Category Archives: Mobility

Post-Antalgic Patterning – Part 2 – Quick Reference for Manual Therapy and the Nervous System

*Note: This is part of a series of thoughts on the topic of looking at movement and movement related symptoms as influenced by the nervous system. These will be dynamic posts with additional content and references being added as time allows, but the primary purpose of the posts are to share my current thoughts on the influence of manual therapy and exercise on what we see and feel in our patients. I hope others will engage me in these thoughts and provide their perspectives and also criticism into the process.

In part 1, I wanted to provide the definition for post-antalgic patterning which I believe is important to understand before thinking about how we treat it (if it even needs to be treated), for which I lay the ground work here:

Post-Antalgic Patterning – Part 2 – A Quick Reference for Manual Therapy and the Nervous System

A little over a year ago Jason Silvernail released a great video summary on manual therapy and the nervous system called “Crossing the Chasm” which definitely had its intended effect on me. This discussion has been a “hot topic” for at least a decade. As I have attempted to share this same information with other clinicians, I have noted a trend towards wanting more “practical” connection between the techniques we use on a daily basis and the nervous system. As a result, over the last year I have started to formulate a way to bring a little bit of clarity to a very complex topic.

Mechanoreceptors – The elephant in the room

In most of our academic preparatory programs for various rehabilitation disciplines, our afferent and efferent sensory nerve fiber education has focused primarily on severe neurological conditions of the peripheral and central nervous system (stroke, spinal cord injury, CNS disease, etc.). However, when it comes to the role of the nervous system in musculoskeletal conditions, the focus tends to be on nocioception (note of importance: nocioceptors are NOT PAIN RECEPTORS!), chemoreceptors (in particular the relationship to inflammatory mediators), proprioception, muscle spindles, and the golgi tendon reflex. We might touch on some afferents when we talk about gate control, but in general, mechanoreceptors are a very minor part of “most” professional academic programming offerings. This is despite that fact that mechanoreceptors may be one of the bodies most densely dispersed points of interaction with our nervous system, in particularly in the tissues we commonly claim to be treating (joint capsules, fascia, ligaments, muscles, etc.).

I remember vaguely talking about Ruffini Endings, Merkel’s discs, Pacinian and Meisners Corpuscles, but I don’t remember much emphasis on them and I certainly didn’t see any value in even recalling their names at the time. Yet now I realize they are probably some of the most important structures I deal with on a daily basis, in particular when it comes to manual therapy interventions. We get so obsessed with the biomechanical properties of soft tissue and joints and the illusion that we can mechanically alter them through our hands and various tools despite growing evidence that this simply is not the case, or at best, has an extremely small role in the big picture. Yet we choose to ignore, or at the very least downplay, the one basic fundamental pathway, the cascade of neurophysiological events which occur every time skin is compressed. These events can result both in short term and long term tissue and movement quality changes which have the potential to explain every single “change” seen through the use of manual therapy. Furthermore, any inflammatory, fluid dynamics, or thermal responses which potentially could come about from an aggressive intervention could have chemical, thermal, and fluid interactions with mechanoreceptors, chemoreceptors, and thermoreceptors thereby compounding and/or altering an existing externally induced neurological stimulus. If the inflammatory, fluid, or thermal process remains active for hours or days, this could yield a sustained stimulus on mechanoreceptors, thermoreceptors, and chemoreceptors thereby influence the nervous system for an extended period of time (think of a “built-in portal e-stim unit” that already exists in all humans).

Perhaps more important than the external stimulus itself is the ability to modify, enhance, and/or guide the therapeutic outcome of the neurophysiologic response from the stimulus with an educational context provided to the patient, allowing for a profound impact on how they perceive touch and movement.

So what does the pathway for this manual therapy to mechanoreceptor stimulus to tissue quality/movement change look like? Dr. Schleip has perhaps best described this in his work on fascial plasticity, of which this diagram provides perhaps the most concise explanation of the relationship between manual therapy and the nervous system.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation Part 2.Journal of Bodywork and movement therapies, 7(2), 104-116.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation Part 2.Journal of Bodywork and movement therapies, 7(2), 104-116.

