The View from Sports Center

Witchy Woman

A few years ago I was driving back from a US Army base where I had given a daylong lecture on shoulder dysfunction. I was looking forward to getting home and relaxing a little over the weekend. Then my cell phone rang. It was Ellen and she was quite excited.

"I have tickets to the Eagles in Little Rock. I think we should go!" she exclaimed. I asked her when and she said, "Tomorrow! I've already checked the airlines and we can fly into Little Rock and be there in time for the show!" I hesitated for a moment and then she said, "Our seats are in the 8th row!" Off to Little Rock - what else could I say!

I can still recall the concert. It was outdoors on a warm and breezy August night. I was an Eagle that night, singing all the hits and coveting Joe Walsh's guitar. An awesome event. Ellen had made a great choice.

But I have always wondered, why are hit songs hit songs? Why have the Eagles remained so popular for so many years? And why do certain things seem to completely captivate us?

Roy Williams, in his book "Magical World's of the Wizard of Ads", proposes an answer he calls a Third Gravitating Body. Not a simple concept to grasp and one I read several times before I finally got it - or at least I think I do. In a nutshell, a Third Gravitating Body is an exceptionally small item introduced into a system (and a system could be a book, a song, a meal or even a treatment) that creates a "pattern within a pattern" thus subconsciously captivating the right side of our brain. Huh? These patterns are too complex and big for the analytical left brain. So the work is shifted to the imaginative right brain to allow us to make sense of these large, wonderful patterns. A Third Gravitating Body is found in crashing ocean waves, sparkling campfires, majestic mountains, and even in the fluffy clouds that whisp by each day. Have you ever found your self attracted to these examples? Why is that? It’s the Third Gravitating Body. A Third gravitating Body, claims Williams, is what draws us to sing "Witchy Woman" a million times. I think he is on to something that could benefit us all.

Think for a moment how monumentally boring straight leg raises are. Why? The movement is predictable. We aren’t required to focus to achieve the task. But if I add one small thing - a tiny laser strapped to the leg and a target for you to hit with the light, the boring movement suddenly becomes much more interesting. The laser acts as a Third Gravitating Body.

Of course, we have no idea if performing straight leg raises with a laser is more effective but it sure is a lot more fun. Which would you rather do? Where can you find a Third Gravitating Body in your day?

Make Today Count.

Doug Kelsey
Author. Teacher. Therapist.

Why Do So Many Things Work?

Have you ever wondered why so many different interventions work for the same problem? A person with low back pain may respond very well to myofascial release, joint mobilization, exercise, craniosacral therapy, strain-counterstrain, SNAGs, NAGs or physical agents. How is that possible? The answer is in the brain. The brain simply does not care which technique you use. The brain does not have regions specifically labeled “myofascial nucleus” or “ strain-counterstrain laminae”. The brain cares about the sensory input parameters: intensity, frequency and duration. 

The higher nervous system centers play a substantial role in inhibiting the sensation of pain. Pain can be abolished with anesthesia, hypnosis, acupuncture, certain pharmacologic agents or from sustained levels of mental concentration often seen in athletes or performers. The thalamus serves as the processing station for all tactile input to the brain with the exception of olfaction. The ventrobasal nucleus of the thalamus is the first processing point for information conveyed by the A-delta fiber pain pathway – the sensations of sharp and immediate pain. The C fiber pain pathway conveys burning and aching sensations frequently associated with deep tissue damage through the midline nucleus of the thalamus. All thalamic nuclei (except reticular), relay information to the cerebral cortex. In addition, these nuclei process emotional and memory information, integrate sensation, or regulate consciousness, arousal and attention. In other words, the thalamus processes your ticket to the higher centers of the brain and it remembers what ticket you used. Mechanoreceptors located in joints and soft tissues end with an inhibitory synapse on the substantia gelatinosa (SG) in the spinal cord. The balance of excitatory and inhibitory activity determines the nature of the impulses relayed through the spinothalamic tract. Many of these axons synapse in the periaqueductal gray region of the brain known for its activation of a descending inhibitory effect on pain. The projections form periquaductal gray then continue on to the thalamus for processing.

Okay, now that we know the anatomy – so what? Here is a creative interpretation of what happens. I trip and ram my naked toe directly into a giant rock – really hard. A family of Angry Impulses hop the pain train running on the Adelta fiber and ride directly to the spinal cord. Here they transfer to the spinothalamic tract bound for the thalamus and periaquaductal gray stations. They have a message to deliver and it is not going to be fun. The thalamus DECIDES, based on the passengers’ message, where the train goes next. It may go back down and unload in the spinal cord causing such a traffic jam that no more passengers can travel or it may decide to send the train on up to the cortex where the passengers can get off a do all sorts of creatively disruptive and nasty things. An hour or so after the first Adelta train departs, a hiking expedition along the C fiber trail begins. It is a long and arduous journey up to the thalamus and the cousins of Angry Impulses, the Really Ticked Receptors, are beginning to shout as they close in on the thalamus. “You think you know pain? Well, wait till we get there! We’ll show you pain all right! Today, tomorrow and forever !” By the time the Really Ticked Receptors arrive, they are livid. The show is convincing. The thalamus is just about to send them on when , suddenly, out of nowhere, a massive onslaught of anti-pain demonstrators arrive. Some from the joints, some from the skin and still more from muscles and tendons. These feel good crusaders are masters at persuading the thalamus to see things their way. They cajole, beg, yell, purr and whimper until finally the thalamus concedes. Ah, there goes the pain. We’re all just friends up here now. Just friends cruising through the cranium on a Golden Thread having a most enjoyable ride. Until the next pain train arrives.

