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Category: Pain

The many pelvises theory

Posted on | Pain
Your soul is mine! Flawless victory.
Go ahead and stand up and thrust your pelvis right now. Which one, you ask? Good question!
 
Today, we go over what I call ‘the many pelvises theory’. You may know a little bit about the pelvis you mostly use, but why limit yourself to just one? Let’s broaden up the characteristics of the pelvis so that we can start enjoying as many as possible. Each pelvis should be like a room – it will have a floor, a ceiling, and walls. Each pelvis can stack on top of the one below so that they share a floor/ceiling.
 
In order to outline the 5 pelvises, we have to define each floor/ceiling. Each of these transition points is like a horizontal hoop along the body. These transition points can be identified by the fascial bands that run along their circumference, the spinal transition zone they anchor into, and what the ‘opening’ of the hoop is. This opening will either be labeled by what structure fills the opening or sometimes just the anatomical name given to that specific opening. As a bonus, there are coincidentally also 7 chakras (energy points) and these also line up pretty well with each transition point so I’ll mention those as well.
 
Note that the article is mostly intended for clinicians since it contains a lot of anatomical terms.
 
Head hoop
  • Fascial band: starts at the bridge of the nose and goes around the eyes, over the ears to the external occipital protuberance
  • Spinal transition zone: sphenobasilar junction
  • Opening: tentorium cerebelli
  • Crown chakra
 
Chin hoop
  • Fascial band: starts at the chin and goes along the bottom of the mandible and includes the hyoid, then goes under the ears to C0-2
  • Spinal transition zone: craniocervical junction (OA and AA joints)
  • Opening: floor of the mouth
  • 3rd eye chakra
 
Neck hoop
  • Fascial band: starts at the top of the sternum and goes along the clavicles and top 2 ribs, splits to go over the shoulder and some fibers through the axilla, then along superior scapula to C6-T2
  • Spinal transition zone: cervicothoracic junction
  • Opening: superior thoracic aperture (usually called the thoracic outlet)
  • Throat chakra
 
Chest hoop
  • Fascial band: starts mid-chest over indention and goes along inferior border of pec major, along lateral border of lats, over the inferior angle of the scapula to T4-T8
  • Spinal transition zone: dorsal hinge – this is where the kyphosis of the thoracic spine is at its peak
  • Opening: top portion of inferior thoracic aperture
  • Heart chakra
 
Mid-trunk hoop
  • Fascial band: central point can vary anywhere from between the xiphoid process to the umbilicus, then continues along the lower 2 ribs to T11-L2
  • Spinal transition zone: thoracolumbar junction
  • Opening: inferior portion of inferior thoracic aperture with respiratory diaphragm
  • Solar plexus chakra
 
Abdominal hoop
  • Fascial band: starts anywhere between the umbilicus and pubic symphysis, then goes along inguinal ligaments to the ASISs, and follows the ala of the pelvis to L4-S1
  • Spinal transition zone: lumbosacral junction
  • Opening: pelvic inlet
  • Sacral chakra
 
Pelvic hoop
  • Fascial band: starts at pubic symphysis and goes along thighs to greater trochanters, along inferior margin of buttocks to sacrococcygeal junction
  • Spinal transition zone: sacrococcygeal junction
  • Opening: pelvic floor muscles
  • Root chakra
 
 
The many pelvises
Now that we have each transition point, defining the pelvises are easy! Each one just extends from one level to the next. I’ve outlined each pelvis’ ceiling, floor, walls, and what important structures they contain.
 
Head pelvis
  • Ceiling to floor: head hoop to chin hoop
  • Walls: skull
  • Contains: yo’ brain
 
Neck pelvis
  • Ceiling to floor: chin hoop to neck hoop
  • Walls: neck
  • Contains: speech and swallowing structures
 
Chest pelvis
  • Ceiling to floor: neck hoop to chest hoop
  • Walls: upper ribs
  • Contains: heart and lungs
 
Abdominal pelvis
  • Ceiling to floor: chest hoop to mid-trunk hoop to abdominal hoop. These 2 are combined since both mid-trunk and abdominal hoops connect into costal arch and diaphragm
  • Walls: lower ribs
  • Contains: lungs
 
Pelvic pelvis
  • Ceiling to floor: abdominal hoop to pelvic hoop
  • Walls: abdominal and back muscles
  • Contains: all of your internal organs except the heart and lungs
 
Clinical implications
It’s notable that each of the spinal transition zones are usually areas of heavy clinical focus for treatment. Clinicians will often target these areas specifically or even view them as ‘key links’ in musculoskeletal dysfunction. This is often accompanied by treatment of the corresponding fascial structures, usually along the fascial bands that connect to the spinal transition zone. Also it can be noted that 3 of the ‘openings’ of the hoops make up a set of muscles that function as a diaphragm and are often implicated in general dysfunction of that region. They are the chin hoop (floor of the mouth and suboccipitals for neck pain), the mid-trunk hoop (respiratory diaphragm for back pain), and the pelvic hoop (pelvic floor muscles for back and lower body pain).
 
There are many other theoretical implications that could be discussed here, but I present this information mostly just for your clinical interest. What is most important is that you now understand that basically all movement is some form of pelvic thrust. Your welcome.

Know how to fold ‘em

Posted on | Pain
This man has all but guaranteed his place as the beta by demonstrating such poor biomechanics in front of his new alpha.
Gravity can be a cruel mistress. Picking things up from the ground is often a source and/or contributor to low back pain. There are 4 things you need to know about your back when lifting.
  1. Keep your trunk straight. This one is the most obvious, but you need to do what your mom always told you and lift with your legs, not your back. The most important thing is that you keep your back in a neutral position and hold it there while you lift. Since you won’t be using your back to bend over, you’ll have to use your legs instead. You can squat down, fold over at the hips, or do a golfer’s lift (stand on one leg while the other is lifting behind you to counterbalance). Even better, use a variety of all 3!
  2. Don’t twist. When you’re lifting, you should always avoid twisting your spine while it’s loaded. A much safer method is to first lift the object, then turn using your feet or hips. While this seems cumbersome, places like UPS require their employees to learn this strategy before they release them to lift anything because its so important for avoiding injury.
  3. Keep the load close to your body. The further away you hold something, the more strength required to hold it up. So when you’re picking something up, and especially if you’re carrying it, try to keep it as close as you comfortably can to your hips or trunk.
  4. Brace your core. Pretend like you’re wearing a back belt (or just put your hands on your waist) and push your core outward into it. Or you can pretend like someone is about to punch you in the stomach. This is bracing your core. After you can do that, you should practice holding that contraction lightly while breathing and moving at the same time. Ultimately, you’ll want to lightly brace your core while lifting, carrying, and breathing.
 
If you follow these 4 principles, you will protect your back as much as your reasonably can. These can help prevent back injury but they are also very important principles for anyone who already has back pain. They can reduce your chance of overloading your back and reinjuring it.

Shoulder impingement – is it what we think it is?

Posted on | Pain
If your shoulder pinches you, you pinch it right back.
If you have shoulder pain, chances are you’ve been told its from impingement. So what is impingement?
 
Impingement means something is being pinched, and in the shoulder, this refers to the rotator cuff being pinched by the top of the shoulder blade called the acromion. Why would it do this? Normally, the acromion is like a roof to the rotator cuff, but it seems like in some people, it hooks downward instead of being flat, leading to an impingement problem when they reach overhead.
 
That explanation seems to make sense, especially when you go to an orthopedic surgeon who takes an x-ray and shows you a bone spur in your shoulder. But does it really make sense?
 
Impingement probably does happen in some people, but its likely nowhere near as common as people are led to believe. Research has shone a light on some of the key findings that the impingement theory is based on.
 
Rotator cuff tear location
First is the location of most rotator cuff tears. If the rotator cuff is being poked by a spiky bone spur from above, it would stand to reason that the tear is on the top of the rotator cuff, directly beneath the bone spur. However, most tears are actually on the bottom of the rotator cuff and its tendon. They also tend to be posterior and lateral to where the bone spur would touch.
 
Why is this? Well if we assume that the impingement isn’t causing the damage, then the next thing would be overload. After all, most people with rotator cuff tears have a history of a lot of overhead work, like athletes, electricians, and other people who work with their hands. There are 5 portions of your rotator cuff tendon but we’ll just classify them as the top, middle, and bottom. They are not equally strong. When the shoulder is in the overhead position, the bottom portion is about half as strong as the other two sections. Therefore, it makes a lot of sense that the bottom portion is the most frequently injured, with the cause being overload and lower tissue tolerance, and not impingement.
 
This also explains why physical therapy helps so frequently. The exercise strengthens the tissues of the shoulder which helps both overload and tissue tolerance. By making the other muscles stronger, it helps shift load away from the weaker portion. By safely exercising the rotator cuff, both the muscle and then tendon gain strength and load tolerance.
 
