I love working with Muscles. Here’s Why

I spend a lot of time treating muscles because they can be the source of a lot of patient’s problems.  This is because they have such a key role within the body and we ask so much of them.  There are 3 types of muscle: skeletal (they move parts of the body including arms and legs), smooth (found in the internal organs) and cardiac (heart).  Today I thought I would discuss skeletal muscle.

Skeletal muscle is a soft tissue composed of muscle fibres. The muscle is attached to bone via tendons (ligaments attach bone to bone). The contraction of the muscle fibres produces movement.  The tendons are connected to at least two different bones and so when the muscle contracts one bone is moved.    Muscles tend to work in pairs.  When one is contracting (Agonist muscle) the other is relaxing (Antagonist muslce).  A good example is when the biceps contracts the triceps relaxes resulting in the elbow bending.  During movement in addition to the agonist and antagonist muscles there is also the synergist and fixator muscles.  The fixators’ role is to stabilise one part of the body to prevent any unwanted movement and the synergist muscles stabilises around the joint where the movement is occurring.

The contraction of the muscles fibres under load or tension is known as a concentric contraction.  Muscles can also lengthen under load or tension and this is called eccentric contraction.  An example of this is the quadriceps muscles lengthening during sitting down slowly.  Muscles can also contract without movement and this is referred to as an isometric contraction of the muscle. For example, squeezing the buttocks together activates a contraction of the glut muscles without any movement.

Muscle action is therefore a complex but extremely clever and efficient process.  However sometimes physiotherapy is required to improve the performance of the muscles.  These are just a few of the reasons why; muscle (including tendon) injury, over use of the muscle, weakness, poor biomechanics, poor posture and stress.  Very often a problem with the muscle results in pain.

Physiotherapy treatments can reduce pain and other symptoms treating the muscle through various techniques including:

  • Massage (Massage): assists with reducing the tension in the muscles and can help with relaxation if stress is a contributing factor
  • Deep tissue dry needling (Dry Needling. What is it Exactly?): can assist with releasing any painful trigger points in the muscle belly
  • Stretches: help lengthen tighter muscles
  • Strengthening programme: make the weaker muscles stronger. Improving the balance between all the muscles ensuring they are working together correctly
  • Advise and education: information on why the muscle is a contributing factor to the symptoms and how this can be improved and prevented in the future.

Treating the correct muscles can have a very positive impact on symptoms which is why I love working with them!

Back Pain

Lower back pain is one of the most common problems I see in my practice.  The severity, duration and intensity is variable but the predominant reason for patients attending physiotherapy is the same.  They are in pain and the pain is affecting their daily lives and ability to carry out activities.

There are short and long term goals when it comes to physiotherapy treatment of lower back pain.  The short-term objective is to reduce or resolve the back pain and therefore increase movement and ability to carry out functional and sporting activities.  The long-term objective (especially for those suffering with chronic lower back pain) is to teach self-management for back care.

Treatment of acute lower back pain will vary from patient to patient as it is dependent on each individual.  However, treatment primarily involves education and advice, some hands-on mobilisation of the spine and soft tissues and a gentle exercise programme to mobilise the spine and begin to strengthen the muscles around the spine.

Long term self-management of the spine involves discussions around ergonomics at work, advice and education, more advanced exercise programme to mobilise the spine, pelvis and hips and strengthen surrounding structures.  Progress can take time, especially if the problem is chronic but it is important that the set programme is followed.

The Chartered Society of Physiotherapy (UK) has recently published:

“10 Things You Need to Know About Your Back.”

Chartered Society of Physiotherapy May 2017, accessed 9th May 2017, <http://www.csp.org.uk/yourback>

It is well worth looking at this as it has a lot of relevant (researched based) information in the publication. It may well answer some questions you have regarding lower back pain.

If you are suffering from lower back pain and unsure whether physiotherapy will be able to help you, please do not hesitate to contact me and we can discuss your problem in detail and determine what the best course of action is for you.

 

 

Physiotherapy Assessment

Often, when it is someone’s first time attending a physiotherapy assessment they do not know what to expect. I thought I would write a brief blog outlining the fundamentals of a physiotherapy assessment in the practice setting and how the assessment determines what treatment comes next.