To further help solidify the connection between our commonly utilized manual therapy techniques and the nervous system, I put together a couple of acronyms to show the connection between groups of mechanoreceptors and various manual therapy technique:

“RuffMerks need tender care”

  • Ruffini Endings (End Organs) & Merkel’s discs are slow adapting mechanoreceptors which respond best to slow sustained and deep tension
  • ANS (PNS) & CNS interactions
  • General massage, myofascial release techniques, and possibly even ischemic trigger point releases likely preferentially engage these mechanoreceptors

“PacMeisners need action”

  • Pacinian and Meisners Corpuscles are fast adapting mechanoreceptors which respond best to fast & vibratory inputs and are key to texture discrimination (think edged/textured tools)
  • Predominantly CNS interactions although ANS (PNS) possible
  • Greater concentration subcutaneously are also more frequent on the tendinous site
  • IASTM style, cross friction (hand or tool), and oscillating techniques likely preferentially engage these mechanoreceptors
  • Also thought to play a role in high velocity manipulation

 “Free nerve endings do it all”

  • Some free nerve endings are intermediate adapting mechanoreceptors and can respond to any form of touch, or any modality (chemical, thermal, electrical) for that matter.

 “Ligamentous Mechanoreceptors – I got nothing”

  • 4 types, varying adaptability, primarily stretch mediated, although possibly facilitated through touch if the ligament is superficial enough to be compressed
  • Engaged primarily with mobilization/manipulation

Last but not least, how can so called “inert” soft tissue, or fascia, have tissue tension or “tonus”?

Smooth muscle fascia copy

More regarding the existence of smooth muscle cells within fascia can be found here.

To be continued in part 3..


Quick Video Link: Furniture Slider Exercises – Multi-Planar Single Leg Squat

Furniture sliders are extremely inexpensive (less than $10 at Lowes) and extremely versatile. I was inspired by Ross from Ross Training to experiment with these tools. One of my favorite exercise progressions is a multi-planar single leg squat. The slider is a great cue to promote mobility and stability as well as adding flow to a sequence of movements. It easily allows progressions and regressions based on the needs of the individual.


Learning about Movement – 2012 – Part 3

This is part 3, the last of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. In part 1, I addressed my experience with Applied Functional Science / Chain Reaction™ Biomechanics and presented an application of this approach using hip internal rotation. In part 2, I reflected my current thoughts on strength and conditioning. Now in part 3, I discuss my thoughts behind Fascia, Anatomy Trains, and Regional Interdependence.

Much of what we thought we knew about the biomechanical science of fascia and myofascial release is bunk. By saying this, I need to make it clear in advance that this does not change how we treat, rather it changes how we educate our patients and perhaps makes you think more critically about why you might, or might not, want to treat in a certain way. Greg Lehman provides an excellent review of fascial science on his blog.

fascia-man

So what about Anatomy Trains, which I have previously stated may be a beneficial overview for regional interdependence? As Dr. Lehman discussed, it is extremely unlikely that from a manual therapy standpoint we are making biomechanical changes to tissue. If anything, the biomechanical representation of Anatomy Trains better represents fascial adaptation to function and will only respond to progressive overload with daily stresses and exercise. Furthermore, if we look at function and movement, “Form Follows Function” , then the representation presented by Anatomy Trains may vary individually because tissue adapts to the stresses induced on a daily basis.

So we need to throw out the patterns presented by Thomas Meyers, correct? I personally do not think so. This is not the first time we have developed a general map which is not truly accurate of an individual representation. Our good friend the cortical homunculus also is an inaccurate representation of the somatosensory cortex.

Homunculus1

Why? Because the brain is plastic and the somatosensory cortex adapts to how we interact with the world over time, which is most clearly demonstrated by cortical reorganization in phantom limb pain. Yet we still can use the homunculus as a general representation to give us a visual to for understanding sensation. Similarly, I still believe that seeing the patterns in Anatomy Trains can help us better see movement globally and therefore help guide treatment with complex patients representations. From a movement perspective, especially globally, we need to have some way to compartmentalize all the information and how they approximately relate to each other. Joint by joint osteokinematics and arthrokinematics help but can get complex quickly when you combine them with muscles and fascia. Patterns, such as those represented by Anatomy Trains, which encompass both bone and soft tissue, can help compartmentalize and make treatment more efficient if used appropriately. Of course, the reverse is also true, chasing patterns religiously will also take away from the most obvious, efficient, and appropriate treatment approach. Needless to say, these patterns do manifest themselves in our clients and patients from time to time, and to be ignorant of their general representations will cost you and your patient time.

