Tall and strong at a young age, I was good at contact sports, particularly rugby and field athletics – running at someone, throwing anything and jumping were all fun for me. It was all about strength, condition and being bullet proof.

Dislocated left shoulder – shrug it off!        Torn right knee cartilage – move on!        Concussion – shake your head and get back up again.

Then, work and career started to get in the way. I married. We started a family. Professional training.  Change of career. More qualifications.  Walking with the kids and dog don’t really count, do they? Sport and exercise got put aside.

Twenty years pass. Sporadic attempts at gym, squash, circuits, and the rest. The kids grow up. Then, “40 years old” arrives and passes. Time to get rid of the growing belly. Back to the gym in earnest.

Boring, boring, boring! Too many ‘beautiful people’ who put me off and seemed so judgemental at my lack of focus and progress. Looking back, the problem was me not knowing what I wanted.

Next? A chance conversation and I was introduced to mountain biking. Now, this presses the right buttons! Wonderful and refreshing in its freedom and variability. Expensive, mind you! Great for aerobic fitness, balance and stamina – but ultimately, you get fit for what you are doing.

The activity doesn’t matter; tennis, running, rugby, and the rest – all wonderful but something was missing – I could bike a steep hill with the best and the rest, but couldn’t run up the street without puffing. The fitness was too specific, too focused.

It took another injury, severe this time, to make, no, force me to think about what I was doing. In my case, I came across kettlebell and body weight training and this works for me, physically and, more importantly, mentally. I enjoyed it and continue to enjoy it. Total body workout, flexible, aerobic and balanced. You can go heavy or light, hard or gentle.

Frankly,what works for me doesn’t matter – at my age so many people are searching for a specific or magical regime or principle that they can work to, a set of rules that they can follow. Well, let me spell it out – THERE IS NO SUCH THING! Human beings are just too variable, we all have the baggage of our particular genetics, history, fears and wants.

This means that even when we exercise in a group, there is a huge range of variability and you have a responsibility to look at what is both good and safe for you to engage in. If this wasn’t true we wouldn’t have specialist participants, (who ‘play to their strength’), in every team sport that I can think of!  Why, then do we imagine that synchronised mass step aerobics, for example, is suiting everyone and yet you don’t see anyone doing their own thing. Peer pressure – think for yourselves!

Most, if not all of this more mature age group, carry injuries. Most will have arthritic changes. The fast, twitch muscle fibres are fast disappearing. Recovery times are longer even just after each training session, let alone injuries!

Then, if that is not enough, even those who manage to get to a class, (of whatever type), are so often greeted by these lovely specimens of male and female beauty and physical perfection!

It’s enough to make you run a mile.

BUT DON’T, please don’t. Don’t blame the trainers for your lack of success in class or even for putting you off from taking up a class.

As an Osteopath, I mostly deal with illness and the effects of injury. Personal Trainers deal with wellness and do their best to avoid injury during training. This is an important distinction, especially as we age and I believe we should keep this in mind when we are choosing our direction.

What I think we should do is to ask,  “WHERE ARE ALL THE MIDDLE AGED TRAINERS?” Why aren’t trainers  staying in the business into their middle years? Why aren’t people of my age taking up training as physical trainers?

Plenty are training as therapists. Why? Perhaps because there are so many people who need treatment and therapy! Why not try and prevent rather than treat?

Let’s face it, these skilled but youthful trainers are wonderful. I have absolutely no criticism other than one that they simply cannot help, and that is their lack of experience in FEELING what I feel.

Most are sympathetic to the middle aged groaning, but aren’t generally empathetic. How can they be?

So, where do trainers go when they get to 35? Why does there seem to be a gap until the emergence of the 65 year old yoga teacher who leads sit-down, ‘aerobics’ in a Care Home?

OK, so I’m going over the top a bit, but I believe that most 40-60 year olds will recognise what I am saying. I try, in my professional life, to encourage exercise, movements, stretching and flexibility to my clients.

Within reason, clinically speaking, I don’t care what they do – If you hate swimming, don’t do it – very good for you but you won’t keep it up. Find your level, use advisors of course, but do what you are going to continue.