Side to side comparison
Many people have shoulder pain on both sides, but its usually worse on one side. However, x-rays of the bone spurs and MRIs of the muscles and tendons show that the sides look the same. This is also the case when people have pain on one side but not the other! How is it possible to have the bone spur, the ‘cause’ of impingement, on both sides, but one side hurts and the other doesn’t? That would both imply that the presence of a bone spur may not guarantee pain. On the other hand, some of the people with impingement-type pain have x-rays and MRIs that show no significant findings.
 
Medical interventions
A common pain relieving intervention is getting a steroid (cortisone) injection. This is to reduce inflammation in the shoulder. As a temporary measure to hold out before getting surgery, I can understand the rationale. But often its used in hopes that it will make the problem go away. I am all for this, because sometimes the pain does go away. However, if its paired with the impingement explanation due to a bone spur, I question the rationale. By telling someone that their pain is due to a bone spur, then giving them an intervention that doesn’t address that bone spur, it seems like you’re planting a seed that eventually their pain must return and they will have to get surgery.
 
Most surgeons also inform their patients that cortisone injections can weaken the tendon if given too often (most cap it at 3-4/year). Since a large part of the problem probably is poor tissue tolerance of the rotator cuff, this precaution is very important.
 
I’m not against cortisone injections as long as they are given with an explanation that more accurately leaves the door open for longer-term pain relief and doesn’t imply that surgery is inevitable. Generally my attitude is, try it and see. If it helps, great! If it doesn’t, let’s move on.
 
Surgical outcomes
In the study “Bursectomy compared with acromioplasty in the manage- ment of subacromial impingement syndrome: a prospective randomised study” by Henkus et al. they compare removing the bursa (a friction reducing structure in the shoulder that has many nerves and is thus a likely source of pain) vs removing both the bursa and the bone spur. They found that removing the bone spur didn’t improve results over just removing the bursa.
 
Rotator cuff tears
This article is about impingement but most people will be wondering more about surgery. First, if you’re told your shoulder pain is due to impingement and you have a bone spur and/or rotator cuff tear – don’t panic. This doesn’t necessarily mean you need surgery.
 
Surgery works better for people younger than 60. Many of the people seeking rotator cuff surgery are over 60, however, as we all know, the older you are, the lower your healing potential. Over the age of 60, research indicates actual healing from the rotator cuff surgery is less likely. It has been said that the reality of rotator cuff surgery for this population may be less about fully repairing the tear, and more about turning a painful, symptomatic tear into an asymptomatic tear. On the other hand, people younger than 60 tend to heal very well which makes surgery a more viable option.
 
Another component is how did the tear happen? Was it traumatic like from a fall? Or did it just happen gradually over time. For a traumatic tear, surgery is often preferred. If its just due to degeneration over time, then more weight is given to the size of the tear.
 
If the tear is large (the definition varies here but your surgeon would tell you), then surgery is generally preferred. The exception is for older adults (over 60). Its generally recommended that they try physical therapy first for 3 months and then reassess. For tears that are not large, physical therapy is becoming the standard course of action, with good results reflected in the research.
 
For adults over 60 who have a large tear, physical therapy has also been demonstrated to be helpful. You will know within 3 months whether or not you may opt for surgery. The research indicates by 3 months you’ll probably have your answer, but in my experience, people will very often notice improvements in the first 2-4 weeks.
 
Ultimately, the decision for surgery will come from a frank discussion with your surgeon on what they realistically think your outcome will be. The research shows that surgery has good outcomes for shoulder pain and function, especially when paired with physical therapy afterwards.
 
Read more
Read the 2011 narrative review “Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion?” by Jeremy S. Lewis for a much more thorough analysis.

IAATG

Posted on | Pain | Sports Performance
Hockey player, stick in hand, pulling his groin.
Straining your adductor muscles is often called pulling your groin, which is actually the lesser of 2 evils, with the alternative being ‘tearing your groin.’ Even so, pulling your groin is no fun.
 
IAATG – something that any athlete in a sport that involves cutting motions (quick movements to the side) can sometimes, unfortunately, find out. It’s All About The Groin. Skating sports in particular have a high rate of adductor strains due to the sideways pushing motion of skating. This injury can be notoriously hard to get rid of due to its nagging pain and likelihood of coming back.
 
Red flags
Before we break down some of the important ideas for solving this, first – red flags. Because this area is close to the pelvis, which as you may know, tends to contain some sensitive material, screening for red flags is very important when symptoms are in this area. When in doubt, always seek a medical consultation. Any changes in bowel or bladder function such as pain with defecation or urination, blood in the stool or urine, or anything else is a red flag. Any symptoms affecting the genitals or ‘straddle’ area such as numbness is a red flag. If you have any of these symptoms, you should immediately consult your primary care provider.
 
Physical Rehabilitation
Now that that’s cleared up, on to the rehab. Generally, there are 2 things that simultaneously need to be addressed. The local cutaneous (superficial) nerves and the adductor muscles.
 
The nerves
There are a bunch of superficial nerves in this sensitive area so I won’t bother naming specific ones. Let’s cut to the groin. Usually, manual therapy and massage techniques work very well on this area – the key is to be gentle (as if you needed to be told). My preferred technique is mobilizing the skin. This means finding a tender point and then gently dragging the skin in whatever direction makes the pain significantly decrease. This is usually downward towards the knee, but can be any direction. You’ll hold this skin mobilization for at least 2 minutes and then recheck tenderness. If it’s still very tender, just repeat the process and be patient. Eventually the area will be less tender and generally the person will also be able to stretch their adductors with much less pain now. If there are multiple tender points, just patiently address each one.
 
Some people also find deep massage gives them relief. In my experience, this relief is usually temporary. That doesn’t make this a bad method, because athletes will often use it to be able to play or workout without pain limiting them. It does mean that afterwards though, at some point, you should take the time to actually work it out. Deep massage can be done on your own using a foam roller or lacrosse ball. You’ll lie face down on the ground with the tool between your leg and the ground. Use contact to the ground by your arms and legs to decrease the pressure. You can just hold pressure or you can roll back and forth. Rolling tends to be more uncomfortable but some people feel they get more out of it. Continue until tenderness feels reduced.
 
The adductor muscles
There are several adductor muscles in the area and differentiating which one is actually strained is not really necessary. Just massage where it hurts and strengthen the whole group.
 
Stretching the adductors – no. First of all, if you have an acute strain, the muscle has been traumatically overstretched. Second, flexibility tends to come back naturally as the muscle heals. If you have a recurring problem, then you might lack adductor flexibility. Usually this is cleared up with the manual therapy/massage techniques. If not, the flexibility is improved with the normal strength exercises anyway. I would only recommend stretching if you are not acutely tight AND either you are so tight you physically cannot move properly OR your sport requires you to be very flexible (gymnastics, a sumo-style deadlifter, martial arts, etc.).
 
So, now the exercise progression. This starts out simple and I’ve seen most clinicians follow a similar style, except for the highest variation which I have almost never seen another clinician do. The highest variation is an accomplishment to achieve and something I consider a return to sport requirement.
 
For these exercises, you can follow a general routine of doing 2-3 sets of 5-10 reps. Once you can do 3 sets of 10 reps with no pain, you can move on to the higher variation. For the knee squeeze and side plank, hold each rep for 10 seconds. Once you’re doing normal side lunges, you can stop the adductor leg lifts and start on the basic adductor side plank variation.
 
  1. Isometric knee squeeze: just put a pillow or ball between your knees and squeeze together for 10 seconds at a time. The contraction should not be painful so go easy at first and gradually increase the intensity.
  2. Mini side lunges: start in a shoulder-width stance and perform small side lunges. Start easy and shallow and gradually go lower and widen your stance.
  3. Adductor leg lifts: lie on the side that was injured. Bring the top leg out of the way by moving it forward or backwards, and you can rest it on a pillow for comfort if needed. Lift the bottom leg upward – this will be a relatively small motion.
  4. Normal side lunges: take a stance that’s about 2x shoulder-width. Then perform side lunges, keeping the leg that you’re lunging away from, straight. You will feel a stretch in the adductor muscles of the leg that is straight.
  5. Slider side lunges: start in front of a counter or something to hold onto just in case. You’re going to do the same side lunges but with the straight leg sliding outward this time. If you’re on a floor with no carpet, you can do this using a towel under your foot. Whether you’re on carpet or not, you can use a furniture slider under your foot. If you don’t have a furniture slider, any solid piece of plastic works like a plastic plate or frisbee. Go slow and shallow with these at first so you don’t end up doing the splits. Once you can do these normally, start putting more and more weight on the sliding foot, both on the way up and down. This makes this exercise much harder.
  6. Reverse side plank: lie on your side on the ground with a normal chair that has a cushion on the seat. Scoot closer/under the chair so that you can put your top leg on the cushion. Start with the chair supporting just above the knee. Now you’ll do a side plank by propping up on your forearm but the bottom leg should not touch the ground. You will be doing a plank only with the adductors of the top leg holding you up. As you get stronger and more comfortable with this, begin to move away from the chair so that it supports your leg lower down. Go to below the knee, then at the calf, then at the foot/ankle.

