Lightning Fast Reflexes is Not just to Athletes

We wrote about proprioception a while back and how it gives us a sense of where our body parts are, relatively to each other. Besides helping us have the right posture, it is a key element that enables us to move around pain-free and accident free. Without it, we will won't be able to move about without falling down and twisting our ankles all the time. We generally don't think too much about our ability to move, walk about or even typing on the keyboard as we are doing now writing this article. It just happens.

Source: Flicker
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In fact, if we had to think about it step-by-step, we would get swamped by the amount of instructions we need to give at precisely the right time. Thankfully, we don't have too. Our brain does it automatically for us. And this happens partly again due to proprioception. Your brain essentially senses the all the huge amount of changes that is happening and making autonomous decisions based on the information patterns it receives. Somewhat like cringing just before a crash. Your body prepares for the event autonomously. Not something you consciously do. If you had to think about it, it would likely be too late. "Hmm….should I brace myself now? Looks like I am gonna crash into that wall."

How is this relevant to injury prevention?

There are usually several reasons why we hurt ourselves in cases of back pain or ankle sprains. We simply over exceed our bodies limits. Stretching or strain a muscle a little too much or far in the case of back pain or rolling your ankle a bit too much in the case of ankle sprain. These things happens because we over do it and our muscles that support the back or ankle is simply not strong enough or doesn't have enough stamina to hold out. Scrambling around a basketball court for 10 minutes is fine but after an hour, your risk of hurting yourself increases. Hence the usual prescription to strengthen and develop these muscles.

But this is only half of the solution. Yes, we need stronger muscles and greater endurance. But like cringing before a crash, if it happens after the crash, it doesn't help. This is very proprioception comes in. Your body needs to know that it is in a critical situation and needs to react. Your muscles supporting the ankle needs to fire at the appropriate time and in the right sequence to hold up the ankle as you scramble all across the court. It needs to react very quickly and autonomously. This is where proprioception training comes in to complement strength-and-conditioning training.

For a start usually after an injury, you can start off with balance training. This typically involves you training to maintain your balance on some form of unstable or wobbly surface like a balance board, gym ball or even a bosu ball. This doesn't seem like a tough workout but remember that we are training your 'brain', not your ankle muscles.

Another type of proprioception training can be found in plyometric training. Like what is show here in this video

Plyometric training is typically used to developed explosive strength. But the exercises done in a rapid sequence and usually in an unstable-wobbly environment is useful in teaching your brain to cope with sudden changes.

So remember, strength and endurance is important in injury prevention but don't neglect your proprioceptive senses that tell your muscles what to do.

Stretching for Tennis Elbow video

After understanding the mechanism of the tennis elbow, the following video is a demonstration of a great stretch to release the tightness of the elbow extensor muscles.

The Deadly Lure of Comfort

If you have been in our clinics, you might have noticed us telling our patients stand straighter for us to check their posture. And them retorting back, "But I am standing straight!". And the look the utter disbelief when we show a photo we snapped of them and the accompanying remark, "But it felt like I was standing straight." That's proprioception gone wrong. So what is the sense we call 'proprioception'? Why does it lure us astray?

Proprioception

Proprioception is essentially an awareness where your body parts are located in space relatively to each other. For example, even if with your eyes closed, you are able to to touch the tips of your index fingers together. You are able to do this because you have a sense of your fingers are relatively to each other. Even if you missed the first time, you are able to quickly correct to the 'near' miss.

So how does the body sense where it is in space relatively to each other? The most well known component is the inner ear that gives us our sense of balance. But how do we know where are index fingers are relatively to each other?

We have nerve receptors embedded in our muscles and ligaments. These proprioceptors sends signals to our brain about the various states each of our muscles and ligaments are in – how taut? how slack? Our brain takes in all this information and processes them. It is processing that fools us overtime.

Source: University of Colorado at Boulder
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If overtime, we believe our current posture is the correct upright posture the brain will recognise the current set of 'information' received from the proprioceptors as to mean 'a good upright position'. This doesn't have to be true.

It is just what we believe to be true. There is no absolute value from the proprioceptors that tells the brain where exactly but rather the pattern of signals it receives that it interprets as a particular positions in space relatively to another part of the body.