The assessment tends to be longer than a treatment session because there is a discussion element at the start of the session in addition to the physical examination. To begin with we discuss why you are attending, expanding on signs and symptoms. We also discuss lifestyle and general health. These questions can sometimes appear a little personal but it is important that the physiotherapist asks them when it is relevant because it helps to determine what may be contributing/causing your problem and then to decide what needs to be looked at and tested in the physical examination. This is known as the subjective examination. This aspect of the assessment is particularly important if you have come directly to the physiotherapist without a referral from a doctor because the physiotherapist is the first health care professional to assess and diagnose your problem. The amount of time spent on the subjective is variable, depending on whether your history is complex or more straight forward. The subjective assessmenthelps determine what is assessed in the physical examination.

The physical examination follows the subjective assessment. During this part the physiotherapist will observe you both statically and during movements. They will palpate and feel the affected area, and often areas above and below the problem area. It can be indicated to look above and below the problem location because on occasion the problem is being caused somewhere else and the problems you can experience can be symptoms of the problem but not the actual cause. In addition, the physiotherapist looks at muscle strength, range of movement and ability to carry out functional tasks (for example standing on one leg). To help the physiotherapist determine whether it is a structural, ligament, muscle, tendon, cartilage, nerve problem the physiotherapist may well carryout special tests which are specific to a particular joint.

The information attained during both sections of the assessment will allow the physiotherapist to establish a cause of the problem and therefore a diagnosis. A problem list and treatment plan can then be established and discussed with you, with an explanation of what treatment would be appropriate and why. Physiotherapists are always observing and reassessing so over time, depending on progress and how you are responding to the treatment, the treatment plan may change. This will always be communicated by the physiotherapist. If you are ever unsure of the reasoning behind a specific treatment choice, always ask!

If you have read this and wonder whether a physiotherapy assessment would be beneficial to you give me a call, we can discuss your problem and determine the next step together (What is Physiotherapy?).

 

 

What is Physiotherapy?

There is quite a varied opinion on what physiotherapy is and what physiotherapists do.  This is not surprising as people’s opinions will depend on their own experiences with physiotherapy which can be very different depending on why they required the physiotherapy in the first place.   Physiotherapists can be found throughout all aspects of healthcare.  From Intensive care rehabilitation, stroke units, children’s wards to a general practice on the high street.

Ultimately a physiotherapist’s goal is the same: “To help restore movement and function when someone is affected by injury, illness or disability”(The Chartered Society of Physiotherapy).  How this is achieved will vary depending on the needs of each individual patient.  In addition to restoring movement and function physiotherapy can help maintain current levels of functional abilities when a patient is suffering from a chronic condition which may cause gradual deterioration in health.

Physiotherapy is a modern medicine concept.  Treatment is based on science based research. Physiotherapy considers the whole person resulting in a holistic approach to each individual patients care. This means considering all aspects of a patient’s health (physical and mental) and lifestyle.  This will include working closely with other members of the patient’s health care team to maximise input and recovery.

Treatment of injury, illness or disability is achieved through a combination of movement, exercises, education, advice, manual therapy and soft tissue release/mobilisation.  The treatment programme will vary and will be individualised to each patient.  The core to physiotherapy treatment is that the patient takes responsibility for their own involvement in their care, participating in treatment sessions and the home exercises prescribed to them.

Physiotherapist are involved with patients who are experiencing acute problems (for example a flare up of arthritis, a sprained ankle, episode of back pain or recovering from a fracture)  and chronic long term conditions (for example Multiple Sclerosis and Fibromyalgia).  Physiotherapy can have a significant impact on a patient’s life by assisting with managing/improving pain, facilitating recovery, aiding people to remain independent at home and remaining in work for as long as possible.  Physiotherapy can help people at any point in their lives from small children to the elderly.

Personally I have worked in many aspects of adult physiotherapy including acute medical wards, orthopaedic wards, intensive care (for rehabilitation and respiratory care), neurological and neuro surgery specialist centre, neurological rehabilitation centre, acute stoke unit, stroke rehabilitation wards, care of the elderly wards, the community (treating patients in their own home) and clinic settings. This has allowed me to develop my treatment skills and knowledge of the human body, disease and illness.  In turn I am able to transfer these skills into ensuring I give each individual patient the best possible physiotherapy care.