Hypnotic pain relief – an explanation

Posted on | Hypnosis | Pain
Where will you be during the heat death of the universe?
I’ve talked about 10 approaches of hypnotic pain relief (https://theunitedstrengths.com/blog/f/approaches-of-hypnotic-pain-relief), but how does hypnosis work?
 
First, you need to understand the neuroscience of pain. Pain starts as a signal that is carried by your nerves and there are several ‘gates’ that can block the signal from getting to the brain. If the signal doesn’t get to your brain, you don’t feel pain. If the gates are ‘open’, then they let the signal through to move towards the brain.
 
Gate 1
It all starts when a danger signal is produced. This is then picked up by the nerves in that area. If you touch a hot stove, then a danger signal at your finger tips is produced which the local nerves in finger tips pick up. The first gate is this local nerve picking the signal up. An example of it being blocked would be putting local anesthesia over your arm before getting a shot. The chemical anesthesia blocks the nerve from picking up the signal, so even though there is a stimulus (the shot), it never gets to the brain so you don’t feel pain.
 
Gate 2
The local nerve that picked the signal up then connects to the spinal cord. Here the nerves of the body end and the transition from this nerve to the nerve of the spinal cord forms ‘Gate 2’. An example of blocking this gate is what most people would think of as a nerve block, when they inject anesthesia into your spinal cord. This is very general, but the body is able to be very specific with what nerves it ‘blocks’. By the way, the chemical anesthesia used in the body is called endogenous opioids (commonly called endorphins). This endogenous (meaning created by the body) opioids can be released at Gate 1 and at Gate 2 to relieve pain.
 
Gates 3 and 4
The nerves of the spinal cord then go up your spine all the way to the base of the brain, the brain stem. Here the brain stem and a structure called the thalamus act as a funnel and front desk to the brain. Signals that aren’t important (think about all the hundreds and even thousands of sensations your body is getting every second from your skin, muscles, ears, eyes, nose, and more) are blocked from distracting our attention. Signals that are important make it through the funnel and go to the front desk. The thalamus is the front desk – signals from all over the body come here and the thalamus tells them where to go in the brain to report their findings. In this example, the danger signal will make it through the funnel because danger is almost always considered very important. It will then go to the thalamus/front desk who will tell it to go to the finger sensation part of the brain.
 
Pain
Only when a danger signal has reached the sensation part of the brain, do we become consciously aware of it – an experience that we call pain. If, at any point, that danger signal is blocked, then it won’t reach the sensation area of the brain and it won’t be experienced as pain.
 
Chronic pain
When you’ve had pain longer than 6 months, changes are made at every level of the nervous system that generally make you more sensitive to signals in that area of your body. These changes are top-down, meaning the brain tells the rest of the nervous system to adjust the sensitivity. Thus, for relief from chronic pain, addressing the brain has the biggest bang for your buck.
 
Hypnosis for pain relief
Hypnotic approaches for pain relief mostly fall into 3 categories: desensitization, altering salience, and shifting experience.
 
Desensitization
Since the nervous system becomes sensitive to danger signals, using hypnosis to desensitize the nervous system works very well and at each of the gates. There are 3 levels of this:
  1. Normalizing sensitivity: when the body is hypersensitive, sometimes just getting it back to normal sensitivity is all that’s needed.
  2. Desensitize to pain (analgesia): this goes beyond reducing hypersensitivity to normal sensitivity. It takes it a step further by actually desensitizing your body to pain signals in general. This is most useful for chronic pain relief.
  3. Desensitize completely (anesthesia): this is complete desensitization. The area is desensitized to all sensation, not just pain. This really is useful just for pain relief that only is needed for a short duration. An example would be inducing numbness in the arm for a shot. Some people have a natural ability for hypnotic anesthesia and can even undergo surgery without any medication and feel no pain.
 
Altering salience
Salience is how important a signal is. If you twisted your ankle crossing the street, your ankle would hurt. But if a car was coming at you and you twisted your ankle, it wouldn’t hurt at all and you would run out of the way. It wouldn’t hurt in the moment because the pain was much less important than the car and feeling pain would possibly be a life threatening distraction. Later, once you were safe, the ankle would hurt because it was now the priority.
 
Hypnosis can alter salience in several ways. One way is dissociation where you feel separate from your body and thus the signals from your body are unrelated to you. Another way is being so absorbed in something else (high salience), you don’t notice the pain. This is like forgetting your headache when you’re wrapped up in a thrilling movie. Often in hypnosis, so many suggestions are given for comfort and relaxation that that experience overrules anything else. Hypnosis often involves interesting imagery like relaxing on the beach which you can be so immersed in that you don’t notice anything else.
 
While this approach probably seems less helpful than the other 2, it’s actually probably the most common form of pain relief in the medical community in general. There’s a phenomenon called the ‘x-ray effect’. When someone badly twists their ankle and they fear they might have broken it, they have a lot of pain. But, when the x-ray comes back and shows that it isn’t fractured, they immediately feel better and quickly recover. This is an example of how decreasing salience can significantly help pain and recovery. Setting someone’s mind at ease can be very powerful. It’s important with hypnotic pain relief that the client is reassured that pain they need to feel, they will. And pain that isn’t so important, they don’t need to feel. This respects their body’s need to protect them through pain, but only to the extent that is appropriate and helpful.
 
Shifting experience
This is when the intensity of the pain is not addressed, but rather how the pain is experienced. As such, suggestions for shifting experience only really take place at the highest level of pain processing, which is in the brain itself. This method can be just as powerful, and even more powerful in some cases, than the other 2 categories. Often when a person is convinced they must have pain (usually those with a terminal illness), suggestions to decrease the pain are ineffective. However, powerful relief can be accomplished by shifting the pain experience to something much more manageable.
 
Time distortion can be used where pain that normally lasts hours can be shifted to just last minutes or seconds. Usually this is paired with amnesia so as soon as the person starts feeling pain, they immediately go into trance, have the shortened pain, and then come out of trance with no memory of the pain and continue whatever they were doing. This not only reduces the pain experience but also the fear of pain which can be just as debilitating.
 
Pain itself can also be shifted. One shift is substitution for a different feeling. This happens by chaining the pain from one thing to the next. If someone has a burning pain, the focus can be shifted to burning. Then it can be shifted to the sensation of heat. Then to warmth. Then to the warm, tired feeling of relaxation. Another shift is displacement. This is moving the pain from one area to another. Again, some people truly cannot conceive of not having pain, but the pain they have is very debilitating. This is often trunk or leg pain which limits moving around. The pain can be displaced into the arm or even a finger. Thus they still have the pain they feel they must have, but it is in an area that doesn’t limit them as much.
 
Conclusion
Hypnosis for pain relief is very real. The mechanisms are carried out through alternations in the regulation of the nervous system. This goes from the level of the brain, down the spinal cord, and all the way to the level of the local nerves. If purely physical interventions (surgery, injections, medication, massage, etc.) haven’t helped you, then consider harnessing the power of your nervous system to get you the relief you need.

Addressing knee pain – a guide

Posted on | Pain
Knees have problems but sometimes we’re just not listening. That’s when the stethoscope is whipped out.

Knee pain is very common but also very treatable. Today’s post will be going over the various things that may be contributing to your knee pain and what can be done about them. This will include ideas you can use for yourself, but always keep in mind that consulting a specialist like a physical therapist will make the process much easier.

Referred pain

We’ll start with pain that is felt in the knee, but may be caused by something else. It’s possible for the hip or the low back to refer pain to the knee. Pain that comes from the hip will usually hurt worse going up stairs than going down stairs. Pain that is truly from the knee almost always hurts worse going down stairs. Another hip sign can be found when you lie on your back with your knee bent and then let it fall out to the side to open your hip up. If this increases your pain, it’s likely that the hip is contributing because this motion doesn’t use knee motion, it just changes the hip position. Finally, signs of significant hip weakness might implicate the hip. The most noticeable sign is called ‘hip drop’ or a Trendelenburg gait. If when you’re walking, one side of your hips drops down with every step, it’s an indication that the hip you’re standing on is weak. If you suspect your hip is contributing to your pain, you can start strengthening the hip by doing side lying leg raises, using a cane if you have hip drop, and, as always, consulting a physical therapist.

Knee pain can also come from the low back. While this will often be pain that radiates from the back or hip itself all the way down to the knee, sometimes it can just be felt only at the knee. If your back is contributing, then in general, trunk motions will increase your pain. You can test this by first sitting down to take your legs out of the consideration. Then test moving your back in all directions. You’ll move into each direction 10 times in a controlled fashion. Start by bending forward 10 times. Then lean backwards. Next, bend to each side. Finally, try rotating left and right each.