And when someone else corrects your posture and tell you that this is the 'correct upright' posture, your brain tells you different because it doesn't feel upright either your lean too far forward or your head is pulled back too far. It just feels odd.

Re-learning and re-intrepreting the senses

Thankfully, we don't have to live the odd sense of something not being right. We can re-train our brain to learn, "now, this is the correct posture" This like a habit, takes practice and persistence. It won't happen overnight. Overtime we can teach our brain to recognise a new set of patterns as the correct posture.

Also remember that your body adapts to a particular position to overtime. So some of your ligaments, joints and muscles might be too tight, slack, stiff, loose or tense. This will cause discomfort in the new 'correct' position. A classic example is women who wear high heels. Their ankle tendons have shortened and thicken to the point that it is unbearable for them to wear flat shoes anymore. Even when un-shod, you are likely to see them tip-toeing around as though they are wearing heels.

These issues with your joint, tendons and muscles can be addressed by your therapist with treatment and training. Simply standing upright in the correct posture will not immediately address these issues.

So remember just because a particular posture or gait feels comfortable, it may not be the right one. Get someone experienced and trained to observe you as a independent party. Don't trust those proprioceptors (at least not all the time). The same goes when choosing an 'ergonomic' appliance. Be mindful that while it feels comfortable, it might be to right for you. Don't be lured in.

Why get manipulated in the first place?

A few months ago in April, we wrote about the risk of VBI when getting your neck cracked, "If you like getting your neck ‘cracked’ or thinking about it, you should know about VBI", a group of researchers from the University of Sydney in collaboration with University of Queensland found that that neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

Project leader, Dr. Andrew Leaver from the Faculty of Health Science, University of Sydney said, "It makes us question why patients or practitioners would favour a treatment which possibly carries risk of catastrophic outcome over an equally effective one with very few reported complications despite widespread use."

So why do then patients seem lured towards neck manipulation?

While over the longer-term results from the mobilisation and manipulation approach is identical, the short-term relief that manipulation provides can be a mis-leading siren song. Patient generally immediately feel better after a crack compared to the more gentler mobilisation. But the VBI risk doesn't seem to be worth it as little is done to improve the underlying functional problem. In fact, it opens a door towards excessive frequent weekly 'cracking' session to sustain the pain relief.

 

Reference:

  1. Controversial study suggests neck manipulation not worth the risk, University of Sydney, 9 September 2010
  2. A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain, Archives of Physical Medicine and Rehabilitation – Volume 91, Issue 9, Pages 1313-1318 (September 2010)

Exercise with Brace

What are some of the facts about exercising with scoliosis brace?

If you are wearing a hard brace:

  1. Due to the weight and movement restriction, you will have to change the way you do sports or exercises. For example, if you used to run, you probably will have to run for a shorter distance or run at a slower speed;
  2. Exercises that require many trunk movements will likely to be difficult;
  3. You may tired out sooner too because of the pressure on the rib cage which affects chest expansion during breathing;
  4. You may need to exercise at a cooler time of the day as it will be hotter to exercise with the brace;
  5. You need to be careful with the skin condition at which the pressure is applied to control the curve; this too may affect how much and the kind of exercise you can participate in.

So…most likely, if you need to exercise like before, you need to keep the brace off.

If you are wearing soft brace:

There will be minimum movement restriction. It is less hot and less likely to cause skin problems. All kinds of land exercises (such as cycling, badminton, and dance) are encouraged as exercising with the brace on speeds up the curve correction. Soft brace also allows much better muscle retaining and joint mobilization, which has a great impact on curve correction retention after the brace treatment is over.

How do I know what exercises are good?

