Treat the Whole Chain - Necessities of Recovery

There's no manual on the human body. You can't just open a troubleshooting guide to find out how to fix a piece that's not working properly. As such, I'm not a fan of calling the body a machine. Rather, it's this moist, fleshy mass of tissue and organs that sometimes comes together to work properly. (Yes, "moist". Deal with it.)

How do I look?

That being said, when a piece breaks down and pain is experienced, we don't have the luxury of focusing our attention on that piece alone to try and correct the issue like car mechanics do. If one segment is out of whack, then, guaranteed, others are as well.

Compensatory Mechanics

We all know by now that, when injury occurs or bad motor habits are left unchecked, that the body will compensate by lengthening, shortening, tightening, and restricting in other spots; thus, maintaining functional integrity.

Because of this type of mechanism, spraining an ankle, for instance, means that the overall issue won't stay isolated at that one joint. Because of that sprain, the body will favour one side with a limp, resulting in a lateral hip weakness on the opposite side. That weakness can then be cause for poor knee tracking, SI joint instability, spinal tension, and more. And do these things require years of being unchecked to occur? No. Try a week or two instead.

Intervention

With that knowledge, how can we expect to correct the issues by only targeting the site of the most pain? Here's a good example of how working globally is a necessity when it comes to correcting dysfunction.

I have one client who had discomfort in their hip. We determined that there was an imbalance around the hips that resulted in one side becoming stuck in a hypomobile position. What we did, for the first treatment, was mobilize the joint manually, provide mobility exercise prescription, and then started working on stability for those lower-chain muscles surrounding the area.

So the hip felt great. However, what happened next was that the spinal erectors tightened up by the time of the next treatment. As we promoted more movement through the pelvis and began activating the hip and core muscles to stabilize the area, we were promoting more movement through the rest of the kinetic chain and creating more mobility through the entire spine at the same time. Thus, even though we were strengthening the core, we were also forcing the back muscles to start activating more than they were used to. As tone and tension increased in the lower back, the tension creeped up all the way to the top, exacerbating neck tightness as well.

Sidenote: When we're talking about headaches and 

pressure, we're usually looking at these guys here.

Does that mean we did something wrong during that first treatment? No. It just shows that the body can very effectively compensate for a dysfunction, but when you suddenly intervene in that dysfunction and start to return a joint to its proper mechanics, you need to keep providing similar retraining to the entire chain, both above and below that area.

Significance for Self-Help

These thoughts hold more significance that just for clinicians who are treating a client's injuries. The principals apply to every individual who is trying to address their own fitness and health. 

I talked about "foam roller syndrome" before and how a reliance on self-releasing only the site of pain on a daily basis signals that there are mechanical errors not being addressed. That's exactly what I'm talking about again here. If you are constantly experiencing lower back pain, then constant work on your lower back along will not fix the problem. Neck pain? You need to do more than simply stretch the neck muscles all the time. 

The point here reiterates the time-tested rule that you can't chase pain and expect to chase it away. When there is a dysfunction, it's important to look up, down, and away from the dysfunction and correct the kinetic chain as a whole. Zoning in on one spot will feel great on the first day, but if you stop the efforts there, you can expect the pain to return just as bad - or even worse - soon after.

From Turf to Table

Well, I'm working my own practice now.

After four years of school, a national exam, and a hell of a lot of prep work, I finally opened my new clinic. As business grows, it's coming with its rewards..and lessons.

During the majority of my time in school and the couple years that followed, most of my work experience was on the sports field. In essence, my scope of practice between the field and clinic are the same. Respond to the injuries, treat the pain, rehab the injuries, and progress my clients to their return to activity.

The work life on the field is high-paced and demanding. You would think that moving to the clinic would be a refreshing change and much easier job. Yeah, no. The clinical life comes with many of its own challenges. I wouldn't call either job necessarily harder than the other, but that's just it; "easier" really doesn't exist.

