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

The business of manual therapy.

General medical practitioners, and now registered nurses, ( who have been granted greater authority to perform certain tasks that were once the sole domain of medical practitioners,) very often decide, that in the event of a percieved acute musculo-skeletal discomfort in their client, the next port of call should be a physiotherapist.

I don't believe there is a statute or regulation somewhere that says this is what must happen - but it is generally the case in Australia. Now, you, as a manual therapist, might complain about this bias among yourselves, but change will not come about, at least for the present, for some very obvious reasons.

Let me list some of these reasons for you to consider, and discuss.

I keep a close watch on all of the major business directories in my part of the country, pertaining to manual therapy, and massage therapy. Under these two headings, I can see several sub-groups:

hot-stone therapy,

reorganization of the myofascial system,

reflexology,

aromatherapy,

trigger point massage,

reiki,

myotherapy,

onsen,

holistic,

dry needling,

chinese cupping,

dorn spinal massage ,

deep tissue massage ,

scenar pain relief,

shiatsu,

vibrational massage,

hawaiian massage or lomi-lomi,

cranio-sacral , and rolfing.

I haven't exhausted the offerings - these are but a few. If the medical practitioner, or the duty nurse, or a rehabilitation officer has an idea that simple, yet competent, manual therapy, would be of assistance to the injured client - what is he/she supposed to think when confronted with this amazing array of options ?

Get real about your profession, possums - these fringe elements are dragging your status down by confusing the injured client with this absurd labelling; we don't want to hurl accusations at the other groups, but, we really have to take steps to provide separation between the two distinctive camps.

Massage Associations

So, you're in business as a massage therapist, (or are planning to,) and you have been advised to join a professional association of people with similar views to yours. If you are reading this is Australia or New Zealand, then you may have been convinced that such a membership is virtually compulsory.

Firstly, membership is just another form of advertising, which you can adopt as a part of your marketing strategy, or you can reject - there is still no law that says "thou must have membership of an approved society".

So, should I join, or should I not ?

As when faced with any cross-road, in life, or in business, I suggest you weigh up the advantages against the disadvantages.

Association membership costs money; not a lot for many therapists, but it's still an expense.

Membership gives you access to Health Benefits Funds, that you would find difficult to obtain as a non-member - it would also assist you with your insurance contract.

On the all-important issue of business revenue, or your reputation in the manual therapy business, I have some serious doubts; membership of an association does not guarantee you success, nor will it be very helpful in day-to-day running of your clinic - this is all up to you and your team, if you have one.

In order for an association to have influence, whether over the therapists, the government, the administrators of the various health insurance funds, the public liability insurers, or even the advertisers in their own magazines, they need high membership numbers.

I am quite familiar with this situation - I have a society of hand-picked therapists, numbering in the low hundreds - so small to be easily overlooked, but so special, that you could easily select any one of them from the directory, and know you would consult a true carer, with high capability.

So; in order to fill the ranks, I'm talking massage therapy here, or better still manual therapy, or massage science, any other association needs to expand their criteria for admission.

Other forms of massage, other treatment systems, other beliefs, even the most fanciful, have to be considered by the association managers - and, as long as there is evidence of training, this application is generally accepted, and, membership granted.

Think about this, possums - you could be a member of a group that numbers in the thousands!! Attend the seminars, and you could be quite impressed by the huge crowds - but, when you advertise to the world that you have these glossy credentials, don't be surprised if the client says - isn't the guy in the next street that uses chanting, and who beats a drum, and who uses hot rocks, in the same association as you - doesn't that make you the same ?

Massage Science - advertising

Each year, when the latest version of the telephone directory arrives, I peruse it to see that the publishers have entered my details correctly; I have another motive for this perusal. There is a general section, listing my name,address, and phone numbers, and a second section, where, if you have paid the extra premium, your details are published in a trade directory - in Australia, this trade section is called the Yellow Pages.

So, you could open the general directory - The White Pages, and find the name Bernard Scully listed, with address and phone number; alternately, you could consult the trade directory - the Yellow Pages , search under "Massage Therapists", and find the same Bernard Scully listed, along with many others.

Ask any advertising or marketing advisor with local experience in Australia, and he/she will tell you " no business could expect to exceed or survive, without a noticeable entry in the Yellow Pages directory. (YP)

There are, of course, many other directories published who want to compete with the firmly established YP, another two were launched just this week, but for the present YP has the upper hand.

Wherever you are when you read this, you can probably nominate the directory of choice, and relate to what I'm talking about. Now, I can at last get to the point I want to discuss with you : why does a person consult you for manual therapy treatment, and not your competitor ?

I have kept statistics for over twenty years on this matter, and here are my findings;

60% say : I saw your ad in the YP,

15% say: I have seen your ad in the YP for many years, and figured you are here to stay,

10% say: a friend recommended you to me,

5% say: my medical practitioner recommended you, and

10% say: I've wanted to have a manual therapy treatment for some time now, but didn't know where to go, because I was uncertain, and suspicious of many of the therapists I heard about, and the advertisements they publish.

This final 10% group intrigues me - you could be well-trained, and capable therapist, and an all-round model citizen, but if you are a member of a group therapists, or if you associate with therapists who continue to condone, and approve, wierd and unscientific methods, you run the risk of alienating yourself from a significant portion of the community.

Frozen Shoulder

Frozen shoulder is a descriptive term often applied when someone has limited ability to abduct the humerus laterally; sometimes, this gleno-humeral abduction can be as small as 45 degrees. any attempt to travel beyond this point can produce pain near the top of the humeral shaft (near the tubercle,) and/or further down the shaft, towards the lateral deltoid insertion.

Quite often, this restricted abduction situation can persist for several months; a discussion of one of the possible causes of this situation is contained on my web-site www.theinsideout.com.au , but today I want to speculate about the possible ongoing symptoms. What is likely to occur, if the condition is not dealt with promptly ?

When abduction of the gleno-humeral joint is unhindered, and you can freely point your fingers towards the ceiling, without pain, and without distortion of the torso, muscles such as the serratus, teres, and pectoralis are enjoying a stretch; limit this abduction movement, and these muscles will become fibrotic.

When abduction of the gleno-humeral joint is freely, and regularly performed, muscles such as the lateral deltoid, levator scapula, upper trapezius, and supraspinatus, experience contractions; limit this contractile experience, and eventually these muscles will develop flaccidity, and a degree of weakening.

So, as a manual therapist who has the opportunity to correct the original fault, i.e., the limited abduction, you may, on occasion, be called upon to deal with, one group of muscles in need of stretching, and another in need of strengthening .