The nervous system is the master controlling and communication system in the body; every thought, action and emotion reflects its activity.  The nervous system is comprised of two main divisions; the central system including the spinal cord and the brain, and the peripheral system that consists of the nerves that leave the spinal cord and carries information to and from the extremities. The peripheral nervous system has two functional subdivisions; the sensory (afferent) division which invades virtually all body tissues and are particularly abundant in epithelial (skin) and connective tissues (ligaments, muscles and joint capsules), and the motor (efferent) division that conveys information from the skeletal muscles and joints to the brain. It is essential for this feedback loop’s response time, this essential exchange of information, to be as fast as possible.  This will allow the joint to react appropriately to prevent injury.

In a sprain, the ligaments and joint capsule reinforcing the joint are stretched or torn.  This in turn can damage the neurons in and around the joint that provide the basic information to keep the joint stable. Therefore the nervous system’s integration coordination, necessary to maintain joint stability, can be compromised.  No longer can the afferent neurons send essential impulses to the CNS at speeds necessary for the efferent neurons to return crucial feedback to maintain joint integrity.  Therefore joint instability can come from two sources; intrinsic factors (inside the body) such as laxity in the torn or stretched tissues, muscle weakness and imbalances, poor flexibility and poor proprioception, and also from the nervous systems inability to quickly respond to extrinsic (outside the body) stimuli such as shoe type, orthotics, playing surfaces and imposed forces such as running into someone or something.

When an individual of any age incurres this type of injury, time must be allowed for the tissue healing process to take place, which can include creation of scar tissue to re-strengthen the damaged muscles, ligaments and capsule.  To prevent re-injury and to return the individual to their highest possible functional level, the damaged neurons must also be retrained.  Balance training on stable and unstable surfaces promotes motor skill relearning, the mechanism responsible for the sequence and speed of muscle contraction around the joint to enhance joint stability. Balance exercises on unstable surfaces can enhance joint stability by increasing the sensitivity and thus the speed of the neurological feedback loop, shortening the onset time of muscle contraction.  The research literature has supported activities focused on sudden alterations in joint positioning to stimulate reflex joint stabilization in previously injured or debilitated individuals.  Unstable surfaces provide sudden alterations and make training more dynamic, and possibly more applicable to an individual’s activities of daily living and athletic requirements.  The individual who sprains an ankle in athletic competition and returns to competition once the pain has subsided, has a 20-42% greater chance of reinjuring that ankle than someone who took the time to retrain the motor learning pattern necessary to return to sports.  When the foot hits the ground the body has about 1/1000 of a second for the foot and ankle to deliver information to the brain and then from the brain back to the foot and ankle to activate the proper muscles in the proper sequence to prevent an ankle sprain and create a rigid leaver for the body to propel itself towards its next movement.  This mechanism also works for the individual who is at risk for falls, has a difficult time going from sitting to standing or has difficulty negotiating stairs. By using unstable surfaces one can improve their pathway sensitivity and promote improved balance and body control.  Although we used the foot and ankle as an example, using sudden alterations in joint positioning can promote reflex joint stabilization anywhere in the body.

The question that has more recently been researched is the idea of using unstable surfaces to train healthy athletes and individuals.  Unstable surface training is sometimes described as functional strength training, in the sense that the strength and stability improvements from the unstable surface training will more readily transfer to sports and daily activities than those from stable surface training.  This assumption is inaccurate.  It was once thought that performing traditional resistance exercise on an unstable surface will enhance core activation and muscle strength (force).  This idea is quickly being disproved in the literature by several researchers.  Unstable surface training potentially conflicts with the advantageous neuromuscular training adaptations produced by stable surface training. It also has shown to alter the recruitment patterns of joint muscles in turn decreasing their functionality. The alteration in neuromuscular recruitment, diminished force output, and failure to improve daily movements or performance, makes unstable surface training less functional than traditional stable surface resistance training.  What they have consistently found is that training on unstable surfaces does not increase muscle activity and in fact decreases the maximum force that can be produced by the muscle as compared to the same movement on a stable surface.  With certain exercises on unstable surfaces, maximum force output by the muscles was 59.6% less than on stable surfaces.  This diminished force output suggests that the overload stresses required for strength training necessitate the inclusion of resistance training on stable surfaces.