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Soft Tissue Injury

Recently I have been treating a lot of sprained ankles because one role a physiotherapist has is the treatment of soft tissue injuries. This will vary depending on the nature and severity of the injury. It is advised to always seek prompt medical attention following an injury as this will ensure an accurate diagnosis and the correct specific care.  However there is some generic research based advice that can be followed immediately after an acute soft tissue injury.

 

The acronym PRICE Protection, Rest, Ice, Compression and Elevation remains one of the most popular approaches to management for the first 24-72 hours following injury.

Protection: a short period of protecting the injured area through unloading/not using the injured area is required after the majority of soft tissue injuries. However excessive protection (and rest) and unloading of the joint can do harm.  This is one reason why it is important to seek advice about how to progress the loading of the joint during the first few days post injury.

For example an ankle sprain: using elbow crutches to walk with for the first 24-72 hours will help unload the ankle joint and so protect it but it is important to wean off the crutches and start loading the joint at the correct time.

Rest: if the injury has occurred during an activity then cease the activity immediately.  Resting the injured area helps prevent further damage and avoids further pain.  However, as discussed previously excessive rest for excess of 72 hours can do harm.

Ice: standard application of ice is for 20 minutes over the injured site every 2 hours for at least the first 6 hours following the injury (the skin must be intact).  The ice can help with reducing the pain and there is some evidence that ice can help with inflammation.

Compression:  applying a firm (but not so tight it causes discomfort) bandage to the injured area can provide support (which can help with confidence as the injured area can feel more supported).  It can also help reduce local bleeding and swelling.

Elevation: placing the body part higher than the heart (if possible) can help reduce the accumulation of excess fluid (swelling) in the area.  Elevation can be achieved by wearing a sling for the arm or placing the leg on a stool or in lying with it rested on pillows.

 

In addition to the above advice, it is important to avoid the following HARMful activities for the first 72 hours following the soft tissue injury:

Heat: avoid hot baths, heat packs, saunas and heat rubs because heat can increase bleeding and swelling at the injured area.

Alcohol: it may mask pain and the severity of the injury increasing the risk of re injury.  It can increase swelling, bleeding and delay healing.

Running/moderate activity: it can cause further damage to the injured area.

Massage: Vigorous massage to the actual injured area for the first 24-72 hours post injury could cause further bleeding, swelling and pain.  Massage in areas away from the injury maybe beneficial but that should be determined by a qualified professional.

 

The advice given above is for the first 24-72 hours following an acute soft tissue injury.  Post 72 hours, rehabilitation to reduce pain, increase movement and strength of the area and increase balance (for a leg injury) is required.  The treatment plan will depend on the location, severity and nature of the injury.  If you ever have any questions or are unsure how to proceed following the injury, always seek medical advice.

Running the Amsterdam Half Marathon October 2016

On October 16th 2016 I ran my first half marathon here in Amsterdam. Prior to this I had run a couple of 10km and 5km races years ago. My reasoning behind running the half marathon was that this year I wanted a new physical challenge. I chose running as it was one of the most accessible and convenient forms of exercise I could do, fitting runs in between work. Also I’ve always wondered whether I could actually run a half marathon.

I am one of those people who enjoys having a physical challenge to train and work towards. When I was living in the UK I worked my way through the Chinese kickboxing belts finally achieving black belt. Up until now that has been the most physically and mentally testing event in which I have participated. I do enjoy the discipline required to follow a training programme to ensure you meet your goal. I could have run the half marathon with less preparation but I would not have achieved the time I did and I would have put myself at risk of injury.