As a side note, we are in a new era of our understanding of pain, with increasing emphasis on a neurophysiological role in this picture. There may be some overlap between the cortical homunculus and fascial adaptation over time. Since fascia is highly innervated with Ruffini and Pacini corpuscles, changes in fascia from physical adaptation to stress and from habituation to particular forms of movement may influence sensory perception and could theoretically be represented in the somatosensory cortex. With some recent evidence regarding the possible existence of a nocioceptive map which overlaps closely with the somatosensory cortex, there is the possibility that sensory rich fascia may be the interface that allows some of our voodoo with regional interdependence to occur, and why sometimes, specificity matters. This is purely hypothetical, but some ground work for the role of fascia and tendon pain (including pain referral) and their related cortical representation  is discussed by Dr. William Gibson (His PhD thesis is available here: Pain sensitivity and referred pain in human tendon, fascia and muscle tissue.) But since we don’t have any other explanation for how manual therapy sometimes requires specificity and sometimes those points of specificity fall in the patterns represented by Anatomy Trains, this is where I am resting my patient education for the time being.

For a better summary than what I wrote above, I highly recommend a post by Alice Sanvito titled:  “If we cannot Stretch Fascia, what are we doing?”.


Learning about Movement – 2012 – Part 2

This is part 2 of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. In part 1, I addressed my experience with Applied Functional Science / Chain Reaction™ Biomechanics and presented an application of this approach using hip internal rotation. In this post, I will discuss how my strength and conditioning beliefs have changed in 2012.

I still believe in heavy sagital plane lifting. Power/explosive lifts, deadlifts, squats, various forms of pressing have important places with strength and conditioning in a number of sports. Gary Gray provides good reasoning to support the idea that athletic development does not gain a great deal from these lifts unless they are a competitive weight lifter. However, standardized tests improved by these lifts have been shown to be related to athletic success in research1,2 and professional experience does show these lifts cross over into training. It is possible these improvements may  be related to changes in coaching over the career of an athlete but it doesn’t change the fact that intense overloads over time result is associated with athletes becoming stronger, more powerful, and faster. The carry over effects might not be driven purely by hypertrophy and increased neuromuscular drive, it could be endocrine related (increasing load is associated with increases in GH, testosterone, etc) and it could even be largely related by the mental discipline it takes to safely and properly lift increasingly difficult loads. The argument that he and others make is that there are other ways to accomplish this carry over and provide more specific tissue and neurological adaptation to sport. That may be the case, but it has not had the sheer volume and history of success as heavy sagital plane loading. There are certainly some sports I could see the value in dumping this type of loading today, but I think we might lose something, or cause a new problem, if we drop it all together.

So what about the multiplanar, multi-joint, functional training, corrective exercise realm? This is where I started my journey into movement through attending a seminar at Perform Better in 2003. At that time and many years looking forward, I just wanted to collect exercises and categorize them for individual purposes. I rode the anti-heavy lifting bandwagon for a good 4 years before I realized there was a value in it and put it back in my own system. I juggled the balance between the use of bigger lifts and the use of mobility/stability/sport specific power/strength development. I also began to realize how stability and mobility training was being scarred by the functional training movement. People see individuals squatting on stability balls and doing bicep curls on BOSUs under the claim of being “functional” when in fact, quite the opposite, they’re producing movements which simply do not exist in typical function unless they have some sort of odd circus specialty as a career.

Squat on ball

In fact, for many the idea of stability training automatically seems to perceived as being on an unstable surface, which could not be further from the truth. Worse yet, when they are not on some sort of unstable surface they are frequently isolated and cued to be worked under artificial constraints of stability. Everyone is given at least 5 cues to tighten one muscle, loosen another, fire this muscle, not that one. These cues have a place when someone is painful or are early in a rehabilitation protocol, but they do not belong in an athlete’s prehab or conditioning program in the long term except if they have another exacerbation of symptoms. They do not allow the athlete the freedom of motion to develop control in multiple planes of motion. Stability is a joint by joint function specific task. Stability is not simply the ability to hollow, brace, or maintain perfect hip hinge technique (go ahead and tell any strong man competitor fully flexed over atlas stone that his spine is unstable while lifting).