The important concept to understand is that almost everything boils down to “Specificity”. If an athlete practices throwing a medicine ball on a foam roller he, or she, will ultimately become very good at throwing a ball on a foam roller. According to an article in a recent Strength and Conditioning Magazine, the transfer effect in throwing a ball with power and accuracy on the playing field may simply not exist. All training is specific, whether it is walking up a set of stairs, kicking a soccer ball or tackling someone on the football field.

In summary, using unstable surface training to improve balance and proprioception with an individual who has been injured, or with an individual who demonstrates decreased balance function and is at risk for falling, is certainly beneficial.   Research shows it takes an average of 12 visits to see objective improvement in these patient populations. However using unstable surface training in individuals, who already demonstrate “normal” or high level athletic ability, provides no benefit.  For resistive training, utilizing an unstable surface can actually hinder improvement or diminish the individual’s strength capabilities or gains. Free weight barbell exercises on stable surfaces have been shown to provide the greatest overall functional effects. These exercises recruit many muscle groups including the core stabilizers. They also require intra and inter muscular coordination to perform.

References

1.Eisen, Tracey C; Danoff, Jerome V; Leone, James E; Miller, Todd A. The Effects of Multiaxial and Uniaxial Unstable Surface Balance Training in College Athletes. J Strength and Conditioning Research Vol. 24 Issue 7 – 1740 – 1745, July 2010.

2.Hubbard, Daniel. Is Unstable Surface Training Advisable for Healthy Adults? J Strength and Conditioning Research Vol. 32 Issue 3 – 64 – 66, June 2010.

3.Kohler, James M; Flanafan, Sean P; Whiting, William C. Muscle Activation Patterns While Lifting Stable and Unstable  Loads on Stable and Unstable Surfaces. J Strength and Conditioning Research Vol. 24 Issue 2 – 313 – 321, Feb 2010.

4.Uribe, Brandon P; Coburn, Jared W; Brown, Lee E; Judelson, Daniel A; Khamoui, Andy V; Hguyen, Diamond. Muscle Activation When Performing the Chest Press and Shoulder Press on a Stable Bench vs. a Swiss Ball. J Strength and Conditioning Research Vol. 24 Issue 4 – 1028 – 1033, April 2010.

As of this publication, 45/50 state practice acts as well as Washington D.C., allow for direct access to physical therapy services without the need of a referral; including the state of Georgia!  This recognizes that physical therapists are experts in the examination and treatment of musculoskeletal conditions, and are qualified to screen for conditions out of the scope of physical therapy practice.  One of our primary care responsibilities within the healthcare community includes assessment of health and fitness levels, as a means of preventative care.  If we can recognize those patients at risk for cardiovascular disease, we can help to educate and treat them and actually provide the tools to REVERSE the adverse effects of inactivity.  This can also help reduce the patient’s risk of a serious event, while limiting the overall costs of healthcare.

What does all of this mean to you? 

The American Physical Therapy Association (APTA) defines “wellness” as “the concepts that embrace positive health behaviors that promote a state of physical and mental balance and fitness.”  This concept has gained increasing attention over the past several years, as studies have identified a link between activity and fitness levels, wellness and overall mortality.  The APTA also defines “fitness” as a “dynamic physical state – comprising cardiovascular /pulmonary endurance; muscle strength, power, endurance and flexibility; relaxation; and body composition – that allows optimal and efficient performance of daily and leisure activities.  Physical therapists are trained in the evaluation and treatment of health and wellness statuses.

