Protected: Shoulder Rehab Slide Presentation
Shoulder Rehab: Activity, Exercise or Training?
At the Queensland Physiotherapy Symposium on Saturday May 15, I presented a short talk on the difference between slow twitch muscle fibre rehab and fast twitch muscle fibre rehab in regards to the shoulder. Sounds boring, but several people told me they really enjoyed it and learned a lot. The core message was for us not to be satisfied with basic rehab which trains our clients to be very good at slow twitch activities (posture, low load movement, balance, control) but instead seek to to train them to a higher level of function in preparation for the unexpected loads that are associated with injury. Yes, shoulder injury occurs at speed and with unexpected loading so training the fast twitch systems in the shoulder muscles and movements will help build in a greater level of performance and protection.
To access the slide presentation and cover notes click on the appropriate link below:
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Living Longer – I want it earlier!
A few years back, a couple of authors (Evans and Rosenberg) came up with the 10 biomarkers of ageing. These were 10 physiological characteristics which changed with the passing of the years. Their list comprised muscle mass, strength, basal metabolic rate, body fat percentage, aerobic capacity, glucose tolerance, cholesterol/HDL ratio, blood pressure, bone density and temperature regulation.
Two things are interesting about this list
- The biomarkers of disuse make up the same 10 factors
- Nine of the ten markers can be improved by working out in the gym (not sure about temperture reg.)
In other words, you can hasten your physiological deterioration by inactivity, and slow the (currently) inevitable changes by doing resistance training and remaining active. The anti-ageing pill is actually PHYSICAL ACTIVITY!
Our chromosomes are built to survive for about 120 years. This is the potential life span we are each born with. These tiny strands of information will reproduce themselves and maintain our body and brain for up to 120 years before their batteries run out. Obviously we don’t all live to such a great age. From conception, when our genetic makeup is established, begins a process of subtracting seconds, minutes, days and years from that 120 year potential lifespan. Our fragile internal ecosystem that is constantly trying to rebuild and maintain its structure and function battles against all sorts of factors that progressively shorten our lives.
Factors such as maternal nutrition while still in the uterus, infant diseases, nutritional excesses (sugar and fat) and nutritional deficiencies (vitamins, minerals, anti-oxidants), exercise or lack of it, stress, smoking, toxic environments or relationships and the list goes on.
Every day your body is rebuilding and replacing it’s entire substance. Cells are being retired, dismantled and rebuilt every breath you take. Your heart muscle is replaced, your bone structure is updated, your skin shed and rebuilt. The raw materials for this project comprise whatever goes into your mouth. Your body is rebuilt using what you eat and drink! Your choice is whether to go with the budget or convenience materials (sugar, fat, fast foods, processed foods, refined products) OR to select the premium ingredients (fresh fruit, vegetables, lean meat, nuts, legumes, pulses, water and all freshly prepared) to build your new cells. I think many of us spend more time and energy researching our electronic equipment or vehicles and making the best decision than we do on how to rebuild our bodies with the healthiest and strongest cells and DNA possible.
Scientists (bless their cotton socks) are working to extend the duration of human life. To increase longevity toward our potential 120 years. Obviously they are having success – more of us are living too 100 years old. Improvements to public health and hygiene and eradication or control of some nasty diseases have already produced results. But I think they are going down the wrong path.
If I was looking to extend my life span, I wouldn’t be tacking on 10 or 20 years at the end. I want my extension much earlier than that. I want another 5 years of childhood. And another 15 or so years between 30 and 35 please. That’s where I want my extra twenty years: during the free and fun years of childhood and the years I missed and messed by concentrating on work, status and money instead of enjoying my kids growing up and savouring every moment with my older parents.
But in the mean time, I’ll just keep replenishing my DNA with high quality nutrition, get a bit of exercise, try not to get too stressed and enjoy whatever extra time comes my way. As my mum always said, ‘Eat your vegetables, go out and play.’
Who needs scientists?
The Pain, in the Main, is Completely in the Brain.
Benedict Spinoza, a centuries old philosopher, described pain as ‘a localised form of sorrow’, and in just a few words summed up the physical and emotional components of pain.
I heard Dr. Lorimer Moseley, esteemed pain researcher, speak at a conference some weeks ago and he made the point that all pain is perceived in the brain. There is no pain in your leg, or shoulder or chin until your brain collects the signals and assembles them into a pattern you then label as pain.
Why am I writing on pain? Because I can’t sleep. I have had surgery on an arthritic toe and my brain is paying particular attention to it. In fact it has told me to interpret the sensations as pain. And to stay awake to keep an eye on it. In fact, I suspect my brain has allocated a larger ‘toe pain’ monitoring area to make sure it doesn’t miss a thing.
