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I Can See Pain in Your Future

Not the best forecast, but its true. By observing one’s posture and movement, a healthcare practitioner should be able to identify the source of pain or the risk of developing pain later on.

I’m not talking about obvious pain, such as a traumatic injury like a strain/sprain, but the nagging, chronic pain or recurrent injuries that nobody seems to be able to figure out.

Why is the cause of chronic pain so elusive?

The answer to this is based on the approach that many practitioners are taught in school and continues to permeate within most orthopedic, physical therapy, chiropractic and massage practices.

This structural approach relies on visualizing static structure, e.g. isolated anatomical areas, such as a joint, and is fairly mechanistic or reductionist. It is a great approach for addressing acute trauma, but when it comes to chronic pain, it will often result in a wild goose chase and poor outcome.

On the other hand, the functional approach looks at movement patterns and identifies mobility and stability issues as well as the role of the core.

This is a more integrative and holistic approach that looks at the entire body and the different structures (e.g. fascia, muscles, joints).

To best appreciate the two approaches, lets take an example of lower back pain.

The typical structural approach

  • Looks at the motion of local structures
  • Uses regional orthopedic tests and a neurologic exam
  • Often relies on imaging, e.g. X-ray, MRI

 

The typical structural approach

  • Looks at the motion of local structures
  • Perform regional orthopedic tests and a neurological exam
  • Order imaging, e.g. X-ray, MRI

Interestingly, X-ray findings of spinal degeneration are present in a high proportion of asymptomatic individuals, as they age.

Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.

http://www.ajnr.org/content/early/2014/11/27/ajnr.A4173.full.pdf


The typical functional approach

  • Looks at the motion of the entire kinetic chain, i.e. A movement screen that observes how the body moves in a functional way, e.g. an overhead squat and/or gait analysis
  • Assess one’s breathing pattern
  • Observes motion of the joints above and below the area of pain
  • Assess muscle length and strength
  • Uses functional tests, e.g. hip  extension and abduction movement pattern tests

As you can see, there are many potential areas, starting at the foot, that can cause low back pain.

How does one get from acute pain to chronic pain?

 

The Pain Injury Cycle

Acute pain from an injury results in a local inflammatory response. This generally resolved in 24-72 hours. If the area is constantly re-injured or irritated, the surrounding muscles will spasm to protect the injured area. Over time, this abnormal muscle tone can cause adhesions to form in the soft tissues. These adhesions affect the length/tension of the involved structures and the joints they surround. The result is dysfunctional/compensatory movement patterns mediated by the nervous system. These compensatory movement patterns eventually lead to more imbalances and ongoing inflammation, hence a vicious cycle ensues.

In acute pain, the area of pain is generally the source. In chronic pain, the area of pain is often the compensation, i.e. a muscle or structure working overtime.

Focusing on the compensation will often destabilize the area,  predisposing it to more pain and dysfunction.

Patterns of Imbalance

Janda, a Czech neurologist, was instrumental in identifying predictable patterns of imbalance which he called the upper, layered and lower crossed syndromes.

These syndromes were characterized by crossed patterns of tight/facilitated and weak/inhibited muscles that resulted in postural distortions and pain.


The core connection to pain

There are three ways to categorize the core musculature:

  1. Local- Intrinsic spinal stabilizers
  2. Global- Muscles that attach from the spine to the pelvis
  3. Movement- Muscles that attach from the spine or pelvis to the extremities

The movement system can be further divided into 4 subsystems. These subsystems or myofascial slings, illustrate force-couple relationships involved with movement.

A force-couple relationship is the action of muscle groups moving together synergistically to produce movement around a joint.

In a structural approach it is believed that a single muscle pulling on a bone creates movement. However, in the functional approach, movement is viewed as the recruitment of muscle groups, which in turn creates a force-couple utilizing various lines of pull and forces to create that movement. These muscles can be agonist-antagonist (opposite) pairs or synergistic pairs.

The  inter-connectivity between the muscles of the core and the upper/lower extremities illustrates how muscles located at one part of the body can influence other parts.


The 4 Subsystems

Posterior Oblique

                        Anterior Oblique          

     

 

 

 

 

 

 

 

 

 

  Lateral                                                                                                           Deep Longitudinal

 

 

 

 

 

 

 

 

http://brentbrookbush.com/category/core-subsystems/

(Great resource for these subsystems and continuing education)

Understanding the subsystems can be the key to identifying how  pain in one area of the body is affected by a dysfunctional muscle on the opposite side. For example, in the Posterior Oblique subsystem, left shoulder pain can be related to weakness of the opposite gluteus maximus muscle


Taking a Functional Approach to YOUR pain involves looking at the body as an integrated unit, rather than a collection of isolated structures.

If you have chronic pain or recurrent injuries, a functional approach could be the answer. If not, then:   “I can see Pain in your future.”


References

Clark, Michael, and Scott Lucett. NASM essentials of corrective exercise training. Lippincott Williams & Wilkins, 2010.

Page, Phillip, Clare Frank, and Robert Lardner. Assessment and treatment of muscle imbalance: the Janda approach. Human Kinetics, 2010.

http://brentbrookbush.com/category/core-subsystems/

About the Author

Dr. Geoff LecovinNaturopathic Physician/Chiropractor/Acupuncturist/Certified Strength and Conditioning Specialist/Corrective Exercise Specialist/Performance Enhancement Specialist/Certified Sports Nutritionist/View all posts by Dr. Geoff Lecovin

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