Congratulations to Lillie and James
My gorgeous sister Lillie is getting married today, to her fiance James, in the tiny church in the village of Kettlebaston. It's the smallest church I've ever seen: I doubt you could fit two abreast down the aisle, and cramming 100 guests inside will be one heck of a squeeze. Perhaps that's why Lillie and James' is only the third wedding there that the vicar can remember in the last fifteen years!
My bridesmaid dress is sorted, and I have a slinkier number for the evening - when I fully intend to dance the night away to the smooth vocals provided by Black Hat.
I *think* it's going to be a lovely occasion for friends but even more for family. Our grandmother, the fabulous potter Janet Allan, is growing confetti in her back garden. Our aunt and uncle, Lis and Steve Henderson, have offered to host a "first day" lunch at their lovely home at Landermere - where various other members of our family intend to set up camp for the weekend! Lillie and James: congratulations - and, James: welcome to the family!
xxx
Rewards for Forces
An interesting conversation on Twitter the other day led me to contact Peter Raith at Rewards for Forces, a benefit website for serving and veteran members of the Armed Forces.
As you know, I used to be a Physiotherapy Officer in the Army. It was a period of my life that I really enjoyed, and I'd recommend it to any young physiotherapist with a strong interest in sports and training injuries, as they offer superb opportunities for both in-house and external training with unrivalled access to physically fit and motivated patients to practise on!
Although I've obviously now left the Army and moved into private practice, I still have strong links with the military. Many of my friends are still serving, and as I blogged recently, I'm still involved in getting the Mobiliser into standard usage in military physiotherapy departments. As this post goes to press, I'm even in Aldershot myself, partnering former Papua New Guinea international Lawrence Tere in the mixed doubles section of the Army Tennis Championships! Perhaps, to bastardise a common phrase, "you can take the girl out of the Army..." etc.
At any rate, I'm still very sympathetic to the needs of the military patient - and conscious that nobody joins the Forces to earn a mint. And as far as I'm aware, there aren't any physiotherapists working with the Armed Forces who practice the Sarah Key Method, which I believe is one of the most effective and patient-centred systems available. So I'm delighted to announce that I'm now able to offer a discount to self-funding serving and veteran members of the Armed Forces of 20% off all physiotherapy assessment and treatment sessions. All you have to do is to sign up to the scheme and present your Rewards for Forces card at your first session.
Membership of the Rewards for Forces scheme costs £12 per year, and at current Victory prices, our discount will give you £30 off your assessment and £20 off each subsequent treatment session... surely a no brainer?
I look forward to seeing you; please e-mail me to arrange a session.
Knees and pelvises - what to do about them
In my last post, I explained how having a stiff and unyielding pelvis can be a real pain in the knee. But it's not fair to leave you hanging, so here's the solution.
The first step is to release the tightness in the low back and pelvis joints. To do that, you need to release the surrounding muscle spasm and then stretch out the muscles and ligaments that are holding the joints so stiffly. This will help to flush out the joints, encouraging the synovial fluid inside them to become more liquid and less viscous, allowing more nutrients in and more waste products out.
At Victory, I release the low back and pelvis joints using my feet, in line with the Sarah Key Method. This is quick, effective and quite gentle, and it gives a "kick-start" to the exercises, which allow you to maintain and improve on the changes we achieve in the treatment session. However, in many cases it is also possible to make significant gains with just the exercises.
Therefore, for home treatment, the two exercises I really recommend to release the low back and pelvis are the appeasing exercise and a variation on the back block exercise. Alternate them, doing three sets of each exercise for 30 seconds each, 2-3 times per day, and your pelvis should soon start to free up.
The variation on the back block exercise is that instead of placing the block horizontally under your pelvis, this time I'd like you to place it vertically - so that it points down towards your feet. The upper end should still be under your pelvis though, not under your low back. Then, once you've lowered your bottom onto the block, instead of sliding your feet away from you, just drop your knees apart, something like this picture from the Egoscue website. If your adductors (inner thigh muscles) are tight, you may well feel a stretch there; if they're loose, you'll feel a stretch at the back of your pelvis as the "wings" stretch apart. Hold the position for 30 seconds before drawing your knees back together, removing the block from under your pelvis, and resuming the appeasing exercise.