Squats or lunges while brushing your teeth. Sumo squats when you stand at the sink. Pull up your pelvic floor and lower abs when weeding the flower bed. Whatever works. Now, this chimes with me with the philosophy that Rannoch Donald is espousing with the 100 Rep Challenge. I strongly recommend you take a little of your valuable time and look at the site and Face Book page and you will see loads of examples of 100 rep sequences. Sure, the macho, the hardened, ‘no pain, no gainers’, the fab abs lot and many more are represented. But you will also find something for you. It’s not how hard you are or even how hard you do it, but that you do it.

Whatever it is!

Find something that fits your life, health state, age and desires. Your motivation doesn’t really matter to anyone other than you, better health, flatter belly, serenity, a better sex life – No one else’s business, but your own – my advice, if anyone cares, is to get your starting premise right and then design your own regime.

Rannoch Donald, Jonathan Lewis, Christian Vila, Steve Cotter, Mark Stroud and many others have great ideas about fitness and can give you a fantastic programme, but, (and I think they would all agree), they will all tell you to be clear about your objectives, don’t just follow the latest trends – think about how their method and advice will fit for you and your lifestyle.

So, what do I want from my exercise regime? None of your business. You have to work out what suits you and do what it takes to achieve it, (with a bit of professional help and guidance, of course).

Good luck.

SHOULDER EXERCISE – MOBILIZATION USING FIT BALL

References;

Wikipedia defines  the general population that use personal/physical trainers “as an age range of 18 to about 50 (45 and younger for males, 55 and younger for females)”. One internet thread I found asked, ‘what is the average age of trainers?’ and was full of well intentioned individuals with great mission statements, but not one of them was over 31!

There are a few certification courses for older trainers and for those training older individuals, but they seem mainly to be in the US.

Interesting article on STRENGTH TRAINING FOR THE OVER FIFTIES

Here at the Adur Osteopathic Clinic, the Osteopathic and Physiotherapy Practitioners are frequently asked to help with understanding and developing Core Stability exercises.

The term ‘core stability’ has gone in to popular culture and is widely used in fitness, training and health circles. However, I do believe that the very popularity of the term’s use often means that people are unclear exactly what ‘the core’ is. I ask many patients to tell me what their understanding is and it is clear that there is a huge range of interpretation and advice being given.

Now it should be said that there is no substantial danger in exercising and strengthening ‘the wrong muscles’, but I believe it is a matter of accuracy and you may not get the result that you want or expect . There may be some risk of aggravating lower back problems is the exerciser if overzealous.

Exercises range from gentle, subtle pelvic floor and lower abdominal contractions to highly taxing and often aerobic dynamic exercises such as Kettlebell and advanced Pilates routines. So, who needs what? That, of course depends on what your specific needs, physical condition and ambitions are. However, I generally like my patients to start off at the bottom, (sorry!), even if they are otherwise fit and able. This is because the technique is very important and running before walking is what leads to the confusion about what core strength and stability  really is.

For example, I have scanned some very fit professional footballers and they have wonderful external and internal oblique muscles – well defined, strong and capable. But, their Transverse abdominis muscle, (the really important one), is thin and poorly defined. Why? I think that it is partly training-specific and partly because they can see fantastic abs and six packs, (so therefore they are worth the effort), and partly culturally-driven within football – pelvic floor stuff, “is a bit girlie”. I do point out that ignoring this area is partly why they are on my treatment couch  in the first place and it my responsibility to educate them of the importance. Give people the right reasons to do something and they will usually do it, even if they do need a good push to get started! Let’s face it, the most valuable, basic structural exercises are also pretty dull – but see them as the base for the more glamorous stuff.

What then, can real-time dynamic ultrasound scanning offer, and why bother? It is all about feedback, a sort of visual carrot and stick – perform an exercise or muscle contraction and see the result there and then, able to visualize what is going on beneath the skin – a quick peek inside at how things work. Action and result before your eyes.

In times gone by I’d have been burnt at the stake for witchcraft, but today? Use the technology to prove a point to yourself and see if you really are doing what you think you are and what you have been taught.

This is an example of BIO-FEEDBACK, where, in this case, a physical action is reinforced by a visual memory. The benefit of real-time ultrasound scanning is that the patient is able to make a connection between what they are feeling when asked to perform a contraction and what they are seeing on the screen.