If any of these motions cause knee pain, then it will be best to consult a rehabilitation expert. They will likely help you improve your trunk strength with exercises, improve your flexibility with some stretches, teach you to move in ways that puts less stress on your back, and use manual therapy on your back.

Movement patterns

Now onto things that directly overload the knee itself. There are 3 movement patterns, often with specific muscle imbalances in both strength and flexibility, that can contribute to overloading the knee.

Knee bending pattern: this is when someone often uses their knees to move their body more than necessary. If you were to pick something up from the ground, you could use your knees, hips, and back to different amounts. The more you squat down, the more your load your knees. The more you bend over, the more you use your hips and back. While one strategy isn’t necessary better than the others, if a segment is hurting, then it makes sense to shift away from using that part. So if your knees hurt, then using your hips more will shift load away from the knees – this will involve folding your trunk over more at the hips. This pattern of using the hips more can be generalized to many activities which include standing up from a chair, going up/down stairs, picking things up, walking on level ground and slants, and getting in/out of the car.

The more you use your knees, the more upright your trunk will be and the more your knees will go forward over your toes. The more you use your hips, the more your trunk will fold over and your shins will stay vertical. So if you want to practice using your hips more, you can think about folding over more and not letting your knees go forward over your toes.

Knee going inward pattern: many people’s knees will move inward towards the middle of their body whenever they use their legs to push such as going up/down stairs or standing from a chair. This is especially true of women due to them usually having wider hips. The knee will go inward as will as rotate inward. Since it can put the knee cap in a less efficient position, the increased pressure on the front of the knee can lead to pain (patellofemoral pain syndrome). The rotation of the knee inward can cause twisting at the knee which can lead to pain on the sides of the knee as well. Controlling the knee position is actually the responsibility of the hip muscles so exercises to strengthen the outside of the hip are key. Start with side leg lifts and clamshells and move up to standing exercises. An advanced exercise often used is walking sideways with a band around the legs.

For people who don’t do sports, being able to rise from a chair and go up/down stairs with good knee alignment is often sufficient to address this problem. For very active people, they will want to be able to keep their knees in good alignment with advanced activities including landing from a jump and single leg hopping.

Knee going backwards pattern: if you ever had an event where you hyperextended your knee – it went backwards too far – then you may have pain in the back of your knee. Sometimes this keeps happening because of laxity in the ligaments of the knee. Practicing normal movement patterns is more important in this case than exercises for strength usually. The goal is to learn to straighten the knee a normal amount. If you’re seeing a physical therapist, they can help provide feedback. If you’re practicing on your own, you’ll need a mirror from the side to see your knee position. I’ll often educate people on the ‘soft knee’ position – avoiding completely locking your  knees. You’ll want to start by lying down and slowing straightening the knee while watching your knee position in the mirror. Focus on learning what it feels like when you’re in the proper straight position. Then work on this in other patterns such as standing, then standing up from a chair, going up stairs, all the way to squatting (if you lift weights) and jumping.

The other possibility with repeated hyperextension is if your ankle can’t flex. When the ankle can’t flex forward, the rest of the leg has to do something in order to get your center of gravity forward to walk. There are a couple of things your body can do to awkwardly make this work, and one of them is to slightly hyperextend the knee. If this is your problem, you will know it because you have ankle problems. This isn’t something that happens without very significant ankle flexibility limitations. The true solution is to increase your ankle flexibility. If you’re dealing with significant limitations in your ankle, it is best to consult a physical therapist for specific treatment. This will generally involve a variety of different stretches as well as manual therapy to help loosen up restrictions in the joint and soft tissues.

Nervous system

When you’ve had pain for longer than 6 months, your nervous system will have made several changes that makes your body more sensitive to pain signals. This happens at the nerves of the knee, the spine, and all the way up to the knee ‘area’ of the brain itself. One of the best ways to desensitize the nervous system is education. Many people believe that exercise might be bad for the knee or their pain will never go away. Research shows that exercise is actually very helpful for the knee, especially in cases of arthritis. Just understanding that things like exercise and massage can help lessen or even eliminate the pain can change the way your nervous system monitors sensitivity in the knee.

There are more specific techniques as well that often include guided visualization or imagery. Since this almost exclusively is directed at the brain and nervous system, it is effective at ‘re-programming’ the ‘software‘ of the body. You can imagine whatever helpful imagery makes sense to you, whether that is walking around in a healing pool of water or imaging bathing your leg in warm sunlight at the beach to anything else. If you don’t know how to do any of this, consult a hypnotist who uses in guided visualization.

 

Nerves of the knee

There are 2 main nerves that supply the knee: the femoral nerve (front and medial sides) and the sciatic nerve (back and lateral [outside] sides). These often contribute to pain so getting the nerves back to normal is helpful.

Sciatic nerve: test this by going into a hamstring stretch. Once you can feel a light stretch, roll your chin down to your chest. It’s normal to feel an increase in the stretch in the back of your calf and your thigh. But, if doing this causes knee pain, then you may have nerve tension. Below is an easy to follow video you can use to start working it out.

Femoral nerve: test this by going into a quad stretch. Lie on your side with the leg you’re testing on top. Wrap a belt or strap around your ankle and then gently pull the strap to bend your knee. Keep the hip straight so that the thigh stays on top of the bottom leg. This will be a quad stretch. Once you feel a light stretch, roll your chin to your chest like you’re curling into a ball. If this causes knee pain, you may have femoral nerve tension. Below is a video on an exercise to start mobilizing or ‘flossing’ the nerve.

Manual therapy

Often, tender points in the soft tissues of the leg can contribute to or even cause knee pain. The skin, muscles, tendons, ligaments, and/or scar tissue can all contribute. You can feel on your own leg for these tender spots and then gently work on them using your hands or soft tissue instruments. Even though these spots may feel like knots, they are not physical lumps you can just mash away. Often they are contracted muscles, adhesions in the fascia, small points of fluid build-up, or even just normal structures like the surfaces of the bones or ligaments in your leg. If you press on them for a few seconds and they refer pain to your knee, then they are probably more important. If you press on them and they don’t, it’s likely they aren’t important. When treating them, use gentle pressure and massage – more pressure is not any more effective and is much more likely to make you sore afterwards.

As you go through this process, you can treat tender points as you notice them. Or you can note them and how tender they are then keep going. Once you’re completely done, you would start by treating the most tender points first. Often after you’ve treated the most tender ones, other ones will have gone away or become less tender.

Start at the front of your hip and work your way straight down to the knee cap. Then start back up at the hip, go an inch or so to the side and work back down. Repeat on both sides until you’ve covered the front of your thigh from the hip to the knee cap. Then relax your leg and gently move your knee cap side to side. It should move freely.

Now the inside of your leg. Start at the very top inside part of your knee which will be at the groin muscles. Do the same procedure as before: start at the top and work all the way down to the knee. Then start over and a little to the side and keep working until you cover the inside of your thigh.

Do the same process for the outside of your leg. Start at the top of your hip, under the crest of your pelvis. Make sure you feel through your butt muscles in your hip as well.

Finally, repeat for the back of your thigh. Cover the entire back of your leg to the back of your knee.

Approaches of hypnotic pain relief

Posted on | Hypnosis | Pain
Keys – always in the last place you look.

There are 10 broad approaches I can think of that are useful for hypnotic pain relief. Each of the things listed will just be a general approach. For any given approach, there are many techniques to accomplish the desired effect.

This list is meant to pique interest in hypnosis as a clinical tool as well as illustrate that their are many ways to accomplish your goals. If one approach doesn’t work for you, there are several other avenues a clinician can go down with you. People tend to naturally respond to certain hypnotic phenomenon better than other ones. Someone may not respond to dissociation suggestions but can achieve anesthesia easily. In the end, the same result is accomplished – pain relief.

Below I’ve listed the 10 broad approaches as well as some general information on them and common usages.

