Muscular Function

One of the prime aims of the manual therapist is to improve circulation- circulation of fluids; this fluid is mainly water, but it contains, among other substances, red blood cells, so it's fairly common to refer to this vital fluid as blood. To get a clear picture of your role as a manual therapist, promoting circulation, I encourage students to visualise this watery substance moving through the veins, arteries, and lymphatic vessels.

Remember, also, that this water moves through the body in much the same way as a river moves through many parts of the country; it is a vital conveyor system, in some places moving ships with their cargo, in our body, it carries whatever is provided by our digestive system, or whatever it is that we consume - if a painkiller that we swallow has to get to the intended site, its only avenue is the circulatory system.

The heart has a major task of a circulatory pump, but it is aided - or it should be - by our muscular system. If you are sensibly active, then the muscles you use will also pump fluids. If you are idle, for whatever reason, then pumping is left to the heart.

So, in simple terms, muscles aid the heart, by:

contracting, moving the adjacent joint, compressing the joint, squeezing fluids out of the joint components,

expanding the muscle bundle, compressing its own blood vessels,

encouraging all opposing muscle groups to be stretched, which influences fluid movement in these zones as well.

This is the ideal situation; contraction of one group, and stretching of another group, followed by the reverse movement - maybe extension, followed by contraction. But, what we are often confronted with, or what we often experience ourselves, is:

(a) an over-strenuous series of flexions/extensions such as participation in a challenging athletic event, or

(b) a sustained contraction of one muscle group, perhaps promoted by stressful circumstances.

An over-strenuous exercise programme can strain the tissues, and interfere with the normal movement of fluids - just as surely as the involuntary contraction of muscles prompted by the demands of living.

Your work as a manual therapist really doesn't need too much modification in this regard; the person trying desperately to stay afloat emotionally in these challenging times will experience almost the same circulatory disruption as the athlete, the truck driver, the school teacher or the parent.

Think about it possums, there isn't a lot of difference between corrective massage and remedial massage when you think about it..

Muscular Balance

I was prompted to put down my thoughts on this topic, after a visit from a client yesterday, who had had a fall the previous night while walking up stairs at his home; this was not his first event, and it reminded me of a few others , (including myself), with similar experiences - let me explain my version of the fall.

The ankle joint - if we compare it to the flagpole we discussed recently, has two particular cables that control its function; sure, there are many others in this region, but let's just consider today the movements of plantar flexion, and dorsiflection - standing on your toes, with your heels in the air, or rocking back on your heels so that your toes are elevated.

The muscles engaged here are :

the calf muscles, (gastrocnemius and soleus, and

tibialis anterior.

If you are a student, don't pressure yourself to memorise the names of muscles - study function, and performance, and the names will eventually plant themselves in your mind; for the present, if you look at an ankle joint from one side, a lateral view, the are a set of calf muscles at the rear of the ankle joint , and a single muscle at the front.

When the front muscle contracts, our toes are elevated, and we rock back on our heels; when the rear muscle(s) contract, our heel is elevated, and we are up on our toes.

Now, it is my opinion that we are more likely, in our day-to-day activities, to use calf muscles much more than we do our tibialis; as a result, an imbalance develops, and although tibialis doesn't suffer the same loss in tone, as say, triceps (as mentioned earlier this month), my point is, many people have a tendency to experience a loss of plantar flexion.

That is, when we walk, we become a little lazy about raising the toes, making us susceptible to tripping on small steps, or changes in the terrain, ( as my client did.)

If you occasionally want to walk with haste, and this is something I deliberately do, as a form of exercise, you occasionally meet uneven ground, or a set of steps. Age, and lack of deliberate tibialis exercises, put me in this category, and I experienced a few minor falls before I put some thought into the cause.

If you see me on the street, and I stumble, you will know that I once again, have neglected my Tibialis Anterior exercises !!!

Muscular Balance

I wanted to add a photo, to further illustrate this muscle balance/imbalance theme, so that I can be sure we are all on the one plane, before I proceed further with the discussion.

Here is an illustration of the elbow joint in action; there is a small amount of flexion, and one rope, (marked "B"), which represents the Biceps Brachii, displays some tension. This is a "drawbridge" situation, an analogy that I often use in anatomy workshops, where the biceps behaves like the rope or cable that raises the drawbridge that you might see at an ancient castle.

One point I am trying to make here is, the same cable that raises the bridge, lowers the bridge. At all times, the muscle marked "T", representimg the Triceps Brachii, is idle.

So, if you or I regularly use the biceps in elbow flexion, such as the person at the gymnasium that might be performing the exercise commonly known as "curls", the triceps will be on holidays; even if you're not a fitness person, many of your day-to-day activities will involve elbow flexion, and the triceps muscle is often under-used, and develops flaccidity, or looseness.