The second step is to stretch your hamstrings, with particular emphasis on the distal (knee) end. Traditional hamstring stretches, where you bend forward with knees straight, focus on the proximal (hip) end of the muscle; but people with knee pain tend to be tighter near the knee.
To emphasise the distal end of the hamstring, you need to start with your hip fully flexed, and then gradually extend the knee. So, as demonstrated here by the lovely Graeme, stand in front of a chair (preferably one without wheels!) and place one foot on the seat. Bend forward at the torso and get your chest right onto your thigh. Hug your thigh tightly with both arms, so that your chest stays attached to it throughout the stretch.
Gradually lean your bodyweight backwards so that your raised knee starts to straighten out. Go as far as you can, until you feel as though your chest wants to lift, then hold the position for 10 seconds. Release slightly and then lean back into the stretch for a further 2 x 10 seconds, then repeat with the other leg.
Another really useful treatment is massage. You may well find that you have tight, sore trigger points in your buttocks, hamstrings, adductors and/or iliotibial bands (fascia that covers the outer thighs). Stretching can be significantly aided by massage to get rid of these small localised areas of muscle spasm. You can either get someone to help you with this (if your helper is not a trained therapist, ask them to start gently and work their way in: kinder and more effective than an aggressive pounding!) or you can self-treat using a foam roller. I really like this comprehensive YouTube video from Alex Poole that shows some effective foam roller techniques.
If you would like to get rid of your knee pain (whether due to the pelvis or not!) please e-mail me to arrange a session and see how I can help you.
Dem bones, dem bones... Knees and pelvises
Dem bones, dem bones, dem dry bones
Dem bones, dem bones, dem dry bones
Dem bones, dem bones, dem dry bones
Hear the word of the Lord
Toe bone connected to your foot bone
Foot bone connected to your ankle bone
Ankle bone connected to your leg bone
Leg bone connected to your knee bone...
OK... you've probably heard a verson of James Weldon Johnson's spiritual somewhere before, and while it's not technically accurate in its anatomy, the concept (that everything in the body is linked and works together, rather than a body being a collection of separate joints) is one I reference a lot.
Today I'm going to talk about the link between knee pain and your pelvis - or, as JWJ might have put it, your knee bone's connected to your back bone.
The large muscles of the thigh - quadriceps at the front, and hamstrings at the back - are biarthroidal muscles. This means they cover two joints, the hip and the knee. The quadriceps work to flex (bend forward) the hip and extend (straighten) the knee. The agonist (opposing) hamstrings work to extend the hip and flex the knee. Both groups of muscles attach to the pelvis at the top, and to the shin (tibia and fibula) at the bottom.
When you walk, and more violently when you run, your quadriceps pull to swing your leg forward, as your hamstrings pay out at a controlled rate to prevent you from hyperextending and jarring your knee, facilitated by a slight backward rotation of the sacroiliac joint in your pelvis. As your foot lands, both the quadriceps and the hamstrings contract to control your landing, and then the hamstrings begin to pull to provide the power to propel you forward over your landing foot.
So far, so good. Everything is working normally; and normal functioning of joints with no structural deficits will cause no pain. But what happens when there is a glitch somewhere in the system?
The sacroiliac joint of the pelvis (between the sacrum at the base of the spine and the iliac "wings" of the pelvis) is a pretty common source of problems. There are many reasons why the sacroiliac joint can stop functioning properly - ranging from an impact injury such as a car crash or a fall, to a general poor posture which involves staying too still and not using the joint enough - but the effect generally is that it stops rotating effectively. When this happens, it impacts on the hamstring's ability to pay out in the swinging leg, and the joint's ability to absorb shock when the foot lands.