In general, exercise does not cause cardiovascular complications in healthy individuals, but there are increased risks to those with underlying cardiovascular disease.  Therefore, it is important to see a physical therapist to determine your risk prior to increasing your physical activity level.  If we determine that you will require more monitoring to safely evaluate your exercise capacity, we will recommend you see your physician or cardiologist.  According to the American College of Sports Medicine (ACSM), there are several benefits to regular physical activity and exercise.  They include improvement in cardiovascular and respiratory function, reduction in coronary artery disease risk factors, and decreased morbidity and mortality.  Other benefits include reduction of anxiety and depression, enhanced physical function and independent living in older persons, enhanced feelings of well-being, enhanced performance of work, recreational and sports activities, reduced risk of falls and injuries from falls in older individuals, prevention or mitigation of functional limitations in older adults, and it is effective therapy for many chronic adult diseases.

Vertigo is the false sensation of motion of oneself, or one’s surrounding environment.  It is a component of dizziness and can be accompanied by nausea and/or vomiting.  Vertigo is the result of a dysfunctional vestibular system.  This system plays a major role in the ability to maintain clear vision during head motion and to determine head position or speed/direction of movement.  The vestibular organs of the inner ear contain nerve endings suspended in a fluid that detect both the forces created by gravity as well as the forces generated as we move.  The brain takes this information from the vestibular system and combines it with other sensory input throughout the body in order to orient the body to the environment and allow movement through a variety of situations. 

Until the system fails, the activity of the vestibular system is noticed only when it is stimulated beyond normal.  That’s what happened in the “dizzy bat” scenario.  The fan shook up the fluid in his ear like a snowglobe and won’t feel quite right until the snowflakes settle.  If the system does fail, which could be the result of a number of causes, one can experience vertigo with minimal, or no stimulation. 

Physical therapists can treat vertigo with many different techniques, depending on the cause.  It may be as simple as performing maneuvers to reposition components of the inner ear organ.  Or, it may require performing exercises which retrain the brain to become accustomed to movement, thus lessening symptoms.

In my experience treating vertigo I have learned that it is a debilitating and miserable condition which, in many cases, can be treated with physical therapy and the results can be life-changing.

If you have any questions whatsoever, or anything to add, please do not hesitate to reply.

The mission of the Arthritis Foundation is to improve lives through leadership in the prevention, control and cure of arthritis and related diseases. The Arthritis Foundation is the largest not for profit contributor to arthritis research in the world funding more than $380 million in research grants since 1948.

This year’s Event Chair is Spine & Sport’s own Sarah Beekman. Please join us for this special event and help raise money for the Arthiritis Foundation. For more information about the event and how you can participate or contribute, please visit  www.2010jbrjax.kintera.org.

Generally, a rotator cuff impingement will develop first. This occurs when the rotator cuff tendon rubs against the bone on the top of the shoulder (acromion), causing microscopic tears in the tendon.  When this occurs, it damages and irritates the tendon causing inflammation. Eventually, scar tissue will replace the healthy tissue making the damaged tendon more easily injured. If the impingement worsens, the microscopic tears in the tendon can become a larger tear (either partial thickness or full thickness rotator cuff tear). A rotator cuff tear can also be caused suddenly with a specific injury, such as a sports injury or a fall.  Physical therapy is an important part of recovering from a rotator cuff disorder. The goals of physical therapy are to decrease inflammation and  pain, while maintaining and improving shoulder mobility or range of motion (ROM). Once the inflammation and ROM are improving, a person is then progressed to a strengthening program as tolerated. This strengthening program will be specifically designed to the person’s shoulder and the activities that they need their shoulder to perform.  Strength will allow for better control and more efficient use of the new motion gained.  This will lead one to be able to perform their daily activities with less pain and difficulty so that they may have a more enjoyable day!

- Sean Quinn, Physical Therapist, is the owner of The Sports and Physical Therapy Center in Eureka. Sean graduated from St. Louis University with a Master’s degree in Physical Therapy in 2001. Sean has practiced in an outpatient setting since graduating. His focus has been on manual therapy techniques, orthopedics, and sports medicine. Sean incorporates all of these areas to help patients achieve their full potential and beyond. He is also a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association. Sean continues to treat patients as well as manage the clinic.