Consider what impact, small or great, this has on the elbow joints - remember, there are three of them, and, scapula position and performance.

More next week, possums.

Muscular Balance

A lot of interest has been shown in the topic of muscular balance - we could pursue the topic from various directions, let me try one - joint weakness, perhaps due to muscular imbalance.

Many of you are manual therapists, massage therapists, or physical therapists; your hands are regularly used, the fingers, and the wrist muscles are flexed, not continuously, but often, as you grip, squeeze, manipulate, and mobilize. We would all agree, then, that finger, palm, and wrist muscles would enjoy advanced strength, and fairly healthy tone - compared, perhaps, to others whose work does not include such activities.

All of the joints in these areas, finger joints. palm joints, and wrist joints, are reinforced, (we're getting back to the flagpole idea again, ) by strong muscles on one side, and relatively weak muscles on the other - I ask you to consider, how does this imbalance affect the joint(s)?

Consider this experiment; many of my students have tried this, and I urge them to attempt it again.

Make a fist of your hand; have your friend clasp your closed fist, with both of their own hands. Now, your job is to try to open your clenched fist, against the resistance of your friend's hands - this is merely a test of the strength of your extensor muscles, hand, finger, palm, all of them together - you will, at least many of you, find a surprising weakness is present.

Now grasp your friend's hand as though in a handshake greeting - and slowly squeeze - don't try to crush the hand bones, this is a friend, after all!!!!

Compare the strength of your flexor muscles, against the strength of the extensors - there is almost always, a significant difference; the same disparity is evident between hip flexors and extensors, lumbar flexors and extensors, and even the elbow displays similar characteristics.

At this stage of my speculation about the relevance of muscular or kinetic balance, all I can say is, if someone consults me about a joint disfunction, ( and all muscular complaints become a joint complaint eventually,) then this in one angle I investigate.

Lumbar Pain

Recently, I had visit from a man who is employed as a handyman/laborer/cleaner, at the local high school. This is a 45 year-old, of slender but muscular build. Typical of his duties was the occasional movement of furniture and other items considered to be too heavy or too awkward for class-room staff.

During one of these events, (moving a heavy waste-bin) he experienced pain in his right hip, in the vicinity of the SIJ. This was followed soon after by referred pain in parts of the lower limb, portions of the ITB, lateral condyle of the femur, and the right heel. Other zones of the R. leg had become numb, in his own words:you could stick a pin in here, and here, and I would feel nothing.

As this was classified as a work-related injury, for which the employer - the state Education Department - could be considered liable for the any costs, he was sent to the local medical practitioner for assessment.

The source of pain was initially diagnosed as linked to possible lumbar spinal disc damage, the extent of which could only be determined by radiological examination. As the local MRI facility was not available for at least a week due to demand, he was advised to take a week off work, while awaiting his turn in the queue.

Time off work, for many unskilled workers, represents a monetary loss, as well as an entry on his work record - not good for his reputation if he should attempt to gain employment elsewhere sometime in the future; he elected , therefore, to remain at work, on so-called light duties.

Impatient with the waiting, and the discomfort, he came to see me for advice; On examining him, I found muscular contractions in his RS lateral rotator muscles. Two treatments reduced these contractions, sufficient to lower the pain, and the numbness. he returned to work, no time was lost, and no compensation claim was pursued.

The moral of the story ?

Not that I achieved a miracle, many of today's properly trained manual therapists would have made the same examination, come to the same conclusion, and achieved the same result as I did.

My point is, that an MRI would probably not have revealed the presence of muscular contractions in the hip area, and, furthermore, the possibility that such muscular contractions, ( in the vicinity of gluteus medius), was not even considered as a likely culprit.

The medical practitioner was not at fault here, this is not a feeble attempt to score points at his expense - such a source of sciatica was, I suggest, probably not even taught at his college.

For about $100, the problem was quickly solved; an MRI would have cost thousands. The $100 might even have achieved a nil result- surely this is a reasonable wager ?

Muscular Balance

One of my many interests in anatomy education is muscular balance; this is not a term I have invented - it is also known as, or referred to as kinetic balance. I usually explain my concept of muscular balance in the following way:

Consider a wooden post - perhaps a tent-post, or a flagpole. The stability of these columns depends on the positioning and strength of, supporting ropes.

Each of our skeletal joints has a similar reliance on supporting structures - the tent-post has ropes, our skeletal joint has muscle tissue.

The vertebral column is a great example - a long, slender column, supporting the cranium at the top, assisted by supporting cables; but as we understand, this vertebral column is made up of more than 30 individual joints. Nevertheless, we could view each joint separately, each pair requiring cables to control steadiness, or movement, whatever is required.