This is what the brain does. If something is deemed more important it will allocate more resources to monitoring. It is particularly good at this in regards to pain. It happens at other times too, for example if you are learning a new language, or a musical instrument or a new skill the brain will find some underused nerve cells and press-gang them into service to provide more computing power for the new activity.
This is phenomenal, but it gets more interesting. As you gradually master the task the brain makes wiring efficiency changes and dismantles the extra zone bringing control back to as few nerve cells as needed. Freeing up the extra computing power for another adventure!
That is not what I wanted to discuss, however. Back to pain. In my previous career as a physiotherapist I treated clients with new, fresh painful injuries and also those poor souls with long-term, chronic, persistent pain. This second group initially had an injury, but their pain had not disappeared as the injury recovered. Their back, or whiplash, or tennis elbow had healed but the pain remained in the brain.
I loved treating these patients, perhaps because I had nothing to lose. Their expectations of successful treatment were poor as many practitioners had failed before me! However, for some we had great success. They returned to work and sport, they resumed gardening and other yard work and they started a fitness program.
Sounds great, but not one of them got rid of their pain. But it was OK, because I told them on day one that I would never cure their pain but I could offer other life improving enhancements. Simply put I told each of them, ‘Today is the day you choose between two lives. A life of pain and disability, or a life of pain and living life to the full. Your choice.’
Most were stunned, having come in to get pain relief, many were disappointed, and some were really pissed. Many of these clients went away, thought about my offer and never returned. I was sad for them but not surprised, they were just not ready for my approach. The clients who took a leap into the unknown and decided to give it a try were fantastic. They were courageous, frightened, anxious and desparate.
We had some great outcomes, and some didn’t complete the journey. I wished them well and hoped they would find their answer elsewhere. For the stayers, I set about reprogramming their brain using activity, words, gestures, encouragement and leadership. But not much empathy! When ever they tried to tell me about their pain I pointed out that I wasn’t really interested, and couldn’t treat their pain. And refocused them on to getting fit and healthy.
Know what? As the brain allocated more resources to learning new exercises and skills, as it got the occasional dopamine shot (your pleasure chemical in the brain) with success, it paid less attention to the signals previously interpreted as pain. The brain stopped listening intently for pain, and instead got excited about doing things again.
And it has worked again. After writing this post, my toe pain has all but disappeared. Time to go back ..to…… bed…… and ……..sle….
The Danger of Knowing
I wonder if we ever really know as much as we think we do. A recent article in Spine (1) looked at GPs with a self described special interest in musculoskeletal or occupational health medicine and their management of patients with low back pain. The conclusion drawn by the Australian investigators was, ‘A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community.’ In other words, those GPs who believed they were more ‘expert’ were actually the opposite!
It got me wondering about the risk of ‘knowing’ something so well that we cease to refresh or challenge our knowledge base.
For example, I have a special interest in shoulders. I have written and taught about shoulders for over twenty years. Yet, how many shoulder workshops have I attended that I didn’t actually lead? Maybe one every couple of years. Post-graduate university teaching and delivering at large conferences have obliged me to try and keep up with other work, but I am only human. And one of our human limitations is the ability to blind ourselves to new information when it suits us. To hold a strong position and then avoid, disregard, mis-interpret or bend new information so as not to rock the conviction already held. I love finding research articles that support my clinical observations and the foundations on which I treat patients. I share these papers, use them in my reference lists and acknowledge the wisdom of the researchers. Upon reflection I suspect I treat papers that don’t resonate with my beliefs and practices somewhat more cursorily. Beyond that, I am sure many colleagues jump on the very papers I underestimate and embrace them enthusiastically because they experience a resonance with them. Academic rigor in research demands a review of relevant published work even those not supporting hypothesis. To keep an open mind pending the outcome. Outside of the research environment there is no such imposed balance.
Knowing stuff can be dangerous. You can retreat to a comfort zone of ‘well that’s that, I understand it now’ and cease to be open to new, different, complementary or even opposing views.
Knowing stuff is cognition. Knowing that your knowing is incomplete and is subject to your attitudes, prejudices, bias, expectations and experience is meta-cognition – the ability to rise above your ‘knowing’ and perceive that your knowledge base is a mere speck of sand on the wide beach of what you do not yet understand. Maybe this is the difference between knowledge and wisdom.
Just like the GPs who believed their ‘special interest’ afforded their patients an advantage, I suspect any complacency in our information quest will impact on our patient care.
That said, I am now going to register for a shoulder workshop…
1.Buchbinder et al, Spine: 15 May 2009 – Volume 34 – Issue 11 – pp 1218-1226
Want to stay healthy? Avoid Hospitals!
Apart from the obvious fact that hospitals represent the greatest concentration of unwell people and thus are a risk by association, there is another reason: things don’t always go to plan in a hospital.