I started the official training 6 months prior to the race. Before then I was occasionally plodding around Vondelpark with no set goal, attending bootcamp and personal training once a week. My Personal Trainer Lorna Wilson of Wilson’s Workouts (Wilson’s Workouts) designed a running programme for me to follow to ensure I was at my peak of physical fitness by 16th October. I cannot say I am a passionate runner. However, I did (and still do) enjoy getting outside in the fresh air to exercise. I am not a runner who enjoys listening to music, rather I use the time to clear my head and compose my thoughts, making work and home to do list, thinking about my shopping list, planning weekend social events etc. In fact this blog was written in my head while running around the park. Having the set programme really helped with the motivation as it meant I had to go out running whether I wanted to or not. Apart from a couple of social weekend engagements I was pretty committed to the programme and stuck to it. I even surprised myself by enjoying running on my holiday. Normally when I am on holiday I do very little exercise. However I went away close too the race to justify a week off so I packed my trainers and running kit. I followed my programme and I felt great for it. I got the runs done in the morning and it meant I could enjoy the local cuisine guilt free!

In addition to the running I continued with my conditioning work at Lorna’s bootcamp once a week and personal training sessions once a week. The combination of the conditioning/strengthening work 2x week and running 3x week meant on race day I felt confident and fit. I knew I should be able to complete it as I had managed 20km in training.

However………on the day it was tough!! I did the one thing everyone advised me not to do…I started off too fast and continued with that pace. After a couple of kilometers into the run I felt comfortable and was really happy with the pace. My goal was always to complete in 2:15 and the pace I started at was faster than the pace I needed to be running at but because I felt so good I didn’t slow down. On the plus side I did run a 5km and 10km BP but on the down side 12-16km were very tough as I got really tired. It took all my discipline to keep going. Fortunately at 16km I slowed down just enough to keep a good pace and to feel more comfortable resulting in beating the 2:15 finish time I was aiming for. I was thrilled with the finishing time of 2:08, even if as I crossed the finish line I was so hot (amazingly hot day for October), tired and a little nauseous.

All the training leading up the run meant that I did not pick up any injuries during the run and I was able to run hard. The following days I was really tired and had extremely tender toe nails but apart from that I felt great. What did surprise me was that during the week after the race I did not run and I really missed it. I was actually looking forward to getting back out there running. That I did not expect!

I have always respected long distance runners, particularly marathon runners, triathletes (half Ironman and full Ironman just blows my mind). I am truly in awe of what they can achieve. The discipline to training and the mental attitude is incredible as I know how much hard work I had to put in to do this race. It does show what you can achieve if you put your mind to it.

So what’s next for me? At the moment I am enjoying running each week but at my pace and at the distances I fancy rather than following a strict programme. I would like to do some 10km races next year to beat my BP and you never know perhaps another Half Marathon. I am not currently feeling the need to do a full marathon but never say never!

 

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Dry Needling. What exactly is it?

Whenever I mention that I do superficial and deep tissue dry needling as a treatment technique, the very first thing people ask me is “Is that acupuncture?”  The simple answer is “No it is not”.  Acupuncture uses a different mind-set and a different language.  I am not an expert on acupuncture and do not want to do the individuals who practice acupuncture the disrespect of even attempting to explain its concepts and complexities.  However I will discuss it in reference to comparing it with the dry needling techniques I use.

Acupuncture is based on the Traditional Chinese Medicine concept of the meridian system, a belief in a path through which the life-energy known as Qi flows. Acupuncture involves inserting very fine needles into specific points of the body to help stimulate movement of energy within the body.  The goal is to restore the proper flow of Qi.

Both superficial and deep tissue dry needling techniques also use the insertion of fine acupuncture needles into different parts of the body but they are based on a western medicine concept.  The decision on the site and the depth of the insertion of the needle is established through the description of the pattern of pain and symptoms which the patient experiences and the discovery of myofascial trigger points through palpation.

A myofascial trigger point is an exquisite spot of tenderness in a nodule of muscle.  When pressure is applied to the tender nodule it reproduces the pain that the patient has been describing.  The science behind the development of thenodule within the muscle is complex and a little hard to explain but ultimately it occurs due to over use, over loading, over stretching and over working the muscle which causes an energy crisis in the muscle, resulting in the painful nodule and referred pain pattern.  The insertion of the needle (particularly with deeper muscles) helps increase blood flow to the area in a way that simple palpation cannot.  This counteracts the local energy crisis and so help reduce/remove the tender nodule that is causing the pain.