Let's consider a small section of the vertebral column, the cervical region; for many of us, our daily occupation requires us to be positioned over a :

treatment table,

a food preparation bench,

a computer desk,or

a computer.

There are many other occupations, I understand, but, unless you are, for instance, leaning back, painting the ceiling of your home, your vertebral column, including the cervical section, is usually in flexion, chin towards your chest. This suggests that the flexor muscles, at the front of your throat, are in some degree of tension, pulling your head forward. This is an incorrect assumption.

The head can sit in this forward position, under its own weight, without any assistance from the anterior muscles; only the extensor muscles at the rear, are active, as they pull back on the cranium, controlling its flexed position. This means that for much of the time spent at a desk, reading, or whatever, the flexor muscles are almost completely idle, while the extensor muscles are active.

One of the results of this overactivity of one set, and underactivity of an opposing set, is muscular imbalance; the extensor muscles maintain their strength, and their tone, while the flexors become flaccid by comparison. Our imaginary flagpole is now supported by a set of ropes on one side that have strength and tension, and an opposing set of ropes that are relatively weak, and slack. This means the complete assembly is adversely affected.

If we imagine the experience of a rear-end collision involving a couple of motor vehicles, the driver of the forward car, hit from behind, is forced into cervical extension; his head thrusts towards the head-rest, if there is one. There is insufficient time for the flexor muscles to contract in an attempt to limit this rearward movement - perhaps their flaccidity adds to this delay.

The head bounces off the support, possibly at the same time that the flexors respond, and there could be a series of this shuttling back and forth, all in a few seconds, until coming to rest.

This is a theoretical script of the scenes in such an accident - investigators more knowledgeable than I would be able to describe the details more accurately; I want you to consider the structure, and contemplate, in your own mind, the effect of muscular imbalance on the cervical spine, in even less dramatic circumstances.

Acute back pain (lumbar).

When a client presents at your clinic, reporting sudden onset (acute) pain, there is, very often in their own mind, no valid reason or cause. If they were attempting to move heavy furniture, or an automobile, then they could easily identify the event.

When the cause is not known, an analysis of the source and the severity of the damage is not simple and the therapist needs to proceed with caution, using logical steps to to determine:

(a) is this a task for a manual therapist - or should it be delegated to another, more expert clinician ?, or

(b) if you deem it prudent to proceed, try to identify which sections of the supporting structure are excessively contracted, and initiate corrective procedures.

Now and then, we see instances of acute lumbar pain, arising from the simple procedure of getting up from the seated position -perhaps after reading, or viewing TV, or working at a computer; no strenuous effort has been involved, and maybe the injured person even offers the defence " I don't understand how this could happen, I walk every day, to keep fit."

There are many possible causes of this sudden discomfort - let's discuss just one of them; many of you readers will already be familiar with this topic, and may wish to tune out at this point, but for you others :

Firstly, in the seated position, as the model is demonstrating, the ilio-femoral joint is to some degree, flexed - the lower the seat, the greater the amount of flexion.

If the ilio-femoral joint is flexed, the flexor muscles are shortened, and the extensors, ( on the opposite side of the same joint) are stretched.

If you stand up from this seated position, and you will probably do so with some haste - certainly not in "slow motion" - flexor muscles are suddenly transformed from the shortened state to the stretched; like any other tissues in the body, muscles have an admirable ability to protect themselves from perceived harm.

If, for example, your finger comes into contact with a hot surface, the reaction will be swift; if a small insect collides with your eye, again the protective measures will flash into gear. In the case of the finger, it is not just the hand that responds - often the whole arm, and even the torso, will become involved.

Any threat to your eye isn't just limited to a closing eyelid - often the head will be drawn back, as the cervical segments are rapidly extended. What determines the need for, and the speed of, and the extent of, this response ? This is not a conscious thought process - there's no time for thinking and consideration here - such luxuries are by-passed.

The automatic, (or autonomic) system - ANS- arranges all this - the selection of the appropriate muscles, and the speed of, and the extent of, the protective contractions.

So, returning to the person who has simply decided to stand upright after a period of sitting - flexor muscles are stretched - if such a stretch is interpreted by the ANS as a possible source of damage - a strain, or a tear - it may well initiate a series of contractions, all in the good cause of self protection.

As an experienced manual therapist, you can identify and examine the ilio-femoral flexors - don't overlook the psoas, (or ilio-psoas) in this task. Oh, and when the clients say that they are regular walkers, or diligent exercisers, remember that although walking is a fine way to achieve a certain amount of mobility, and see the country at the same time, give some thought to just how much the ilio-femoral flexors are really stretched during a normal, or even vigorous, walking programme - not very much, I hear some of you reply.

Bernard Scully

www.theinsideout.com.au