A Physical Therapist is a health-care professional that evaluates, diagnoses and provides treatment to individuals to develop, maintain and restore maximum movement and function throughout life. This includes providing treatment in circumstances where movement and function are threatened by aging, injury, disease or environmental factors. Components of movement and function that are evaluated by a physical therapist include strength, range of motion, flexibility, balance, posture, body mechanics, coordination, endurance and general mobility such as walking, stair climbing, and getting in and out of a chair or bed. A physical therapist evaluates the components of movement and develops an individualized program to decrease deficits and restore function. Physical therapists help people with orthopedic conditions such as low back pain or osteoporosis; joint and soft tissue injuries such as fractures and dislocations to “Physical therapists help people with orthopedic conditions including low back pain, sciatica, neck pain and radiculopathy to name a few.  Physical Therapists can also help with joint and soft tissue injuries such muscle strains, ligaments sprains, dislocations, subluxations and joint pain. In general, if a physical condition is preventing you from doing what you want to do, most likely a Physical Therapist can help.

A physician—also known as doctor of medicine, medical doctor, or simply doctor—practices maintaining or restoring human health through the study, diagnosis, and treatment of disease or injury. One goes to their physician when they feel sick, get injured, experience any unknown symptoms, or for annual checkups.  A physician applies prior medical knowledge to accurately diagnose a patient’s ailment. A physician may prescribe medications for the ailment or may provide healthier lifestyle recommendations. There are many different types of physicians who each have a specific scope of practice. It is common for a physician to refer one patient to another physician who specializes in another area. Examples of different physicians include pediatricians, internists, and surgeons, just to name a few. Just as physicians refer patients among themselves, physicians also refer to other medical experts such as chiropractors and physical therapists, dependant on the diagnosis and needed care.

There are several reasons your back may feel weak and not healthy.  After the very first time you had back pain, one of the primary muscles which helps to support your spine, the lumbar multifidus, changes from muscle to fat.  There is nothing you can do about this at the first terrible onset of the pain as exercising at a high enough intensity to stop the wasting away only makes your pain worse.

The importance of this discovery was that it explained why, when a person has back pain one time, that person is more likely to have back pain again.  The lumbar multifidus muscles that change from muscle to fat reduce on average by nearly 1/3 from the size they were before you had pain.  The lumbar multifidus muscles are hard to see on yourself unless you look in the mirror at your low back, so it is not normal to notice that they have wasted away.  Even if you stand and look at your low back in a mirror, unless you are very very skinny, it is hard to see these muscles as they are very deep and about the size of a tootsie roll. 

In thinking about how these muscles waste away, it can be comparable to injuring your knee.  Can you imagine hurting your right knee to the same intensity of pain as how bad your low back feels?   Could you then imagine that your right thigh muscle (quadriceps) would start to waste away as compared to your left thigh muscles over the course of a couple weeks?  Just from the pain alone your right thigh muscle would start to not look as healthy as the uninjured left one.  Now imagine that this goes on for several weeks!  You would be able to see the difference easily between your right thigh and left thigh, the injured and uninjured sides.  That  is exactly what happens in your Low Back!

In reality, the majority of the population do nothing the first time they hurt their low back or knee.  So  now, you are walking around with one leg or one side of your low back weaker than the other.  Going back to the knee comparison for a second, 3 months later let’s say you have no knee pain, but you go to climb a flight of steps, can you imagine that the right knee injury and wasted away muscles on the right side?  Can you believe that this is exactly because the right knee did not have the strength of complete that task without re-injury.

Back to your back.  Now your low back has the exact same thing happen.  You have an injury to your low back which produces pain and specific muscle wasting.  The pain goes away over time, but you unknowingly have a weakened low back.  You goto do something but your low back does not feel quite right and you are cautious.  This is your weak low back trying to communicate to you to do something about it.

The great news is that there is a very specific group of exercises that can be done to exactly target increasing the strength of those weakened low back muscles, and no they don’t show this to you on infomercials.  If you have allowed your pain to go on too long.  If it is keeping you from being healthy and doing what you want.  If you are fearful it is worsening, then make it stronger.