  1. Analgesia. This is the classic and most straightforward approach. Analgesia is changing your body’s sensory processing so that you don’t feel the sensation of pain. However, you are still able to feel other sensations such as pressure and temperature.
  2. Anesthesia. This is taking analgesia a step further. The body’s sensory processing is altered so that you don’t feel anything at all. In other words, it’s inducing numbness. This is the effect most commonly used for preparing people for surgery. The difference between hypnotic analgesia and anesthesia is mostly just a matter of scale. Here are 4 common ways of producing this effect. Direct suggestion – once trance is induced, you can directly suggest that their hand/body part will go numb. Chemical anesthesia – you can have them visualize receiving a chemical anesthesia such as gas or a numbing cream. Cold anesthesia – you can have them visualize dipping their hand/body into an ice cold river/body of water and feeling it go numb from the cold. Nerve conduction anesthesia – you can have them visualize a circuit metaphor where the circuits are their nerves and they can control the switches to the nerves. By ‘turning off’ the switch to the back (for example), the nerve would no longer carry the signal from that area, resulting in numbness.
  3. Sensory shift. This is similar to analgesia/anesthesia, but instead of taking away a sensation, it relies on just altering the sensation. A specific example is in hypnobirthing classes (hypnosis to help with childbirth) the suggestion is often given that contractions will be perceived as ‘baby hugs’ and every contraction brings you closer and closer to getting to see your baby for the first time. This alteration helps change contractions towards being a positive sensation. A more general usage of this approach is to help someone change the focus of the pain sensation. Most people can describe their pain in a particular way using pain descriptors – burning pain, squeezing pain. With a sensory shift, you suggest they notice the pain by focusing on the descriptor, but then you add an adjective. So if the descriptor is burning, you could draw their attention to notice that it’s a quick burning. If they don’t agree with that adjective (quick in this case), you can just keep trying other ones until they agree. You then shift their attention towards focusing on the adjective (the quickness). Ultimately this changes their pain experience (which is almost always helpful) and often changes it to something much less distressing, here going from a burning pain to a ‘quick’ feeling.
  4. Alter sensitivity. If you twisted your ankle, it would hurt. If you twisted it while a car was coming at you, it wouldn’t. This is because, at that moment, the signals coming from the ankle would be relatively unimportant compared to the car. The brain would filter out these ankle sensations to prevent them from grabbing your attention. Imagine if it didn’t – your attention would be focused on the ankle and you’d likely get run over. The brain can learn to filter some sensations out by altering the nerves’ sensitivity to that information. Often the nerves of a certain region have become hypersensitive. Hypnosis can be used to return that area back to a normal level. Technically, this is probably a very similar, if not identical, application as analgesia or even anesthesia, if all sensation is filtered out. I make it a separate approach for 2 reasons. First, this is used to return hypersensitive regions to normal sensitivity, while analgesia/anesthesia both remove sensation. Second, altering sensitivity can actually be used in the opposite direction. Some people expect sensitivity with an experience, so the idea of numbness is inconceivable. An example is going to the dentist or getting an operation. For some people, it’s too much to believe that they can just have that done without any pain and so they can’t accomplish hypnotic anesthesia. In these cases, you can suggest hypersensitivity of a different region and tell them they will need to protect that area. Dr. Erickson did this with someone who was getting dental work done. He induced hypersensitivity of one of the man’s hands and the man was so focused on protecting his hand from being touched that he developed a spontaneous anesthesia of the mouth (which he previously hadn’t been able to do).
  5. Dissociation. This is the feeling of being out of your body. You can be dissociated from your entire body – feeling like you’re in two places at once or you are outside of your body. You can also be dissociated from a part of your body – like you can see your arm, but it doesn’t feel like it’s part of you. This is a very useful approach, especially for anyone who participates in guided visualizations very well. When you get involved in a visualization, say a relaxing trip to the beach, you are automatically dissociated because you can feel yourself at the beach but you’re also aware that you’re in the room in trance. Many hypnosis techniques that are used suggest some form of dissociation, often floating out of your body. This adds the comfortable feeling of floating as well as dissociation.
  6. Association. While this sounds like the opposite of dissociation, it is actually closely related because you cannot have one without the other. Association is becoming completely immersed in a separate experience. You can become so immersed that you don’t notice what’s happening to your body. An everyday example is being so absorbed in a movie you forget the headache you had. In hypnosis, this can be doing a guided visualization and they become so immersed that they feel like they are actually there. This would be the association effect, while the dissociation effect is feeling like they are there but also feeling like they are in the room with you. If someone associates into a pleasant visualization, like relaxing on the beach, then they won’t have pain. You can also give suggestions to associate into a feeling, like the feeling of comfort or relaxation.
  7. Time distortion. How fast or slow time feels is subjective. If you’re having a great time, 2 hours can feel like 10 minutes. Sometimes you might feel like you just went to sleep, only for your alarm to wake you up 6 hours later. This effect can be recreated with hypnosis. It is used for people who have waves of pain (often due to a severe illness like cancer or a neurological disease). The unpredictability of the waves of pain makes it very hard to use medication and often medication won’t help that much without very high doses. Hypnosis is used in these cases to distort the person’s sense of time so that the hour of pain they actually have only feels like a few seconds/minutes of pain. Some people are also strong responders to hypnotic amnesia which can be paired with time distortion so that they don’t remember their wave of pain. This can considerably reduce their suffering. From the outside it would appear that their pain begins and they go into trance for the duration of the wave. From their perspective, they just briefly zone out (go into trance) and then go on with their day like nothing happened (even though in real time an hour might have passed).
  8. Ideomotor effects. This is the name for hypnotic suggestions that affect the muscles. A general application of this is deep relaxation. Many hypnotic inductions and routines contain suggestions for relaxation. Deep relaxation can help pain in a general way, but you can also associate into the relaxed state so that you only notice the relaxation and not the pain. In deep hypnosis, some call this the Esdaile state – a state of hypnosis that people have been able to perform surgery in without chemical anesthesia. A more specific application is called catalepsy which refers to being unable to consciously move. An example would be suggesting that someone’s arm can’t move, even if they try to lift it. If a person responds to these types of motor suggestions, you can suggest they ‘lose’ their arm, meaning they can’t feel it or even be aware of it. This often is accompanied by spontaneous anesthesia since they have ‘lost’ all awareness or connection to that body part.
  9. Behavior modification. Hypnosis is probably most often used to make changes to behavior automatic and pain management is a great place for this. There are certain behaviors that can be helpful (like exercise) and some that can be harmful (like lifting with your back). Hypnosis can help people change their behaviors much more easily and this can help significantly reduce pain, or even eliminate it completely depending on the cause.
  10. Healing. Probably pretty much any hypnotist you talk to has had both professional and personal experiences with using hypnosis for healing. The most scientific explanation I can give you is that hypnosis has been demonstrated to affect blood flow to certain areas and this may help the healing process. In any case, it’s never harmful to give suggestions for healing. While healing isn’t directly a pain control technique, it is indirectly (in that, once an  a healed area won’t hurt in the future). Also, adding suggestions of healing tends to have a natural pain control effect even without suggestions for pain control because of the natural association between healing and pain going away.

Breaking bod

Posted on | Coaching | Communication Techniques | Pain
Tell me where you keep the Thera-bands and no one has to get hurt.

Last post we discussed helping people change their limiting beliefs they have about themselves in order to move past their problem. Nowhere is this more important than with pain. Things that affect our body, affect the mind. The most common belief is “I have X which causes my pain” with X being arthritis, slipped discs, bone spurs, etc. This can be simplified to the belief: “X causes pain”.

Let’s take the statement, “my pain is due to arthritis.” The fundamental belief of this statement is that arthritis (A) causes pain (B). To ‘crack’ this belief open, you can cast doubt on the cause-effect relationship by explaining counter-examples of when A happens but B doesn’t (A, not B) and when B happens and A doesn’t (B, not A).

A, not B: arthritis but no pain.

  1. This discussion can be started with general counter-examples. Research indicates that many people who have x-rays showing arthritis, don’t have pain. For example, 37% of those over 65 have x-rays showing knee arthritis but only 10% of men and 13% of women have arthritic knee pain. Then you can plant this seed of doubt: what’s different between those people with pain and those without?
  2. Now you can also get specific to your client. When you took their history, they probably already told you how their pain fluctuates throughout the day. But if all of their pain is due to arthritis, why would that happen? Since arthritis is provoked by weight bearing, it shouldn’t hurt while sitting down but many people do report aching at rest. Why does it hurt worst just after standing up but then gets better after they moved a little? If all of their pain is due to arthritis, shouldn’t it feel best after resting and only get worse with walking? If they don’t tell you these things, you can ask probing questions about when they have pain so you can later point these counter-examples out.
  3. Research is all well and good, but most people don’t think it applies to them because they’re a special case. You can, innocently, ask about other areas in their body. If one knee hurts, does the other knee hurt? Or hurt just as bad? If their back hurts in one area, do the other levels of the spine also hurt? After they answer these questions, you can point out that if one knee has arthritis, you can almost guarantee the other one has a similar amount of arthritis. So why don’t they hurt the same? And the same logic goes for different levels of the spine.
  4. All of these counter-examples serve to point out that all of their pain might not be due to arthritis alone. This leads nicely into ‘B, but not A’.

B, not A: pain but not all due to arthritis.

  1. So now your client is likely more open to believing that their pain might not all be due to arthritis. The question, then, is what is causing their pain?
  2. If you’re working with someone in pain, then I assume you’ll also do some sort of examination in order to make your own decision on what is wrong with the client. Say you do your examination and you find they have weak core muscles, tender/trigger points, muscle tightness, nerve tension, soft tissue restrictions, joint mobility restrictions, etc. These are your explanation of what else is contributing to their pain (besides arthritis). You’ll then follow-up by explaining how you will help them resolve these problems which will decrease or eliminate their pain.
  3. This is incredibly important to success because now your client understands that there are other contributors to their pain and that you can address them.