  1. Exercises that are designed to work specifically on muscle imbalance, posture faults are more beneficial than general exercises like swimming, jogging, generic yoga & back stretching exercise; the reason is that general exercises usually fail to stress the “imbalance” in scoliosis, either for strength or flexibility;
  2. Swimming is good to unload the spine and improve the breathing function; it may also help to reduce back pain that results from excessive loading or tension;
  3. Correct breathing techniques are important as rib cage deformity is common in scoliosis;
  4. In order to specifically work on the muscles affected, the curve of the scoliosis needs to be assessed, the posture changes need to be analyzed in details;
  5. After the study of the curve type and the posture changes, specific movement can be taught and implemented to work on the faulty muscle and posture development;
  6. The exercised then can be progressed with resistance or more repetitions;
  7. Do not perform general weight training for scoliosis, as those usually only works on the muscles that are being used all the time and are already strong, and the weak ones will still remain un-used and weak!

Surgery: The Machine Analogy Misconception

Source: 62 mile club
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Surgery as a treatment option brings up a lot of mixed emotions amongst patients. Often it is seen as the last resort. Something that carries with its risks and pain but should definitely work. This ties in with our sense that something complicated and riskier should be better than something simpler and risk-free. This creates an unrealistic expectation of surgical procedures to deliver miracles. Recently, Spine discuss several articles on how back surgeries fail.

Of course, as with most things, there are always two sides of the story. There will be surgical cases where too much was promised, too little delivered. But often too, there is a case of the patient simply expecting too much either refusing to understand the risks and possible outcomes or simply (which often I believe is the case) the patient not having a firm enough grasp of the situation and implications.

As this is a musculoskeletal site, lets focus on orthopaedic surgeries as an example.

First of all, what do surgeries generally achieve.

Most of the surgeries, do one of the four things below.

  1. The removal of some part that causes an obstruction, impediment or impingement – for example – disc bulges (Removal)
  2. The replacement of some part that has failed or deteriorated for examples spinal discs (Adding)
  3. The strengthen of the some part, for example – adding cement into vertebral body. (Enhancing)
  4. The weakening of a part, for example tight muscles or severing inflammed tendons in the wrist (Weakening)

Complicated surgeries will combine two or more of these things. All of this seems simple enough. So where do we go wrong? Our tendency to over simplify the situation.

One of our most common tool we reach for to understand something is comprehension through analogy. We use somewhat similar alternative to explain key concepts. Like the human heart is the "engine" for the human body. The eyes are like video cameras. This helps narrows the gap in our understanding of new complex idea or concept. Unfortunately, analogies can sometime mislead us.

One common area is spinal disc replacement (Removal and Adding). Patients are often surprised that the new hi-tech disc doesn't work as well as their original human discs. Unlike, cars or computers where parts are easily replaceable. In fact with very specific numbered replacements parts. Parts in machine are relatively simple and have very precise functions and operated within a very specific range of conditions. Not so for the human body. In our human body, each part usually have several functions and interacts with the rest of the body in very unique ways. This helps us to be adaptable to our surroundings. Currently no replacement spinal disc has the same degree of freedom movement as a real human spinal disc. This implies a slight impairment to your body's actual biomechanics. Something and somewhere else will adapt to compensate for the slightly reduced degree of movement.

Also often fixing the faulty part does fix the underlying problem. In a machine when a part fails, it is usually because of poor quality rather than the machine operating beyond its specifications (thought that does happen. In fact, some machines are designed with some parts to be the designated failure points so that it is easily replaced and cheaply). Replacing a poor quality part if easy and usually eliminates the problem. But in the human body, parts fail not because of poor quality but often somehow it is not being used in the correct manner. Like sitting a poor posture leading to back pain. Solving the pain is only a short term solution if the external cause – poor posture is not corrected. This situation occurs less frequently for machine. Machines are usually used for the purposes they are designed for. If your coffee maker is crushed because you used it as a door stopper is not something covered under the manufacturer's warranty.

While some machines are large and more difficult to build (not something you can hammer out at your workbench) doesn't mean they are complex by any means. At least not relative to human body. Complex machines are far more difficult to repair and a point of failure can have far reaching and heavy consequences. Something that is beginning to show up in complex systems that we are building. So use analogies carefully. They help us understand a new complex topic but remember it is no substitute to actual understanding. Take you time and find out as much as you can about your pain and condition, and especially the solutions proposed.

Stretch.. Stretch.. Stretch your Fascia..

Do you know why you need to stretch your body? Let Gil Hedley tell you more about the importance of stretching to prevent "fuzzing" of the fascia.