When the hamstring doesn't pay out effectively, your body will respond by altering your gait so that it doesn't have to. You'll take ever-shorter strides and your running gait will alter from a smooth glide forward to a jerky bob-up-and-down movement, which requires more shock absorption from the sacroiliac joints... and thus the cycle is perpetuated. And if the sacroiliac joints can't absorb shock properly - well, the shock of impact has to be absorbed somewhere, and the knee (particularly the patellofemoral or kneecap joint) is often the victim. In my experience, this is a very common cause of knee pain, especially in runners.
What can you do to break the cycle? You need to reverse it: get your pelvis moving, and your hamstrings flexible. I'll explain how in my next post, so watch this space!
If you are struggling with knee pain when you run, it may well be linked to a dysfunction at your pelvis. Please contact me for assessment and treatment.
Bloodgate physio free to practise again
The debate continues over the striking off of "Bloodgate" physiotherapist Steph Brennan. As I blogged before, Steph was struck off the physiotherapy register by the Health Professions Council (HPC) in September 2010 when he pleaded guilty to helping the rugby team for whom he was head physiotherapist, Harlequins, cheat by providing a fake blood capsule to one of the players on the pitch. By this time, he had already been banned from working in rugby for two years. In contrast, the pitchside doctor (who cut the player's mouth to "prove" that he had been injured) was deemed fit to continue practising by the General Medical Council.
Steph - by all accounts a superb clinical physiotherapist - appealed to the High Court against his striking off. The High Court agreed that he had grounds to appeal to the HPC; and last month the HPC (after initially claiming that the High Court had no jurisdiction) revoked its decision, imposing instead a five-year "caution period".
Since the HPC initially struck Steph off, there has been hot debate among physiotherapists as to whether striking off was the correct action for the HPC to take or whether it was excessive. Some have taken the view that Steph failed to maintain the "high standards of personal conduct" which form a part of the HPC's regulations and that he therefore deserves all he gets. My own view is that it was excessive: that Steph clearly made a stupid mistake to put Harlequins before his profession and his morals; but that the public (whom the HPC exists to protect) is not better served by banning this man from practising. He has also shown very public remorse and has clearly been reflecting on his actions, having undertaken a series of lectures to physiotherapy students on the importance of medical ethics. I am therefore very glad that the HPC has overturned its own decision.
However, I'll leave the last word to Steph, who feels that his case has highlighted not just the pressure that is faced by physiotherapists working in elite/professional sport but also the importance of withtanding that pressure and keeping a cool head under fire: "I want the profession, and most importantly sports physiotherapists, to learn from my mistakes. Sports physiotherapy is a very different role for the physiotherapist than any other job in public or private health, but that should not mean we forget our standards of ethics and practice."
Mobilising the Military
Today I took a trip to RRU Aldershot. This is the flagship of the military Regional Rehabilitation Unit network and only opened six months ago, so I was intrigued to see it; but I was also there to do some work.
As I've previously mentioned, in 2004 I designed and carried out the first piece of formal research on the Mobiliser bed, a passive spinal mobilisation device created by engineer David Newbound, the owner of the Back in Action chain of ergonomic furniture shops. My pilot study bore out the manufacturers' claims that the Mobiliser could help to improve range of movement in the spine, improve thoracic expansion and reduce pain levels in patients with back pain - and I've been using the Mobiliser ever since.
Finally, it looks as though I am winning in my battle to have the Mobiliser recognised by the military as a therapeutic tool, an adjunct to physiotherapy. The RAF have just bought a batch for use in their RRUs - where more seriously injured servicemen go for periods of intensive rehabilitation - and it is anticipated that the Mobilisers will be awarded NATO Stock Numbers or NSNs very soon, meaning that all military medical rehabilitation departments will be able to order Mobilisers.
My job today was to demonstrate the use of the Mobiliser to the RRU staff who will be responsible for introducing it to their practices, along with David Newbound and senior MOD physiotherapist Dr Cathy Daborn. I also explained my theories as to how it acts on spinal mechanics and helps to restore normal motion.
