Acute vs Chronic Pain:
We have all experienced acute musculoskeletal pain (pain from joints or muscles) at some point in our lives. Most of these are minor injuries that heal quickly and respond well to rest, ice, and over the counter medications and do not need much medical intervention.
However, if the pain persists for over 2-3 months, it is classified as chronic pain. Chronic pain usually does not respond well to the same things that helped with the acute pain. For example, a very common medical diagnosis for chronic joint pain is “tendonitis” whether it’s your shoulder, knee, or ankle. “Tendonitis” by definition denotes an active inflammation process. However, research studies demonstrate that when samples of the tendon were examined under a microscope, there were no signs of an active inflammation present. Therefore, taking anti-inflammatory medication would probably not be very helpful and there is emerging research that suggests that it could actually retard the healing process even further.
A better term for these conditions would be “tendinosis” which can be defined as small, repetitive injuries to the tendon that are not healing. It is a chronic injury of failed healing that involves degeneration of the tendon due to atrophy.
Tendinosis injuries are slow to heal and further research is needed to determine the best course of treatment. However, Manual Structural Therapy can aid in the healing process by identifying additional areas of movement restrictions that may be interfering with the healing process.
Take for example a client with chronic knee pain without any specific trauma. Image testing of the knee reveals “no structural damage” and the diagnosis of “tendonitis” is given. From what we now know, this is not a technically correct diagnosis. Looking at the body as one functional unit would be very helpful in identifying additional areas of restriction that may not be painful, but relate to the function of the knee. Tightness of the hip and ankle are very common and can contribute to chronic knee pain. Poor lumbar spine and hip strength can also be major contributing factors.
Proximal Stability before Distal Mobility:
This is a PNF concept (Proprioceptive Neuromuscular Facilitation) that was first introduced in the 1940’s and 50’s by Dr. Kabat. His goal was to develop a system to evaluate and analyze patient’s movement patterns. “Proximal stability before distal mobility” simply refers to the fact that we must first have good mobility and strength along our core (midline structures along our spine) before we can maximize our extremity function (distal mobility).
In developmental terms, babies are born with great mobility, but very little stability (muscle control). Babies first develop head and trunk control and strength. They then start to roll over and eventually start sitting up. Only after they gain good control of their trunk, do they start to reach with their arms and eventually pull themselves up to start the walking process.
How does this concept apply to the treatment of musculoskeletal pain? This developmental concept supports the rationale for the evaluation, treatment, and strengthening of the midline structures first before evaluating and treating the extremity. For example, the client with shoulder pain will need to have the thoracic spine (middle back and ribs) evaluated and treated before the shoulder is worked on, even though the “pain” may be located in the actual shoulder region. Remember, we are taking a structural approach to treatment, not pain driven.
The same can be said about chronic hip, knee, or ankle pain where the lumbar spine would need to be addressed first. Can the lumbar spine (lower back) provide first the mobility and then the stability needed for proper lower extremity (leg) function?
The Body’s Compensatory Response to a Hypomobile (stiff) Joint:
Bodies were designed to move, with the priority of getting us from point A to B. regardless of the long term ramifications on the musculoskeletal system. In response to a hypomobile or stiff joint, the body will increase movement somewhere else, usually in the least desirable area. This could potentially lead to a hypermobility and instability in other joints as compensation to the stiff joints.
For example, a commonly seen scenario in the clinic: A client presents with chronic left lower back and leg pain. If the clinician lets “pain” drive the treatment protocol, then it’s the left side of the lower back and leg that usually receives the majority of the treatment, whether it’s popping the joint, ultrasound, massage, injections, stretching, etc.
Using the Movement Loss model of evaluating musculoskeletal pain may reveal a different area that needs to be addressed first. The key is to do a movement analysis to determine the area of greatest restrictions and then start treatment there – almost never the most “painful” area in chronic pain.
Staying with the above example, usually the opposite hip will exhibit stiffness or hypomobility that may be relevant to the current complaints of pain. The treatment approach would then be to mobilize, stretch, and eventually strengthen the right hip (non painful side) since the left hip may have become hypermobile in response to the lack of movement in the right hip. Therefore, instead of additional stretching and mobilization of the hypermobile site (contraindicated), treatment would focus on stabilization of the left lower back and hip while we mobilize the stretch the right hip.
The Role of Strengthening Exercises:
Regardless of age, the role of strength training in allowing us to lead healthy, active lifestyles cannot be overstated. Please see the Health News link for additional information on the safety of strength training in children.
Although the programs need to be age appropriate, everyone should be on a progressive strength training program. Free weights are more “functional” but require greater control and places greater emphasis on form.
A common mistake made in weight rooms everywhere is the “loading” of poor movement patterns. Before any weights are added to a movement, the pattern must be pain free with perfect form and symmetry.
Take for example the squat. You can’t get much more functional than a squat. This is a movement that we all do, multiple times per day and one that gets very difficult as we age. If we cannot perform a squat with good technique, but yet we “re-enforce” the movement by adding weights, we are creating a “dysfunctional movement pattern”. Poor movement patterns may increase the chance of injury during activity.
Therefore, first focus on basic, fundamental movement patterns, which stress form, balance, and symmetry. Examples include the deep squat, lunges, side stepping, and single leg balance activities. Upper body exercises would stress opening of the anterior chest wall and strengthening of the scapular musculature to help maintain an upright posture.
Remember to include core or midline strengthening activities to the program since we must first have proximal stability and strength (the trunk) before we can maximize our distal mobility (arms and legs).
Maximizing Functional Potential by training the “’Weak Link”
All body types have built-in strengths and weaknesses. Some individuals have a stocky build and have a natural tendency to be strong (even without lifting weights) but they may not be very flexible. Others may be built “long and lean” and have great flexibility even without much regular stretching, but they may lack strength.
In order to fully maximize our functional potential, we must identify and train our “weak link”.
Think of a chain as only being as strong as the weakest link. The naturally strong individual may have tailored his or her exercise program to focus on strengthening activities since this will be the most rewarding on many levels. However, this individual will ultimately be limited in their physical endeavors by an overall lack of flexibility. Conversely, the naturally flexible individual may enjoy Yoga and stay away from weight training since it may feel difficult for them to make steady gains or even defeating. What will eventually limit this type of individual will be a lack of overall strength and power.
While it may take one out of his or her comfort zone, the strong individual needs to continue building strength, in addition to adding a large flexibility component to the exercise program. On the other hand, the naturally flexible individual must add a strong weight lifting component to the exercise routine.