Atlas_Stone

Nor is stability hip abduction and external rotation strength and endurance which keeps this hip, knee, and ankle in a perfect sagital position. Stability is also nearly impossible to tease away from mobility. When mobility with load and force are only practiced in one plane of motion (IE: sagital plane heavy squatting, dead lifts, etc.), mobility will not improve in other planes of motion unless loaded in those planes of motion. Which brings me to our next topic, mobility needs training, not just stretching (dynamic or static):

I believe we can incorporate loaded and body weight exercises into general strategies for improving mobility which I think is more beneficial than a stretching regimen alone. We now know that long term static stretching flexibility improvements are primarily related to stretch tolerance, not tissue change. We are beginning to see that long-term resistance training with full ROM have similar flexibility improvements. 3,4 My belief is that incorporating more full body multiplanar movements with appropriate loading will therefore make more lasting changes in mobility in ways which are more functionally applicable than stretching because they reinforce active patterns of movement. Furthermore, performing these mobility exercises in weight bearing may theoretically promote joint stability at these newly acquire ranges of motion.

Finally, addressing the concern of timing of implementing all of these exercises into anyone’s program. Overall, I see some effectively implementing multi-planar/multi-joint mobility and stability into supplement work for their heavy sagital plane work. Some incorporate into into their metabolic days. To some extent, I will acknowledge it is possible that the advent of diverse multi-planar dynamic stretching prior to every session is already adequate to address my concerns. However, I still wonder if these are enough to make long standing changes in freeing up movement patterns, in particular in the transverse planes. Simply peppering a couple of mobility exercises from time to time may not be enough.

I began this year developing a program meant to complement existing training programs rather than replacing anything. It started first as a way to implement many of the old school strong man training and unconventional training techniques popular these days: focusing on grip strength and lifting and moving diverse objects into a dedicated session, as a way to expand motor patterns for force generation and just to mix up training. Some of this was just for entertainment and variety. Ultimately, after my exposure to the AFS approach and some of the group training at Shoreline Sport & Spine, this progressed to include a variety of multiplanar activities to promote mobility and stability. I now call these the “Mix” sessions, with the idea being utilize full body movements, lift and move diverse objects which require multiple forms of grip and body positioning, and integrate multiplanar/3D mobility and stability to complement an existing training plan.

The idea behind having these as separate sessions rather than integrated into existing sessions was that although I wanted some mild/brief fatigue from a metabolic style warm-up and a finisher at the end, I wanted to not have neuromuscular fatigue be so great prior to, or during, the session as to prevent the body from learning new movement it might not be familiar with.

I put together a video of some the exercises used in group sessions over the last year as this thought process evolved. This video is not the best representation of everything involved in a mix session or the balance of single plane vs. multi-plane diversity. I still have a large number of sagital plane based exercises, but it still demonstrates how the movement is changed by using objects other than barbells and how freedom of motion is promoted throughout. Of additional note, these sessions were designed for group sessions, the exercises recorded below were primarily for non-competitive athletes, these are different than a competitive athlete and the sessions can be customized be more “general sport specific”, but they are inherently limited in the ability to address an individual’s functional needs.

And if I’m completely honestly, it is just fun to have an entire dedicated session to experiment with movements that are different than what are traditionally used. Sometimes a little change is all that we need to move forward.

1.) Hansen, Keir T., et al. “Do Force–Time and Power–Time Measures in a Loaded Jump Squat Differentiate between Speed Performance and Playing Level in Elite and Elite Junior Rugby Union Players?.” The Journal of Strength & Conditioning Research 25.9 (2011): 2382-2391.

2.) Gonzalez, Adam M., et al. “Performance Changes in National Collegiate Athletic Association Division I Women Basketball Players During a Competitive Season: Starters Vs. Nonstarters.” The Journal of Strength & Conditioning Research 26.12 (2012): 3197-3203.

3.) O’Sullivan, Kieran, Sean McAuliffe, and Neasa DeBurca. “The effects of eccentric training on lower limb flexibility: a systematic review.” British Journal of Sports Medicine 46.12 (2012): 838-845.

4.) Morton, Sam K., et al. “Resistance training vs. static stretching: effects on flexibility and strength.” The Journal of Strength & Conditioning Research 25.12 (2011): 3391.