Sure, they don’t always go to plan any where, but in a hospital the consequences can be most unfortunate. Is this a big problem? In NSW during the 2005/2006 reporting year there were 499 highest level adverse ‘significant incidents’ out of approximately 1.5 million admissions. This represents a one in 3000 chance of a serious incident occuring. I wish I had those odds in the lottery! What is a ‘serious incident’? They are things like retained instruments, wrong site/wrong procedure, suicide, medical device or equipment failure, medication or blood products problems and falls.
It is impossible to remove the ‘human’ from ‘human error’, but avoiding a one in three thousand chance of disaster seems a great reason to avoid a hospital admission. How? By taking more personal responsibility for staying well. By making better decisions on a daily basis about nutrition, activity, stress, work, relationships, sleep, play and joy. Seems simple enough, which it is. Simple. But not easy. If it was easy, we would all be healthy, lean, strong, have good skin and smile more. There is much in our lives that will (and does) undermine our noble attempts to make good decisions.
I hope never to become one of the ‘health police’. Those that advocate their health models with no consideration that life is here to be lived – not just regulated. Health decisions should also allow for fun, sensations, excitement, ambitions, relationships, experiences, risk and joy.
However, removing a one in three thousand chance of disaster seems a very good reason to avoid hospitals. And the best way to avoid them is to stay well. So eat your vegetables, and go out and play. It’s not rocket science.
‘Which Pillow is Best?’
I must have been asked this question about a million times during my time as a clinical physio. Plus another half million at various social events! Perhaps I am exaggerating, but it sure is a common question from clients with neck pain; especially neck pain that interrupts sleep quality.
In my attempts to find the ‘perfect pillow’ I have recommended and sold many different pillows in the clinic – feather filled, contoured, tri-compartmental, latex, mixed, kapok, foam and probably a few others. I have just had a look on Google and pulled up a whole new range from which to choose – Euro pillows, boudoir pillows, Lap pillows (shaped like a lap!), Pirate pillows (true), traction pillows, pillows filled with silk or wool, pillows that play music and even one that has an inbuilt alarm that lights up as it wakes you! None of which will probably help my clients.
Research on the optimal pillow is not strong. However Dr. Sue Gordon (a physio at James Cook Uni in Townsville) has done extensive research on sleep position and waking neck pain. She found that ‘subjects who reported that they slept mostly on their side were significantly less likely to report waking cervical pain or waking scapular or arm pain compared with subjects who slept in any other position (1). This is useful, but still doesn’t address the ‘which pillow’ question.
So I got thinking – a lot of my advice to clients when trying to change pain patterns associated with position is to ask them to avoid sustained positions. To move the body area that is painful. This alters postural loads, changes lengths of structures, pumps fluid through the area, dampens the incoming pain signal by stimulating proprioceptive afferent nerve fibres, distracts them and gives them a degree of control as opposed to being a ‘pain victim’. Might not the same idea apply to pillows and neck pain?
For the last year or so my response to the ‘which pillow’ question has been ‘your next pillow’. My advice is to have two or three different pillows and to rotate between them on a two to four weekly cycle. My idea is to prevent them using the one pillow style for long enough to adapt to the particular support mode and posture associated with that pillow, and instead introduce a different support/posture interface on a regular basis. The short turnaround seems to reduce the initial discomfort of a pillow change and the regular change might be the equivalent of a postural position change in (say) a workplace situation.
This is in no way a thorough study on pillows and neck pain. But my initial impressions are that this system firstly does no harm and secondly can improve waking pain and sleep quality in some clients. Whether this occurs at a higher rate than placebo or another intervention I cannot say. I will leave this up to a research minded colleague to determine.
Meanwhile I would be interested in any feedback from clinicians out there as to whether they have tried anything similar, or indeed a different strategy that has proved effective. Feel free to leave a comment, below. Meanwhile, Dr. Gordon has some useful information on pillow types, selection and sleep facts on her website – www.wakeupbetter.com
1. Gordon S.J., Grimmer K.A., Trott P. 2007 Sleep position, age, gender, sleep quality and waking cervico-thoracic symptoms. Internet J. Allied Hlth Sci. & Prac. Vol 5 No. 1.
Work Life Balance…..
I love motorcycle touring. Today I met up with a bunch of like-minded mates and we took off for 300km around the hinterland of South Eastern Queensland, Australia. Stopping for ‘smoko’ and lunch gives us a chance to tell a few lies and laugh at a few stories. Later this month I am combining motorcycling and work when I conduct my first workshop tour ‘on the road’.
Travelling south as far as Canberra, I will be delivering twelve “BizFizz’ workshops for private physiotherapists in rural New South Wales. Four or five hours riding each day through some of the best motorcycling road in Oz, then after a walk, some exercises and a feed – four hours on the business of physiotherapy.
Combining your passion with your work transforms the way you feel about your ‘job”. Sometimes the links are obvious, sometimes it takes a little more innovative thinking. See how you go.