Essentially, the spine is able to perform large global movements such as bending and stretching, leaning forwards, backwards and sideways. But it does this with the help of a lot of very small accessory movements between the vertebrae, which slide and tilt and twist on each other infinitesimally in order to produce the obvious, big movements. Stiffness occurs when the accessory movements - the slide and the tilt and the twist - are reduced, by disc dehydration, joint disruption such as injury or by muscle spasm.
I believe that the Mobiliser - with its regular, fairly gentle but relentless repeated movements - calms muscle spasm and then (using the gravity-induced backward shear I discussed in the last post) passively pulls the joints apart to restore the sliding accessory movement. Over time, with the muscle spasm reduced and joint mobility restored, pain is reduced and function improved.
What the Mobiliser doesn't do - and this is why, particularly when there are rotational components to a spinal problem, you still need a therapist to mobilise the spine with hands or feet - is to restore the twisting accessory movements. After all, it's a machine, and not capable of intelligent touch or clinical reasoning. But it is a very useful adjunct to manual therapy and exercise therapy, and I believe is a valuable tool in the treatment of chronic spinal stiffness.
If you're interested in discussing using or hiring a Mobiliser, the best option would be to contact Back in Action, or pop into one of their shops to try it for yourself.
And if you'd like to read my original research, please e-mail me for a copy.
Why use the back block?
I had an e-mail this week from a blog reader who asked whether the Sarah Key exercises I've blogged so far would be good for spondylolisthesis.
Spondylolisthesis is a condition which affects 3-6% of the population in which one vertebra - most commonly the L4 or L5, at the bottom of the spine - slips forward on the one below it. Left uncontrolled, it produces a more exaggerated curve of the low back, like those you often see in men with really big tummies or pregnant women. The grade of spondylolisthesis is determined by an X-ray to see how far the upper vertebra has slipped - a grade I being a forward slippage of 1/4 of a vertebral body, grade II being half, and so on. Surgeons tend to get involved with grade II+ spondylolistheses as the slippage is more likely to be a danger to the spinal cord.
There is a fair amount of evidence in the literature for strengthening the core muscles of spondylolisthesis patients, particularly the transversus abdominis which acts like an internal corset, and the multifidus which acts like the guy ropes of a tent to shore up and stabilise the slipped vertebra. I'll go through some useful exercises for these in future posts as they are excellent for any form of instability, but incidentally this is one situation where I think exercise methods such as Pilates can be really useful.
As well as core exercises, I really rate the back block for spondylolisthesis patients. Traditional physiotherapy extension exercises are carried out from the prone (face down) position, where the patient pushes up onto elbows or hands to extend the spine. I don't use this for spondylolisthesis patients because gravity, as you can see from the top diagram, acts on the vertebrae to produce an anterior (forward) shear - exactly the same force that causes spondylolisthesis! Lots of physiotherapists have therefore moved away from prescribing extension exercises to spondylolisthesis patients.
By contrast, however, the back block exercises are done in a supine (face up) position. This results in gravity pulling the vertebrae towards a position of backward shear, as you can see in the lower diagram - and thus into a more neutral position away from the spondylolisthesis slip.
The effect of this tends to be (gradual, cumulative) better alignment of the spondylolisthetic segment, and also reduced muscle spasm and reduced pain.
Of course, not every case is that simple: longstanding spondylolisthesis problems often lead to altered muscle control and movement patterns, as you start to compensate for the discomfort of the injury. Using a back block doesn't replace a proper assessment and treatment plan in every case. But if your physio isn't already getting you onto a back block, it might be something to discuss.
Please feel free to ask questions - either here on the blog or by e-mail - or get in touch to arrange an appointment.
Victory and the City
Last week I took an afternoon off to join personal trainer extraordinaire Dave Thomas from The Foundry, who was playing for Citi Rugby in the Norton Rose City Scrum, a corporate touch rugby event held at the Honourable Artillery Company's grounds in Moorgate. As Dave is more commonly known as "Hospital" Dave, I was attending in the role of his personal physiotherapist - despite being a touch tournament, he was apparently carted off by paramedics last year with a badly-sprained ankle. Opting to minimise the risk, I taped the dodgy ankle firmly in place before I allowed him anywhere near the pitch!