How to use this

With this covered, I’ll now go into how I believe this can best be accomplished. First, when you’re planting seeds of doubt, it’s usually best to ask pointed questions rather than just bombarding them with counter-examples. Telling them, “Well you told me your other knee doesn’t hurt as bad and since that also has arthritis, arthritis must not be the only cause of your pain” – is a great way to get them to shut down and clam up. Instead, you can ask, “does your other knee also hurt this bad? If that knee also has arthritis, what might be different? Ok, so you think arthritis is the difference?”  The last question really plants the seed when you place a doubting tone on the word arthritis, to convey to them that you might have your doubts about it. They’ll probably respond by being slightly confused at which point you can just move on to either counter-examples, or straight to your examination. Your examination will then reveal other factors that were contributing or even causing the pain which will answer your question for them.

I won’t tell you how to do your examination or what impairments to look for. However, I will say that I think every clinician should include a discussion of the nervous system. This doesn’t need to be complex, but explaining how the body’s “software” contributes to pain is extremely valuable. First, there is the threshold concept. This is usually explained using the metaphor of a cup. Your body’s pain threshold is like a cup. Different things can fill it up which is no problem. But once it is overflowing, then you have a problem. Similarly, the different impairments in a region can all add to the ‘cup’. This can include arthritis, muscle weakness, soft tissue restrictions, etc. If the cup is overflowing, then removing some of these problems (treating weakness or using manual therapy and so on) can decrease the problem. This is the equivalent of pain reduction. If you can remove enough of the problems so that the cup is no longer overflowing, well then you have no pain. Even though there might be things in the cup like arthritis, if it’s not overflowing, you don’t have a problem. This nicely opens up the possibility of partial or complete pain relief while still acknowledging that you cannot remove things like arthritis for them.

The other important piece of information is where pain is. If your right knee hurts, you assume pain is in the right knee. However, your right knee is just sending the signals up to your brain. Where you actually have pain is in the ‘right knee’ area of the brain (to be more complex, in the somatosensory cortex). This information can be extremely important because it helps explain why your interventions and treatment might work. After all, most believe that exercises, adjustments, massage, etc. can’t really ‘solve’ problems like arthritis, a torn meniscus, bone spurs, cancer-related pain, and other ‘structural’ problems. Sure, they can help, but the relief won’t last or they’ll never truly get rid of it. By explaining that your interventions not only affect their body but also their nervous system, you can ‘change the target’ so to speak from something impossible to change, to something that can be changed (how the nervous system processes pain signals).

Summary

When someone tells you their problem is something you can’t change (like arthritis), you goal is to open up the possibility that their problem is something you can change. This often starts with planting doubt that what they believe is the problem may not be the problem, or at least not the whole picture. Then, you should identify, with your examination, what the problem is and how you’ll address it.

Not PC(L)

Posted on | Pain
“Mmm, tender. This one’s almost ready…”

I worked with a young man who came in with a diagnosis of a PCL strain/minor tear. The PCL is a ligament of the knee, very close to the ACL. It’s important to do your own examination and make your own decision on what is wrong with your client because you’ll often be surprised by what you find that is at odds with their history and medical imaging. I was very surprised when he did not test positive for any of the functional PCL loading tests that I did, but instead tested positive for having sciatic nerve tension, which completely reproduced his pain. We worked on addressing the nerve tension and within 3 visits (about 2 weeks) he was back to normal function, which for him was doing manual labor and riding his dirt bike. That would indicate that the treatment was effective, but it is also important to note that during that time his knee would also be healing naturally, just as a function of time. The injury had been bothering him for a while though with no resolution, which is why he went to an orthopedic physician, got an MRI, and came to PT in the first place. Prior to coming to me, he had been potentially considering surgery since it hadn’t resolved.

Our pain threshold is like a cup. It can be filled up, but it is only when it’s overflowing that it’s a problem. In the same way, someone can have arthritis in their knees but no pain because that only ‘fills the cup up’ a certain amount. But if they have arthritis, weak or inhibited muscles to reduce shock absorption, fascial restrictions that add tension to the knee, and nerve sensitivity of the skin around the knee – their cup might be overflowing and then they’ll feel pain. Physical rehabilitation is often about ‘bailing water out’. If you can remove some of the contributing factors, their pain will lessen. If you can remove enough so that the ‘cup’ isn’t overflowing, then they may have no pain at all – even with arthritis. This is why research indicates that a significant number of people have arthritis in their knees and didn’t know it –  they don’t have pain, so they would not have suspected they have arthritis. Physical therapists can’t remove your arthritis, but they can help strengthen your muscles, improve your coordination and movement patterns, release muscular tension, decrease nerve sensitivity, and address soft tissue restrictions. With all of this ‘out of the cup’, you will be surprised by how you feel.

Windows pain

Posted on | Pain
Do you have a radioactive spine? If so, you may be entitled to some compensation by your local nuclear power plant.

Circle ’round folks, it‘s time for a clinical case story. I worked with a lady who had pain on one side of her neck that went down towards the top of her shoulder blade and into the area between her shoulder blades. Just based on that, I knew that the structure that was irritated was either her levator scapulae muscle and/or her dorsal scapular nerve. We started with the normal things – some neck exercises, manual therapy to release the tension, and education on posture. All of it worked in the short-term but was not long lasting beyond a day or so. This went on for 2-3 visits.

Finally, I asked about her work set-up at home. I had asked about her work station before but only gotten relatively general answers. This time she elaborated – she sits on the couch with her laptop seated next to her. And she sits… And works… Looking down and to the side… All day…

She changed her work set-up that day and her symptoms resolved soon after and stayed gone. Often the value of seeking outside help isn’t just the  expertise in that field, but just getting an outside perspective on things. We tend to be stuck in a problem because we only see it through our lens, but if it were looked at upside, backwards, or from above, the solution would be plain in sight.

So if you have persistent neck pain, consider these 4 neck positions and if you’re in any of them for long periods of time.

Flexion – looking down

  •  At a screen, a book, or doing crafts. Address this by raising up whatever you’re looking at. If you hold it, like a phone or book, you can use something to comfortably support your arms like a desk or pillows in your lap.

Extension – looking up or forward head posture

  •  If you have to look up for long periods of time (electrician, painter, belaying a rock climber), consider getting vertical periscope glasses. These are glasses that use a mirror to reflect your vision upward so your neck can be in neutral while you look above you.
  •  Having slumped posture with the head coming forward is also the same as neck extension. The best way to improve this is to alter your work station to put your screen at, or closer to, eye level. Additionally, getting proper lumbar support in the chair so that you can sit more upright without having to use your muscles to hold yourself up is also helpful. You can elevate your computer with a special desk, but a stack of books or a box works fine. Similarly, you can get a lumbar support cushion for your chair, or you can use a small pillow or rolled up towel for the same effect.

Rotation – head turned to the side

  •  Often this happens if you work at a computer that isn’t directly in front of you (reception desk usually). This can be improved by using a swivel chair so you can swivel the chair to look forward at the screen instead of keeping your head turned.
  •  Sleeping on your stomach requires your head to be turned to one side all night. While changing your sleeping position is pretty hard, it would be  very helpful here. If that is too difficult, you can also use pillows under you to support yourself in a semi-face down/semi-side sleeping position. This will reduce the amount of rotation your neck is in.
  •  If you use a CPAP, sometimes the tube (due to being too short) will pull your head to the side while you sleep on your back. This can be addressed by trying to improve the amount of slack you have in the tube – either getting a longer tube or repositioning the machine closer.

Side bending – head tilted to the side

  •  Answering the phone all day with it wedged between your ear and your shoulder is often provocative. Fortunately, most work places are happy to pay for either a headset or BlueTooth earpiece that eliminates this.
  •  If you’re a side sleeper, then you might have your head tipped to the side at night. Too low a pillow and your head will be tipped down. Too high a pillow and your head will be tipped up. This can pretty easily be addressed by using a pillow that supports your head with your neck straight.
  •  Having the shoulder pulled downward is functionally the same as loading the side of the neck due to the muscles involved. This can happen to women who carry a heavy purse, always on the same side. It can be addressed by emptying your purse of extra weight, switching to a lighter purse, or switching to a different carrying mode (backpack, hip or leg case). Bra straps can also pull the shoulders down and switching to a sports bra may help in this case. Carrying using only one arm frequently can pull the shoulder down. This can be a heavy load in the hand (construction or manual labor) or holding your child in your arm. This can be addressed by carrying with good posture. Ideally, it should look like you’re not carrying anything because you are not leaning over to the side or one arm is not lower than the other. Additionally, switching sides to split the load is recommended.

Finally, even when using good posture and support, a key element is knowing that no one posture is perfect. The body doesn’t like being in the same position for a long time. So taking ‘movement breaks’ every 30 minutes by moving your neck around and switching positions is a crucial part of good posture.

Sports elbow – pain in the ol’ cranon

Posted on | Pain | Sports Performance
“If you kick me in the elbow one more tim- agh!!”