Superficial dry needling technique is also used.  The needle is inserted more superficially over a specific are, rather than deep into the muscle.  This technique is often used for pain relief over a specific area.  For example if you have sprained your ankle, superficial dry needling can be used above the injury to help relieve the pain caused by the injury.  This occurs due to the stimulation of certain pain fibres that result in a natural opioid release– which is your own body’s natural pain relief.  As a result of controlling the pain further therapy can commence and it reduces the risk of secondary problems associated with pain.

It is important to understand that dry needling techniques are not a quick fix.  They may well help reduce/resolve some symptoms.  However the reasoning behind the trigger points forming in the first place need to be established.  If they are not addressed then there is a strong likelihood that the trigger points and the symptoms will return in the future.  Dry needling is an excellent treatment technique to use alongside other physiotherapy treatments for example education/advice, stretches and exercises.

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Massage

The term massage is a generic word that covers a wide range of soft tissue techniques that are used inside and outside the therapist treatment room. Massage is just one component of physiotherapy holistic intervention and is normally used in conjunction with other elements of physiotherapy treatment techniques.

I have found using massage in conjunction with other physiotherapy treatment techniques to be a highly effective treatment combination. There are so many physical and psychological benefits to massage:

– Touch can be comforting
– Aids the relaxation of muscles which helps relieve muscle tension
Reduces pain
Increases blood and lymph circulation
Increases range of movement and flexibility
Releases endorphins (happy hormone)
Improves the immune system
Increases oxygen flow
Postural improvements
– Helps with improving sleep
Increases energy
Rejuvenates tired muscles in an athlete

Many of those points can be interlinked. For example relieving muscle tension in the neck might reduce pain, increasing ability to sleep and therefore reducing stress levels.

However you don’t have to be in pain/recovering from a sporting activity/under physiotherapy treatment to benefit from a massage. The above points can benefit everyone. Ultimately massage can help with relieving the body of physical and mental stresses that day to day life throws at us all, which in turn improves overall wellbeing. I personally feel most people would benefit from a regular massage. To you it may feel like a pampering but it is actually a highly effective investment in your own health.

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Pilates – Practicing What I Preach

I have mentioned core stability before in my blogs and have spent the last 2 years working on my core strength. So, I felt it was time to practise what I preach by going to a Pilates class.

Essentially, Pilates focuses on the postural muscles in the body, building strength from the inside out. It can help to correct postural alignment and educates the body on proper and more efficient movement patterns. It was developed nearly 100 years ago and is taught internationally to date.

Some of the benefits are:

  • Stability of the entire spine, pelvis and shoulder girdle
  • Strengthening of the pelvic floor, deep abdominal musculature and gluteals
  • Strengthening of the upper and lower extremities
  • Spinal mobility and flexibility
  • Peripheral joint mobility and flexibility
  • Overall postural improvement

Pilates 1Pilates 2

 

I really believed I could physically improve from practising Pilates particularly as I naturally have a very stiff spine and find certain movements quite difficult. So, I joined a beginners class two months ago and I can already feel the benefits. I am getting more spinal movement and my strength is improving. In two months I have noticed some of the exercises have become easier and my movement more efficient. As a result of my experience I now recommend Pilates to my patients.

The class is an hour long and I love for that one hour I feel completely in tune with my body.   It is a very enjoyable experience.  My teacher Michelle is excellent at instructing what we need to do and it takes all my concentration to try and get my body to do it!  I am one of those people who finds it very hard to switch off mentally.  I am always thinking about the next thing, whether it is something about work or what I need to pick up for dinner.  My mind never stops.  However in that hour class all I do is fully concentrate on the movement of my body and the activation of the correct muscles, completely clearing my mind of its usual busy thoughts.

Pilates is certainly challenging, getting your body and spine to move in particular ways but like everything the more you practise it the easier it becomes.  It is a very satisfying to feel the benefits and see the progress over the weeks.

 

You do not need to have an injury, be in pain or have an active problem to profit from doing Pilates.  The list of benefits above can be applied to everyone. It is important to remember that each person moves differently, with different physical limitations.  If you have a good Pilates teacher they will be able to instruct accordingly.