Time Constraints

Firstly, yes, the fast-pace lifestyle of the field can be stressful. When you have a 10-minute intermission and seven players in line to see you, you need to be on your toes to give them what they need in a restricted amount of time. Often, you have to make some tough calls and prioritize the injury needs of some players over others in order to get your team back on the floor in as optimal order as possible. Bad bruise on your arm? Sorry, I have a thrown-out back and two fresh ankle sprains to manage. Come back to me after the game.

Pictured: The third blown-out knee in the game, probably.

On the flip side, now that I'm in the clinic, I have nothing but time to spare with my clients. However, this puts a different kind of pressure on. Athletes on a team are so eager to get back on the floor - adrenaline rushing in their veins in higher volume than blood - and half the time they'll feel better the moment you put your hands on them, even if you haven't done anything yet. (A lot of them don't seem to feel pain.) Clients in the clinic, on the other hand, have just as much time to think as you do, and so all their own focus is on their pain and sensations. With that being said, there's the extra stress of missing something or not being maximally effective with a treatment technique; stresses that you realize weren't there before when none of your athletes ever had the time to think about it.

Motor Patterns and Compensations

Yup, so athletes get injured. A lot. Every game, there's going to be something new happen, and it often feels like you're in a hopeless loop of never-ending accidents and players in pain. Arrggh, why doesn't it stop!

That's the nature of sport. Crap happens. However, the good thing about all of these constant injuries happening in your presence is that you can do something about them immediately! I'm talking within five minutes of them occurring. Do I get that convenience in the clinic? Not at all.

When an acute injury occurs, there is the traditional, tried-and-true protocol of RICE: rest, ice, compression, and elevation. You can minimize the secondary tissue damage by minimizing excessive swelling, ensure that a player isn't going to hurt themselves more by discontinuing activity, and get them on early rehab exercises as early as the next day. Range of motion, proprioceptive training, and strengthening in those first few days does amazing things for recovery by making sure that damaged tissue heals and reorganizes itself in the proper patterns and line of pull immediately.

When it comes to clients who book in at the clinic, it's once in a blue moon that someone books in for an injury that was sustained just the day before. More often than not, these people have been in pain for months - if not years or decades. Their injured tissue has healed in haphazard directions, they've developed poor motor habits around their conditions, and muscles have become strong, weak, tight, and loose in compensation. It's not longer a matter of simply getting the injured joint moving; now we have to pick apart months and years of improper motor training. A sprained ankle four years ago can cause a limp, resulting in a hip weakness on the opposite side, compounding into knee and back pain and so on.

That toe sprain has completely mangled your neck.

Never Easy, But Always Fun

As you can see, both the field and clinic worlds have their challenges that contrast but don't trump one another. You can't call either job easier. However, I love both sides of my professional life. The slow, controlled pace of the clinic as well as the exciting, non-stop action of being on the field. A healthy balance keeps things interesting, and my job is definitely a lot of that!

How Do Pain and Spasm Work?

I had a client this week ask me why the body seizes up so violently when it experiences injury, even when the muscles that are seizing up weren't the ones that were damaged. You've sprained a ligament at your AC joint, so why has your entire upper back and neck become so tight and restricted?

As I've mentioned before, the body has this fantastic mechanism when it comes to protecting its joints. Normally, when it detects instability around a joint, the brain signals the muscles to tighten and tone in order to guard the joint from harm. However, when the instability is severe or when the body experiences an acute, traumatic injury, this tension becomes spasm.

Spasm is an involuntary muscle contraction and is how we define this "seizing up" of muscles when we experience injury. The body is desperately trying to do whatever it can to maintain the integrity of the joints by minimizing any further harm. Unfortunately, this spasm is very often even more debilitating than the injured structure itself. Why is that?

The Pain-Spasm Cycle

What happens is this delightful process known as the pain-spasm cycle. First, your body experiences pain. As we know, the body now tightens and spasms up in response. However, this tension has made the pain even worse. As a result of the increased pain, the body throws in even more spasm, and the cycle continues.