Qualifications & Education:

• Doctor of Science: Orthopedics, Rocky Mountain University
• Masters of Physical Therapy, Saint Louis University
• Master of Manual Therapy, University of Western Australia
• Residency Trained: Orthopedics
• Bachelors, Exercise Science, Saint Louis University
• OCS – Orthopaedic Clinical Specialist, Diplomate, American Board of Physical Therapy Specialists
• PT – Licensed Physical Therapist

Dr. Bull is considered by his peers as an expert in the examination and treatment of orthopedic conditions. His doctoral research on spinal pain has led to development of new techniques and technology to help his patients achieve faster results. Dr. Bull has lectured internationally on spinal and shoulder pain and developed programs for rapid post-surgical return to work and pain reduction techniques. His passion for physical therapy has acquainted him with Olympic hopefuls and weekend warriors.

Muscle trigger points (TrP) are defined as a tender point within a taut band of skeletal muscle that is painful upon compression, contraction, or stretch and usually responds with a referred pain pattern distant from the point.[1]  These points can either be active, meaning they hurt all the time, or latent, meaning they only hurt when you press on them.  TrPs have been shown to have concentrations of chemicals that are associated with inflammation and pain with the active TrP having much higher concentrations.[2]  The cause is thought come for a variety of factors including psychological stress and mechanical overload.  As with most things, they are not all or nothing.  TrP are on a spectrum from very mild latent ones (you would have to dig at it to elicit pain) to really active ones (when your friend puts his hand on your shoulder and you almost drop to the floor).

Sometimes these knots or TrP just go away on their own or they stay latent and you never know they are there until your annual massage, but other times they are a daily nuisance.  If you find yourself rubbing your neck often, making circles with your neck or shoulder blades because they don’t feel right, or constantly getting in the hot tub and letting the jets hit the area then you may need an expert to help you relieve the discomfort.  Researchers have found links between problems within the joints of the neck and these TrP.[3][4]  That may be why some people have to keep going back and getting massages which keeps the TrP at bay, but never truly solves the problem.  If there is joint irritation and stiffness between two vertebrae, then symptoms of muscle tension and pain will keep occurring. 

Physical therapists have various techniques in their arsenal that improve joint stiffness or hypomobility including but not limited to joint mobilization, manipulation, stretching, and muscle-energy techniques.  We are trained to isolate the involved segments and direct specific treatment to the area in need.  This is the most effective use of the patient’s time and healthcare dollars as the underlying problem must be solved before the patient has a full recovery.  Please visit a Spine & Sport location or give us a call to learn more or schedule a free consultation. 

Cervicogenic means ‘originating from the neck’.  A headache (HA) produced from the neck joints, muscles, or nerves is more common than you think accounting for 15-20 percent of all chronic and recurrent headaches.[1]  What does it mean to have a cervicogenic HA.  One, it can be easily tested and determined that it is coming from the neck, but don’t think you need to have severe neck problems in order for this to happen.  And two, by treating the neck it will alleviate the HAs. 

                The pattern for a cervicogenic HA is pain radiating to the front of the head, side of the head, or behind the eyes.  This mimics other forms of HAs, but the cervicogenic will have other signs such as 1. Being aggravated by neck movements or postures.   2. Reproduced by pressure over the upper neck.  3. Usually starts at the base of the head, where the head meets the neck, then spreads up and around the head.  4.  Can be confirmed by nerve block if a definitive diagnosis is required.[2]  Physical therapists are trained to recognize these traits and can tell if someone’s chronic HAs are stemming from the neck. 

                The actual source of the pain is most likely the joints between the upper bones of the neck.[3]  If those joints are treated effectively then the HAs resolve and the person can go about their day without taking medication.  Treatment would consist of manual therapy to loosen any tight or restrictive joints and to relax the muscle spasms that are sure to be present in the area.  Most often postural exercises will need to be performed to correct faulty body mechanics or to counteract poor sustained postures i.e. sitting at a desk for 40+ hours a week.  Modalities such as electrical stim, ultrasound, massage, or heat may help reduce symptoms but will not correct the underlying problem. 

                If you or someone you know has recurrent HAs it may be worth getting checked out by a physical therapist to see if the upper neck is a part of the problem.  HAs can be very debilitating and for 1 in 5 people there is a true cure, not just management.