The event did have a serious side - it's run for charity, plus I had the additional responsibility of fixing Dave and his team! - but was also a lot of fun, and the HAC is a fabulous venue. Each team is "coached" by a member of the Harlequins team (many of whom have never played touch rugby) - and this year, Citi were coached by Quins' captain Chris Robshaw, pictured here with Dave.
After a slowish start, Citi hit their stride and Dave - with a freshly flexible back and hamstrings - performed a try-saving ankle-tap diving tackle to deny UBS a win. Unfortunately, in doing so, he managed to face-plant into the sand around the try line, temporarily blinded himself, and had to come off; but the vital tackle had been made and there was no real damage to Dave (which, I confess, was a relief to his physio!)
In the semi-final, Citi played against last year's winners, JP Morgan. A stalemate ensued, and at full time the score was 0-0. Each team lost a player and they played 5 v 5 for a few minutes... still no score. 4 v 4... still no score. The teams went down to 3 v 3 and suddenly the pitch looked much bigger. Dave - on the left wing - received the ball at about the half way line. Accelerating off his right foot, he sprinted left, and - throwing an outrageous dummy - scored in the corner. Citi were in the final.
As Dave had to train some clients, we left at this point. I'm not sure whether he was more sorry to leave before the final, or happy to leave on a high. But a text message an hour later confirmed that Citi had won the final - with Will Myers as player of the tournament. Well done Citi!
Sarah Key Method - Back Block
Time to get back to backs!
This exercise is another of Sarah Key's, and is great for stretching your low back. You'll need what Sarah calls a back block; they're also known as yoga bricks. Roughly the size of a house brick, they come in a variety of materials including wood, bamboo, cork and foam - I usually use one made of solid foam, though in an emergency I have also been known to use a hardback copy of a Harry Potter book!
When we spend all day with our spines in an upright position (sitting, standing, walking, running), gravity combined with our bodyweight squashes our spinal discs, and over the course of the day they flatten out a bit. It's not unusual to be 2cm shorter at the end of the day than you were at the start. Generally, the discs rehydrate and plump up again overnight when you're lying flat, but over time - with age, or particularly with injury - the flattening starts to have a greater effect than the rehydration, and you develop stiff spinal segments.
Sarah's theory is that this process is reversible if you regularly take steps to decompress your spine, and this is where the back block - coupled with the appeasing exercise I described before - comes in.
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Lie on your back on a firm surface such as the floor, knees bent so that your feet are on the floor, and feet and knees together. - Squeeze your knees and buttocks together. Keeping them squeezed, roll up your spine, curling your bottom off the ground first, and - bone by bone - then your low back, mid back and upper back, until your weight is on your feet and shoulders.
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Bone by bone, roll your way back down again, trying to make the space
between each bone as long as possible, and making sure that when you reach your pelvis, the left and right sides hit the ground at the same time. - Make sure your knees and buttocks are squeezed together, and roll all the way up to your shoulders again, bone by bone.
- This time when you are at the top, slide your back block underneath your pelvis (NOT under your low back) and roll your bottom down onto it. The block should be horizontally aligned and on its shallowest side.
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Slide (don't lift) one foot along the ground and away from you, and then the other. Allow your ankles to relax and roll outwards. Relax your calves, then your knees, then your thighs, buttocks, low back... - Let your arms roll outwards so that your palms face the ceiling, and relax completely for a minute.
- Then slide one foot back up towards you, and then the other.
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Squ
eeze your knees and buttocks together, and roll your way up off the block (at first this may be sore; don't worry, this is quite normal and it does get better!) - Slide the block out from underneath your bottom, and roll down just as you did before.
- Now do 30 seconds of the appeasing exercise, and repeat the whole thing three times.
NB - any discomfort you feel on curling up off the block should fade quickly and should improve over the first few days of practising this exercise. If it is too painful, or remains significant for more than a week of doing this, you should discontinue the exercise and get your back assessed. (Of course, I'd recommend that you see a Sarah Key-trained physiotherapist...)