One of my workout partners and I were sparring and he complained afterwards of mild elbow pain after he tried to repeatedly uppercut me. He asked me what the cause of this was and how to fix it… A part of me considered explaining that proper uppercut form was to wrench your back while simultaneously hyperextending your knees and jutting your chin forward, but the physical therapist in me prevailed.

Most sports-related elbow pain comes from 2 things.

  1. Amount of rotation at the elbow: the elbow is caught between the hand and the very mobile shoulder. Most people put their hand in a certain position (palm down, racket facing this way, fist facing upward, etc.) and just let the rest of their arm figure it out. Try this right now. Hug your arm close to your side with your elbow bent and face your palm as far down as you can, like you’ll be typing on a computer. Now lift your arm off your body and see how much further you can rotate your hand. You can also do the opposite: how your arm at to the side and turn your hand palm up as far as you can. Then lower your arm to your side and see how much further you can rotate. This was my “friend’s” problem – he was kindly trying to uppercut me by trying to rotate his fist so that his palm faced towards his body, but when his arm was out to his side, he didn’t have the range of motion. This led to a high amount of torque that the elbow was forced to endure. This problem is also common in any sport where the hands are put in a specific position: golfing, racket sports, rock climbing, and more. The solution then is to avoid maximum rotation at the elbow. This can be accomplished by moving the upper arm closer or away from the body. Yes, this will almost always change the mechanics of your sport’s movement in other ways, but pretty much everyone I’ve worked with on this is able to accommodate the position without much trouble. They also almost always find they perform better because their body is in a more natural position for them and they don’t have pain. So I  grudgingly told my friend he could either bring his arm in closer or just punch with his hand in a natural orientation (instead of trying to control what way his palm was directed).
  2.  Overload due to muscular tension: the other main contributor to elbow pain from repetitive strain is overload. In some cases, this can be very obvious. You go from playing tennis or golf 2x/week to playing 5x/week. But often many people find that after reducing their volume, and sometimes even after medical treatment like steroids or physical therapy, their elbow starts hurting again as soon as they ramp their volume back up to a normal playing level. Try this. Pick up a pen as you normally would. Now pick it up again but with as little effort as possible while still securely holding it. Finally, pick it up one last time but use a death grip. Each one of these trials you accomplished the exact same thing, but they each had a different amount of load on the grip muscles (which insert into the elbow). The death grip is what most people use, not only at the point of contact, but often in between hits. All of this adds a tremendous load to the elbow. The solution here is two-fold. First, practice gripping only as hard as necessary (not too hard, not too loose). Second, learn to squeeze only when needed and relax the rest of the time. In tennis, for example, this would mean squeeze the racket as firmly as necessary during your swing but relax your grip before and after shots. It’s often helpful to think about pulsing. Pulsing is when your muscles contract just before and through contact to add that extra whip to your hit. This allows the body to be fluid and relaxed with the windup, then generate a tremendous force on contact, and relaxed again on follow-through.

So there you have it. If you have sports-related elbow pain, try experimenting with arm position to avoid maximum rotation at the elbow/forearm, and practice pulsing on contact and relaxing in between hits to reduce load. There are, of course, things other than repetitive strain injuries that could be causing your elbow pain. Irritation of the ulnar nerve is not uncommon, but you’ll need to see a physical therapist or orthopedic physician for a specific diagnosis based on your presentation.

Skin city

Posted on | Pain
We do things differently here at “Taxes and More”!

Clinicians are taught to mobilize pretty much all components of the movement system from muscles to joints to nerves to fascia. All of these are being mobilized in theory because you cannot actually touch them directly. You only ever touch them indirectly, through the skin. Ironically, mobilizing the skin, the one thing you can directly mobilize, is not taught much, if at all. This is a huge gap in most people’s skillset because the skin is rich in cutaneous nerves which are responsible for much of the pain people have.

Here’s a list of some common areas that are usually related to impaired skin mobility and hypersensitivity of the cutaneous nerves that can be addressed with relatively straightforward hands-on techniques. If you are not a clinician, but rather someone who has pain, then apply these to yourself to eliminate your own pain. Whether you’re doing it yourself or you’re a clinician working with a client, first find a movement that is painful or a tender spot. Next apply the skin glide/mobilization and now re-test the movement or press on the tender spot. If it is no longer painful, or much less painful, then hold the glide for 10 s. Then reset – go back to the start position or stop pressing on tender point – and release glide once reset. Now re-apply glide and perform movement or press tender point again. Go through this process 5-10 times, with a 10 s hold each time. Afterwards, re-test by doing the movement or pressing on the tender point but this time without the skin glide. It should now feel significantly improved. If the first skin glide direction doesn’t work, go ahead and explore other directions until you find one that works.

  •   Anterior ankle pain – “pinching in the front of the ankle”: Lightly grab the skin an inch or two above your ankle bones and then twist to gently mobilize the skin. Usually it will feel best to twist inward but try both ways. Hold this position while then stretching the calf. Try this same position with calf raises.
  •   Anterior knee – knee pain going down stairs: Place one hand on top of the knee and gently move skin towards the foot, almost like you’re trying to slide the knee cap down the leg. Apply this while bending and straightening the knee, while contracting the quad (tightening your thigh), and while going down stairs (will require someone else to apply the skin mobilization).
  •   Lateral thigh – “IT band pain”: Glide the skin of the outside of the thigh, usually down towards the knee/foot. This can be accomplished by using a hand to slide skin towards the foot or by having someone else wrap their hands around your thigh above the knee or even as far down as the ankle and then gently pulling the skin towards the foot. Other directions that sometimes are helpful are twisting the skin inward or outward as well as moving skin upward by starting with a hand at the hip and lifting towards the head. Once the glide has been applied, perform side leg lifts.
  •   Local low back pain: First find a point on the back that feels tender to the touch. Keep one hand above this spot and use the other hand to gently glide the skin next to it in any other direction. Then press on the tender point and assess how tender it is. Try multiple different skin glide directions until you find the one that feels the most comfortable. You can work through multiple different tender spots in the back. Generally, there will be several tender points that need to be resolved before significant relief is accomplished.
  •   Neck pain when turning head: Place one hand on the back of the neck and glide the skin rotationally around the neck. If you are applying this yourself, just place your hand on your neck then relax your arm down so that the weight of your arm naturally applies the glide. Holding this mobilization, then rotate your head. Generally, one glide direction and one head rotation direction combination will feel the best. Once you find what works, do 5-10 reps of 10 second holds. If gliding and rotating the head both feel best in the same direction but your hand gets in the way of rotating your head, you can use the opposite hand by reaching across your body to apply the glide.
  •   Headaches: First try the neck pain mobilizations because many headaches come from the neck. For some direct work, you can address the skin of the scalp. This can be done by placing both hands on the top of the head and then ‘lifting’ the skin upwards. Sometimes it helps to interlace your fingers to give you leverage to lift upwards. You can also actually lightly pull on the hair to mobilize the scalp.

Pyramid scheme – rob your clients of their pain!

Posted on | Hypnosis | Pain | Relaxation
You too can learn to make complex rock sculptures after a single 6-hour seminar!

Hypnosis is based on eliciting different ideodynamic phenomenon, such as the ideomotor response of muscular relaxation or the ideosensory response of feeling like you’re floating. Everything is on a scale though. For relaxation, it can range from light relaxation in the face muscles, to full body relaxation so deep the person can’t even move (similar to sleep paralysis). For sensation, this could range from a mild feeling of lightness in the hand to complete anesthesia (the Esdaile state or hypnotic coma used for hypnosis-assisted surgeries).

In order to elicit these more powerful responses, most people bring in the concept of ‘depth’. There are many depth scales for hypnosis, but the general idea is that the ‘deeper’ a person is in trance, the more they can achieve some of these advanced effects. While putting numbers to hypnotic depth seems to make it more objective, the idea of depth is really just a concept. Some people may be very ‘deep’ in trance and able to accomplish some advanced ideomotor effects but unable to elicit relatively simple ideosensory effects. These pretty much just makes seeking a certain ‘depth’ before trying to elicit a response, a crapshoot.

The more clinically useful approach is to do ‘chaining’ or ‘pyramiding’. This is where you start by eliciting simple responses and then build on top of those to get to more advanced responses. You can also think of it as linking a series of suggestions together. If you wanted to help someone produce hypnotic analgesia (pain control) in their leg, you wouldn’t start by saying, “close your eyes. Good, now notice your leg going numb!” You could try to do this, but if it failed, your client probably wouldn’t trust you or your ability that much afterwards. Instead, you could start by leading them through a general relaxation sequence. As they become noticeably relaxed, draw their attention to this new sensation of relaxation.

“The more relaxed you become, the lighter your body feels. Every breathe relaxes you even more, filling your body with that lightness. Almost like you’re breathing in helium and you can float even further into relaxation. Or like you’re breathing in a pleasant, odorless anesthesia. Drifting further into comfort, feeling your body go pleasantly numb. The more your breathe this in, the more you can feel it fill your body up with that relaxing numbness.”