Michelle Lee is my Pilates teacher.  She is a Canadian qualified Physiotherapist.  She is a fully qualified floor Pilates instructor and is currently undergoing her Pilates equipment training.     Her physiotherapy background allows her to have an in depth understanding of the anatomy of the body and how it should move. This knowledge can be seen when she is instructing her class and individuals.  If you would like to discuss Pilates class or individual session with her please contact her on: Michellejlee84@gmail.com

Put quite simply – Pilates has so many physical and mental benefits and I am loving it!  Give it a go.

 

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Core Stability Exercises

As promised ( in How to Carry Out Core Stability Exercises Correctly  ) I want to go through a few basic core stability exercises that can be carried out at home or in the gym. These exercises are a great way to train the muscles around the lower spine and pelvis. It is worth noting that it is important that the exercises are done correctly. If you are unsure of your technique I would always encourage you to get advice and have a professional (eg. physio/personal trainer/yoga instructor/Pilates instructor etc) observe how you are carrying out your exercises. If you are currently experiencing or have a history of lower back problems I recommend you seek advice from a physiotherapist before commencing any of these exercises.

Before trying the exercises listed below it is worthwhile seeing if you can actually activate your deep stabilising muscles. Can you carry out the action of “drawing in” your abdominals? Most people, on their first go end up drawing their stomachs in by taking a deep breath in which is not correct. It’s surprisingly harder than you think! Have a go:
Lie on your back with your knees bent and feet flat on the floor. Draw your stomach (abdominals) in towards the floor (towards your spine) without taking a breath in at the same time. Keeping your stomach drawn in now push the lower part of your back that is at present not in contact floor down into the floor. Your pelvis will tilt forwards a little (Fig 1)

trans abs blog Fig 1

If you are not quite sure you can try it in another position:
Kneel on all fours, with your hands directly below your shoulders and knees below hips. Draw you abdominals up towards your spine without taking a breath in. At the same time tilt your pelvis slightly forwards
Once you have mastered the position you can concentrate on breathing in a normal manner, holding the contraction for 10 seconds.

When you feel you have learnt to stabilise your back/pelvis region (through the above exercise) then you are ready to try the exercises below (starting position is on the floor):
1. The Plank (Fig 2): Positioned face down. Support yourself on your forearms and through your feet (toes), with your pelvis in a neutral position (don’t let your bottom sink or stick up) and your legs fully extended. Brace your stomach and buttocks throughout the exercise. Aim to hold for 30 seconds but discontinue if you start to feel your back.

plank blog Fig 2

2. The side plank (Fig 3): Position on your side. Support yourself on one forearm and the side of the lower foot. You can have the top foot placed on the floor in front on the lower foot or on top of the lower foot. Lift your hips off the floor to get the body into a straight line. If you can, lift your upper arm up towards the ceiling. Brace your stomach and buttocks throughout the exercise. Aim to hold for 30 seconds but discontinue if you start to feel your back.

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3. Bridging (Fig 4): Lying on the floor with your knees bent and feet flat on the floor. Draw in your abdominals. Squeeze your buttocks together and lift your pelvis off the floor until the body is straight. Hold for 10 seconds and then slowly lower to return to the staring position.

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4. Superman four point kneeling position (Fig 5): Kneel on all fours with your hands under your shoulders and knees under your hips. Draw your abdominals in. Raise one hand off the floor (as if you are reaching forwards) at the same time lifting the alternate leg off the floor (as if it is being pulled behind you). Repeat this action with the other two limbs.

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The number of repetitions depends on how many you can manage. It is better to do less if it means each repetition is done correctly. It is beneficial to be working on your core stability a couple of times a week.

There are so many exercises that can be completed to help with core strength. The exercises can be made progressively harder through introducing controlled movement or holding the position for longer or even adding another element to the exercise for example using a swizz ball.

If you are keen to work on your core conditioning you are welcome to contact me and we can design a programme that is appropriate for you. Alternatively Pilates is an excellent way to exercise the whole body and mind, working on improving strength, suppleness and control (Michelle Lee at Michelle Lee Pilates Plus is an excellent teacher michellejlee84@gmail.com). Have a go and enjoy!