This is essentially the physiology of any injury and the reason why it's so hard to find relief. This cycle can be an extremely debilitating process and is tough to break. But it CAN be broken, and that's where I come in to do my job.

Breaking the Cycle

How do you break a cycle? Well, you remove one of its pit stops, of course. Through whatever means are used, if you can reduce either the pain or the spasm, its counterpart, by principle, will become alleviated as well. This is the purpose of modalities that therapists use. Massage and needling, for instance, help to relieve muscle tension and decrease the amount of pain that a client has. On the flip side, electrical stimulation machines are also used solely to block the pain signals from the tissue to the brain, causing the brain to allow the muscle to relax and cease its spasm.

However, these modalities are often not enough. Even IF the symptoms can be completely alleviated through a treatment (spoiler: most often, they're not), the symptoms can easily return. The way that I explain to my clients is this: Regardless of muscle tension and pain, there is going to be some degree of dysfunction or joint instability remaining from the injury. By not correcting these issues or by leaving behind even a small amount of pain and spasm still, the symptoms are likely to return full-force.

And how do you correct that? Movement. Athletic Therapists recognize that treating the tissue ourselves is only half the battle and that the rest of the work is up to yourself to stop the problem from coming back. Strengthen the muscles around the joint. Create stability. Rebuild the trust between the brain and the muscles that movement can be done safely and pain-free. This is only way to truly correct a dysfunction and prevent this painful boomerang effect.

The most useful medical tools.

These principles are well-known to most medical practitioners, but it seems that it's often missed by the public. By offering this understanding on how exactly pain and spasm work and how to correct them, hopefully it will prove to be a valuable resource to motivate people as they move through their recovery process and back to health.

Case Study: Why Not To Over-Mobilize

I've got a case study for you, and it's a great example of why we need to be careful to not take mobility principles out of context. (Look at me, kicking that horse again. Get used to it.)

The Client

In this instance, I had an adult recreational hockey player in to see me for treatment. He had a history of shoulder injuries, some shoulder pain, and ongoing neck tension and headaches following his weekly hockey game. He exercises regularly, but doesn't often workout his upper body at the gym due to his lifestyle demands not requiring it.

In short, my plan of attack was to do some moderate soft-tissue release through his traps and neck, give him some self-mobility exercises to do before hockey, and some stabilization movements to strengthen his scapular and deep neck muscles. From the rehab side of the world, basic basic.

We tried this approach for two sessions in a row, a week apart. In both cases, my client felt great all week.

Oh wait, except for the two days after his weekly hockey games. Then the pain was like none other.

What Went Wrong?

I'll tell you what went wrong. My client was very responsive to the stabilization exercises and could feel himself standing taller and his shoulder sitting back much better all the way through. However, by increasing his shoulder and thoracic mobility (both through the treatment and through his home exercises), we inadvertently created instability that his muscles weren't yet ready to fully compensate for. 

He described the pain after the second hockey game as "piercing straight from the back to the front" of his thorax. Essentially, after we freed up his joints and increased the movement happening through his thoracic spine and ribs, we created a need for the muscles in the area to work harder to maintain stability, Unfortunately, the strength and endurance in those muscles weren't yet there, and pain resulted for the days after the demand was placed upon them.

So after puzzling this one out, our third session was spent exclusively on strengthening exercises. We purposely avoided doing any hands-on soft-tissue release or joint mobilizations (aside from his self-mobility drills) to try and create a better foundation for stability first. After that treatment, he went to his hockey game and reported, finally, a relief in pain in the days following.

The Takeaway

This is a great reminder to be cautious with the amount of mobility and soft-tissue release that we're providing to our clients (whether you're an Athletic Therapist, a chiropractor, or personal trainer) or even to yourself. Rapidly releasing muscles and freeing up joints does not automatically translate to good health. It must be balanced with proper strengthening to allow the muscle to compensate for the increase joint movement, and those muscles will continue to need further conditioning in order to endure any extended workload demands. Even the best of us will still overshoot when it comes to these principles, but all's good as long as we can take care to reevaluate and not try to maximize range of motion in too short of time.