Notice in that sample routine, relaxation (a simple response that you’ve already helped them accomplish) is linked to the ideosensory response of lightness. Then breathing is linked to relaxation and lightness. The metaphor of breathing helium is introduced to further link breathing with a feeling of lightness. Then this is moved to breathing another gas – anesthesia. Breathing, relaxation, lightness, and anesthesia are all linked together –  with the corresponding ideosensory response of numbness. In this way, you’ve built each response on top of the other ones to reach the desired effect (numbness).

I’ll give another example of chaining ideomotor responses. Generally, you begin by focusing on the small muscle groups – the eyes and fingers. For the eyes, the most common effect is catalepsy or lack of movement. This would be getting someone to relax their eyelids so much that they don’t work, even when they try to open them. For anyone curious on more about this, look up the Elman induction which is very fast and the most common one taught to those in the medical field because of it’s speed.

“Relax your eyelids all the way to the point where they won’t work. When you’re sure they’re relaxed that far, go ahead and try to open them – just like you would try to open a
locked door, just to make sure it stayed shut. Good, now you can stop trying and send that relaxation down through your body, like a wave of relaxation. Feel that flow all the way through your body, from the top of your head to the tips of your fingers and toes. Notice that as that wave flows through your body, it can sweep up any pain or discomfort and carry it along. All of that pain and discomfort will pool somewhere in your body, I don’t know if it’ll be in your left hand or your right foot or somewhere else. And as it pools there, immersed in all of that relaxation, you can allow it to drain away now. Notice it draining away, completely out of your body, leaving behind only that relaxation and comfort that’s flowing all throughout your body.”

Here, the ideomotor effect of eyelid catalepsy was first elicited. Then full body relaxation was built on top of that. This relaxation was chained to feeling discomfort. As the relaxation changed (by going through the body), the location of the discomfort changed. Finally, the discomfort itself was changed using a suggestion for analgesia and then a refocusing on comfort and relaxation.

Go number too

Posted on | Hypnosis | Pain
Skinny dipping status: currently not advised. Keep checking for updates!

That’s number like to be more numb. Originally this post had the subtitle “relieve that pain in your ass” but I thought that would be too confusing.

Today, we continue our talk on eliciting ideosensory phenomenon for addressing pain and discomfort. Last post I talked about using the sensation of warmth to bring comfort and relaxation. Now I’ll talk about using cold for numbness and relief.

Who doesn’t know the relief a timely cold shower can provide? Using cold imagery and sensory details can help elicit relief through numbness. Building on last post’s routine (bathing in warm water) – you actually can do the exact same routine just using cold water. It could be mountain stream or winter lake. In the warm water routine, you have them place the pains in their body into a block of ice and then, generally, melt the ice (and pain with it). In the winter routine, you have them place their pains in a block of ice and then freeze the block even colder until it expands to the point that it shatters and disappears.

As awesome as shattering your pain is, I tend to use a much simpler, but more natural (in my mind) method. I guide them through a winter place visualization where they come upon a stream. The kind of stream made by the ice that melts on top of mountains and flows down into a valley. Then I inform them that they have a water bottle in their hand. In a moment, they will bend over and plunge their hand into the crystal clear water to fill the bottle. As they fill the bottle, they will feel the sensation of the ice cold water flowing over their hand for a few seconds and then their hand will go completely, and comfortably, numb. It’s important to fully explain what will happen to prime their nonconscious to create the sensation of numbness. Then, I tell them to go ahead and bend over, plunge their hand in the water, fill the bottle, and feel their hand go comfortably numb.

From here, you can do 2 things. You could then tell them they could use that hand to touch anywhere on their body to transfer that sensation, replacing any pain or discomfort with the comfortable numbness. Or you could tell them that in a second, they can take a sip of that pure mountain water from the bottle. They’ll feel it, ice cold and refreshing, flow through their body – going anywhere in their body that could benefit from that calming sense of comfort and numbness.

Like any guided visualization, you could then chain more things on to accomplish either greater or different effects. A common one with this would be to keep walking, leaving the river behind, and move towards a winter cabin. There you could do any number of additional things in this winter cabin, like have them get in a warm bath or hot tub to increase their relaxation and comfort. Another interesting winter routine is to walk to the top of the mountain where they can form a snowball in their hands. From there they can think about a goal they have in their life and “place” that in the snowball. Then they can roll that snowball down the mountain and watch it grow larger and larger, until it’s so big that it breaks through any obstacles that stand in its way.

Healing water for pain and discomfort

Posted on | Hypnosis | Pain
Bubbles in bottom left – there is definitely something about to get her.

My first real exposure to ideosensory phenomenon was in childhood at a sleepover. I learned that you could take the hand of someone who is in a very relaxed state and gently place it in warm water. You would then be able to actually see them relieve themselves with no further guidance from you.

As amazing as that was, it’s also fairly limiting because 1) you need a warm glass of water nearby 2) the person has to already be in a relaxed state and 3) it’s pretty selective which muscle group you relax and response you elicit. Fortunately, now I know hypnosis which addresses all three of these obstacles.

Hypnosis for pain frequently follows a similar format, regardless of the technique or routine used. A pre-talk –> relaxation routine –> focus on the pain –> change the pain –> focus on comfort. Below I’ve outlined a sample method for the first 3 steps, to set-up whatever technique you might use.

  1. Talk to the person you’re working with to explain what you’ll be doing and what outcome you’ll both be collaborating towards. This is a crucial step because it plants the seed in their mind about what their nonconscious will be working on.
  2. Guide the person into a state of relaxation. This step isn’t strictly necessary (and often, people in severe pain have a lot of difficulty doing so), but it’s generally helpful.
  3. Focus the person’s attention on their pain experience. This tends to be very easy because pain is pretty attention grabbing. However, the key word here is experience. Don’t just have them focus on the pain – focus on what the pain is to them. They might say something like “it’s a stabbing pain”. Get more details on this. “Where is it stabbing?” “And it’s stabbing like what?” If you know clean language techniques, that tends to be very helpful (but not necessary).
  4. Build on the seed you planted earlier by finding out from them what needs to happen to their pain experience. If they say it’s a “stabbing sensation like a needle in their low back”, then you can ask, “what needs to happen to this needle in their low back?” Many people will give a very simple answer like “it needs to go away” or “I don’t know.” For the first answer, it’s important to build on that by asking things like “and before it goes away, what needs to happen?” You’re really just trying to help them to elaborate on the transformation process. For follow up responses and the original “I don’t know” response, it’s helpful to tell them that this is all hypothetical. You could say, “hypothetically what might happen?” or “if something could happen, what might that be?” or “pretend/imagine it’s possible. What would need to happen?”

At this point, you will have done the pre-talk, relaxation routine, and focused them on their pain experience as well as found out what ‘needs’ to happen for their pain experience to improve. The technique or drill you use here is now entirely dependent on what they said. Generally, you would lead them through a guided visualization routine that allows them to experience the solution they talked about. Here, it’s very useful to be familiar with a wide variety of general routines so that you can draw upon one and modify it slightly to make it specific for them. To that end, below is a sample routine using warm water (if they are afraid of being in a body of water, you could change it to a warm bath – or just do something else unrelated to water).

  • Have them imagine they’re in a peaceful forest. Set this scene up and give plenty of suggestions for calm, peacefulness, comfort, and relaxation.
  • Guide them to a warm body of water – a lake, a river, a hot springs, a bathtub, anything. They can get in and relax.
  • Have them imagine they now have a block of ice in their hand. They can go through their body and put any pains they have into the block of ice.
  • Once all of it is in the ice, they can get rid of the block of ice. The ice gradually melts and those pains melt away with it, never to return. People can get rid of it anyway they want – release it into the hot water to melt it, throw it away, blow it up, it doesn’t matter how.
  • Return their focus to relaxing in the warm water.

This routine can be varied in any number of ways and is pretty easy to customize for each individual. One variation that might be useful is to imagine a waterfall on the other side. Once the ice has been gotten rid of, they can then sit under the waterfall and let it wash away any other stress or tension they have (with the tub, it would be turning the shower on). Another variation is to add a dam. At the end, they can open the dam and let the water flow away, taking with it all other tension or stress they have (with the tub, this is just pulling the plug). Or you can add invigorating elements in. They can go to a rock and bask in the sun, soaking up all the renewing energy. They can dive down to the bottom (where breathing is no problem because this is their place after all) and explore all the exciting things down below. The more routines you know, the more ideas you can chain together for a unique and customized experience.

Today I focused on warm water because it capitalizes on the natural ideosensory response of relaxation. Who doesn’t enjoy a hot bath or shower? Next post, I’ll outline a guided visualization routine using cold water. Cold water capitalizes on the natural ideosensory response of numbness which is a very useful sensation for addressing pain.

The United Strengths