY PROGRESSION

Blog published on Tuesday, 21 May 2013 

Neural cascade leading to disc injury:

  1. An injury occurs assaulting the neural integrity of the system.
  2. As a result, lower extremity motor reflex loops become down-regulated.
  3. The motor cortex responds by initiating a protective mechanism.
  4. This results in an altered movement pattern or neurological compensation.
  5. A net increase in cortical asymmetry becomes established (BAD).
  6. A reduction in postural integrity ensues because the down-regulated cortex loses capacity for inhibiting ipsilateral flexor musculature.
  7. Further neuromuscular asymmetry, delayed reflex, and inappropriate neuromuscular sequencing is promoted (winding up because of resulting poor motor afferentation).
  8. The system becomes vulnerable to injury due to a lack of force absorption capacity.
  9. The L5/S1 joint is a prime candidate for injury because of its anatomical location.
  10. Overwhelming force causes fraying of the peripheral disc, until bulge or sequestration occurs. 

      Cascade of events include:

  •       Discogenic pain
  •       Potential spinal nerve entrapment / compression
  •       Inflammatory products flood tissue
  •       Paraspinal musculature becomes pathologically short and tight to splint injury
  •       Further nociceptive stimuli and poor motor afferentation increases neural windup                                

The progression that develops in the neuromuscular system is usually overlooked and can lead to unnecessary delay in recovery time, unnecessary expense, and avoidable surgery in many cases.  Addressing the neural factors in disc pathology are a vital component of recovery and increase success rates for non-surgical rehabilitation.

WELLNESS CARE. EXPLAINED.

ORIGINALLY Published on Sunday, 21 October 2012

I want to take this blog to speak to a confusion that I firmly believe both doctors and patients share.  That is, the concept of wellness or maintenance care.  Often, in my first visit with a patient, they will share with me their concern of having to see me 'forever'.  Or, I will hear in passing the reason patients choose not to see me is they have a concern that I will try to keep them coming. Or, patients will ask me after I have helped them resolve a complaint, "What is the maintenance schedule?"

This perception about wellness or maintenance care stems from a poor understanding of what is trying to be achieved.  And as a practitioner, I could argue that doctors across our field are philosophically spread on this topic.  So, without delving into the array of opinions - I want to provide a clear description of my reasoning for care that goes beyond resolution of a patient's complaint.

My primary objective when a patient presents with a complaint that can be positively impacted through the methods I practice, is to get to the end point as elegantly as possible.  I try to identify the most direct reason that pain is being produced, and provide positive stimuli to reduce or completely alleviate the pain.  On a more complex level, most complaints that present to our office are a function of poor force absorption.  To understand this concept in detail, please see http://www.pittsfordperformancecare.com/services/in-balance.html.

I would argue that poor force absorption is the common denominator in most neuro-musculoskeletal injuries / pain presentations (from carpal tunnel to a torn ACL).  And as a result, when working to alleviate pain in a patient, I am specifically targeting neural deficits that are responsible for permitting unwanted force to get in the body.  This is the premise that guides my recognition, evaluation and treatment of injuries.  

An example for clarification:

Chronic or acute lower back pain means undue force is consistently reaching the lumbar spine during any force production (which can be as simple as walking through the mall or being seated at 90 degrees in a chair).  Everything that we do creates force.  And when force is not absorbed with a rapid, accurate response by the muscles, it will penetrate the body and travel the path of least resistance to a stress point.  An extraordinarily common stress point is the lower back, due to its anatomical position.  It is important to understand that the body's ability to absorb the force that it creates is dependent on the brain's control of our reaction time- or motor reflexes.  If these reflexes are healthy and fast, the muscle system is capable of absorbing tremendous force.  If the neural circuitry has been compromised, the motor reflexes become down-regulated and compensated movement arises.  

Causes of this down-regulation or compensation can include any negative neural stimulation.  Examples:  poor biomechanics, tissue sprains / strains, concussive injury, emotional stress, and chronic pain syndromes (not exhaustive).

Once I feel confident with the one or multiple triggers causing neural compensation - treatment begins.  In-Balance treatment involves a receptor-based activation process that stimulates deficient neural pathways with directed positive afferentation .  I know it sounds complex, but I assure you that my patients would say it's actually pretty simple.  The process from evaluation to repairing neural integrity takes just a few visits.  Remaining care is dependent on how much strength work is required to support accurate movement.  

Hopefully this has provided some clarity about our process and methods.  And when the question of maintenance or wellness care is posed, I have 2 comments.  If activities of daily living (which can include periods of exercise) cause a level of 2 or greater on the (1-10) pain scale, then it is expected that compensation will ensue and correction is recommended.  In addition to care for injury, I also recommend the In-Balance procedure for optimization.  Because this methodology directly impacts cortical (top of the food chain) neural function, whole body benefits can be achieved.  These benefits include dynamic increases in strength and stability as mentioned earlier, but also autonomic stability (lower resting HR, lower blood pressure, more efficient energy utilization, and decreased pain sensitivity).

 So, yes, I do recommend wellness care.  I think my definition is different than most. Ultimately, I am trying to balance self-sufficiency with optimized neural health for my patients, relative to ongoing care.  I hope this post has helped.  Please email me if you have comments or questions @ dr.rob@pittsfordperformancecare.com

FOOLPROOF FOOTWEAR SHOPPING

ORIGINALLY Published Thursday, 14 June 2012 

I find myself often asked to help assess my patients' footwear and what I might recommend for their next purchase.  So, in an effort to simplify a process that has way too many things to think about, I am sharing my secret.  When buying shoes today, especially training or running footwear - the single most important feature that I look for, is how the sole of the foot integrates the ground force during movement.  

Traditional thinking recommends postural correction of the arch (whether too high or fallen), in addition to correction of any rotation (pronated or supinated foot alignment).  This is commonly accomplished by inserts, altered uppers in the shoe, or orthotics.  In my opinion, these corrections are used under the wrong premise.  

Thinking the foot needs to plant in a neutral, stable position makes sense in theory, and is how most people make their selection.  The problem with this approach, is that it does not take into account how the patient's joint receptors interpret the force entering the body.  Healthy proprioceptive input from the ankle-mortise joint through receptor activation in the tibio-fibular ligament is vital.  This is how our motor cortex knows what type of surface we are walking on, and what muscles need to be activated or de-activated in accordance to our environment.  In addition to moving with power, speed and efficiency, this circuit is a major source of brain power (neural fuel).  

Therefore, the better the fuel delivery or the more pure the neural activation from this receptor pool, the better the muscles will fire to absorb force through the foot.  And the greater the ability to absorb force the instant it enters the body, the lower the chance of injury.

Now to the secret:  We can test this integration by muscle testing the patient in a standing posture while wearing the footwear they are interested in purchasing.  If the muscle tests with a weakness or delay - it can be ascertained that the footwear provides for very poor integration. If the muscle tests with strength and speed of contraction - I am in full support of the purchase.  I usually suggest if a patient is in the market for a new pair of sneakers to purchase 3 or 4 pairs and keep all the receipts.  And next time they come in, we spend 5 minutes determining what pair provides the best integration. This has become an easy and effective way to recommend footwear for my patients.  I love the objectivity.

 I always welcome comments or questions.  Email:  dr.rob@pittsfordperformancecare.com