Thanks to the lovely Graeme Marsh for posing for these pictures at The Foundry.
Shoulder pain - an underdiagnosed dysfunction
This post is triggered by Dave Thomas of The Foundry, who commented yesterday on Facebook following a therapy session with me that “if you haven’t had your subscapularis walked on before, it’s a treat!” It seems to be a relatively unusual technique, but one of my favourites, and this is why.
The subscapularis (aka subscap, to rhyme with hubcap) is a triangular muscle which sits between the ribs and the shoulderblade (scapula) – its name meaning literally “below the scapula”. With its base covering the entire of the inside edge of the scapula, it narrows to a tendon which attaches to the inner part of the humerus (upper arm bone) and the shoulder joint capsule. Its role is to twist the arm inwards (place your hand on your stomach and try to push through to your spine: you’re using your subscap) and to pull the humerus forward and down when your arm is raised, thus preventing your shoulder from dislocating.
It’s one of the four muscles that make up the rotator cuff, (the others being supraspinatus, infraspinatus and teres minor, if you’re interested!) but far less frequently torn than the more vulnerable supraspinatus and infraspinatus. Probably because of this, it’s a muscle that’s often ignored by therapists when treating sore necks and shoulders, but in my view that’s a mistake. Good subscap function is essential to good neck and shoulder function, and I have a few theories as to why this is the case.
One theory is the effect that subscap has on the ribs. As I’ve mentioned, subscap sits between the ribs and the scapula. Normal shoulder movement depends on the scapula being able to glide freely over the ribs. When muscles are sore, they tend to tighten up and develop trigger points – isolated areas of muscle spasm; and subscap is no exception. It’s my belief that tightness and/or trigger points in subscap can be partly responsible for dysfunctional movement of the scapula over the ribs. This in turn places excessive strain on the rib and shoulder joints, leading to pain in the upper back, neck and/or shoulder.
I believe that another problem with subscap trigger points is the effect these have on blood flow and nerves. I suspect that when a muscle is tight, its spasmed fibres affect not only each other, but also other local structures such as blood vessels and nerves. In the case of subscap, this could – theoretically - affect the axillary (armpit) artery and the ulnar branch of the brachial plexus – the nerve that goes down to the inside of the elbow and the ring and little fingers. It’s certainly noticeable that patients often comment that they feel odd sensations in these areas, as I release their tight subscaps; or that once I’ve finished, they feel a rush of heat to the area (increased blood flow?)
Releasing the subscap is pretty tricky to do on your own. I often use my heels to release subscap in my patients – most therapists use their fists or fingers, but it’s hard to do that without jabbing your patient and causing more discomfort than necessary. If I have to release your subscap, I’ll ask you to lie on your back with your hand behind your head. This brings the edge of your scapula out to the side of your body, and I can then fit my heel between the edge of your scapula and your ribs, and use my bodyweight to stretch and massage the subscap, gently and rhythmically until the spasm subsides.
Not only does this tend to release the subscap spasm, it also frequently seems to relieve neck pain and increase in rotation at the neck, which is a great side effect. I’m not sure whether this is also due to better rib mobility, or whether there is some sort of chain reaction going on whereby the subscap release causes a release in the levator scapulae – any bright ideas gratefully accepted!
After I’ve released your subscap, I’ll show you how to stretch it yourself, using a chair, Swiss ball or yoga brick, so that you can maintain the improvement at home.
If you're having problems with a shoulder, please e-mail me for advice or for an appointment.
Blog for Victory
Hi, I'm Nell Mead. I'm a former Army physiotherapist and I specialise in sports medicine and back pain. This is my blog, where I write about issues that are on my mind. Some of these are about issues that are specific to particular injuries or medical conditions but I will also be updating you on events occurring inside Victory and in the wider world of medical rehabilitation. I also publish guest posts by Victory's other therapists whenever I can persuade them to sit still for long enough to write something!
When we're not writing, we're offering appointments at The Foundry in Liverpool Street. We'd love to see your comments on our posts - and we'd love to meet you even more, so do pop by and meet the team.