Make Today Count.

DK

What's Your Vector, Victor?

Sometimes things just don't make sense. Take for example the common scenario of knee pain secondary to patellar tendonitis or perhaps "patella-femoral syndrome". I have seen a number of referrals with the instructions "strengthen the quads" or "push strength" along with " 6 sessions only". After thinking about that, I have a few questions:

How do I strengthen a muscle if the effort produces joint or tendon pain? To produce muscular strength, don't I have to take the muscle to the point of exhaustion? And if the effort is painful, am I truly taxing the muscle or am I stressing something else?

Assuming I can produce muscular exhaustion, how long does it take to produce muscular strength?

What is muscular strength?

Does it matter to my muscles whether I gain that strength in any particular manner? In other words, are my muscles a non-discriminating group? Are they an equal opportunity functional employer?

These are things that keep me up at night.

Muscles are highly discriminating. Ask my muscles to do one thing and I will learn how to do it really well like cycling. But, ask for a run in a 10k race after spending my training time cycling and I'll be lucky to finish 2k of it. Even though the muscles I used in the cycling are exactly the same muscles in running, the training effect of cycling has little transference to running. I am what I do.

The challenge is to change physical function not from "strength" but from neuromuscular learning. The good news is that practically anyone can do it. To better understand this, I conducted a small experiment a few years ago. I asked a student (a great resource for experimentation by the way) to serve as a subject for my study of the quadriceps mystery. I attached surface EMG electrodes to the right quadriceps. I then asked my student to perform a maximum, volitional isometric contraction of the quadriceps to produce a baseline EMG reading. I used this to later reference electrical activity during other tasks.

Next, I instructed my student to step up and down a 9 inch step while I recorded the EMG activity. I discovered that to step up and down the step, my student used about 50% of her maximum volitional capacity. She had therefore a considerable amount of "reserve" capacity if she needed it. I then recorded EMG activity during the following exercises:

Quad sets - EMG activity was 20% of maximum

Straight Leg Raises - EMG activity was 25% of maximum

Full arc open chain knee extension with 10 lbs resistance - EMG activity was 38% of maximum

Stepping up a step with a 5lb force pulling to the right applied at the waist - EMG activity was 80% of maximum

I discovered when I applied a second line of force, a vector, the EMG activity was much higher than any of the other tasks. When I tried this with patients, I found many of them with "anterior knee pain" were initially unable to step up and down a 9 inch step. But if I applied the second line of force, the step became pain-free. I was then able to "push strength" but do so in a functional and pain-free manner. I had found a way to take advantage of the body's inherent learning ability and accelerate it. This technique has worked literally hundreds of times in my clinic as well as others around the country.

The next time you see a patient with "anterior knee pain", try adding a second vector. What do you have to lose? You might just surprise your client and yourself.

Make Today Count.

Doug Kelsey
Author. Teacher. Therapist.

So, What Exactly Is the Problem?

“It hurts right here,” as Jim pointed to a region of his lower back extending down over the right side of his sacrum.  “I’ve had this thing for a while and now it’s really getting in the way of things,” he said.

I talked with Jim for about 30 minutes using my standard set of questions: who, what, when, where, how and why. The following story unfolded: About two years prior he moved his household and did much of the heavy lifting.  About two days after the move, he noticed an intense pain in his lower back and pelvis.  Any bending or turning was very painful as was the use of his arms.  The pain subsided upon lying or sitting down, but he could not stay in one position very long.  If he did, he noticed soreness and stiffness in is back.  He took some over the counter pain relievers and anti-inflammatories for a few weeks and tried not to aggravate his back.  Slowly, he began to feel better but whenever he exerted himself, such as in raking the lawn or house cleaning, his back would hurt.

Jim was otherwise in good health. However an interesting discovery was made during the interview.  About six years ago, Jim underwent spinal surgery for a herniated disc at L4-5.  From his perspective, he recovered from the surgery (this becomes an important piece of information a bit later on).

On physical exam, I found very little:
Tender to palpation over the region of the right side of the sacrum and lateral to L5.
Pain with resisted rotation of the trunk right and left
Pain with sidebending the trunk to the left
Trunk flexion 46 degrees and mildly painful

So, what is Jim’s problem?  Since his complaints and history did not suggest anything ominous, let’s think about his complaints from a functional perspective. He has pain with movement and an increase in pain with an increase in tension loads (the pain with resisted trunk rotation).  This could occur with joint disease since the contractile forces also load the joint surfaces, but Jim’s symptoms subside when he sits down.  Most individuals who have lumbar joint disease do not like to sit.  He also hurts mostly with activity that is inconsistent with joint disease (activity causes symptoms to subside then increase later after the activity stops).

After lumbar surgery, a large percentage of people experience atrophy of the multifidus muscles.  Depending on the type of surgery, the muscle may even be resected.  Just as a reminder, the multifidus is the single largest, secondary stabilizer of the lumbar spine (primary stabilizers being intervertebral disc and ligaments).  It is only palpable below L4 and it is most superficial over the sacrum.  It serves to guard against anterior-posterior gliding of the vertebral bodies.  It is an anti-shear muscle. Jim has all of the classic signs of tendinitis. If his complaint had been in the shoulder, we would have easily identified it. But, how often have you had a referral for multifidus tendinits?  I’ve never had one.  Ever.

Based on the evidence, I suggest Jim has multifidus tenditinis as at least one of the components to his problem. If you can treat tendinitis elsewhere in the body, surely you can treat it in the spine. The question is how?

Stay tuned.  We’ll cover that part next week.

Make Today Count.

Doug Kelsey
Author. Teacher. Therapist.