Two of the most important muscles that we can image are the Transverse abdominis muscle, (TrA), in the side of the abdomen and the Multifidus in the spine.  These, along with the pelvic floor, are among the most important muscles targeted by Pilates Instructors and are crucial for Core Stability.

It must be stressed that while the pelvic floor muscles are key components of core stability, WE DO NOT scan them specifically. The scan is performed over the patients side, just below the rib cage. Put plainly, no internal examination is required and no clothes need to be removed.

You do NOT need to be undergoing treatment to make use of this type of service and the scan and exercise advice will last approximately 15 minutes.

For those who are receiving osteopathic or physiotherapy treatment at this clinic, the technique can help in improving recovery from lower back injuries by reinforcing exercise advice.

So, is it worth doing? This is the age of information and being informed, I am constantly being told, is both a right and a necessity. My belief is that the more informed you are, the better able  you are to make the decisions that suit you and best help your personal circumstances.

Contact us at the Adur Osteopathic Clinic on 01273 455 775 if you would like to know more.

To see a short video screenshot

Adur Osteopathic Clinic

Osteopathy, Physiotherapy, Ultrasound Scanning Physiotherapy Aromatherapy Dry-needling Reflexology Shiatsu, hypnotherapy, EFT & NLP Sports Massage

‘Our patients visit us from Shoreham, Southwick & Lancing, (Adur), Brighton, Hove, Bramber, Steyning, Worthing & other towns in West Sussex & East Sussex’

First, I am a Registered Osteopath and must state that my interest in this opinion piece is for the relevance of Kettlebell for people who already have back problems and more specifically for the chronic or long term sufferers. Also, this is quite a long rant, but please bear with me because the general issue of how we tackle chronic back pain in this country is a serious one and often badly tackled.

Anyone with an acute back problem should avoid strenuous exercise until they have been properly assessed by a Registered Osteopath, physiotherapist or appropriate medical practitioner.

Second, you may well ask, what on earth is Kettlebell? This dynamic exercise and training form is currently making itself felt throughout the fitness industry and claims the patronage of many celebrities, (Jennifer Lopez, Matthew McConaughey, Gerri Halliwell and Penelope Cruz are often mentioned), Russian Special Forces, boxers, cross-fit trainers, MMA* fighters and football clubs.

Raging through the US for the last decade with crossfit trainers and fitness adherents, the discipline has been in the UK for the last few years and it has now reached a prominence that is hard to ignore.

Its origins are not entirely clear but lifting weights to improve strength and fitness goes back as long as boys have wanted to show off . Kettlebells have been claimed by the Russians, Turks and Scots, (who apparently trained with small church bells!). The kettlebell or Girya resembles a cannonball with a handle. Incidentally, they do not ring. The only sound created is the heavy breathing of the user and the occasional clang as the bell finds the floor early!

Weights vary from 4Kg to 60kg, although typically 8kg, 12kg, 16kg and 20kg are used by normal mortals. The more capable and ambitious ‘kettlebellers’ are called Gireviks, Russian for weightlifter.

Now, it is not my business to promote Kettlebell as a practise, there are plenty of more able people out there who can do that, but must declare that I am an enthusiastic participant who has benefited, and has done so at a number of levels.

What is the technique?

A good whole body mobilisation is essential. Some moderate aerobic exercise such as jogging, star jumps, squats and arm swinging,  shoulder, neck and quads stretches take place over several minutes. Now I know that the evidence for stretching before exercise is now felt not to help in preventing injury, but you will need 6-10 minutes of cardiovascular ‘warm-up’ for the session that follows.

For the chronic back pain sufferer, I think this gives hope. All too often, rehab programmes concentrate on passive stretching and mobilisation, rather than a return to CV health and strength. Personal and professional experience tells me that someone with a 20 year history of back pain is afraid of the consequences.

The attitude is ‘better the devil we know’ and all that. Maintaining the staus quo is better, in the minds of many, than ’stirring things up’, which is often the experience they have starting a new exercise programme. It takes a lot of courage to start a regime knowing that it may well make things feel worse to begin with.

However,the important word there is FEEL. I spend much of my clinical time agreeing with patients when they say, “but won’t that exercise make it hurt more?”. They don’t expect me to agree, because previous advice will often have been about caution and ‘don’t do too much’.

Being frank about what will happen is often more to do with the therapist making their own life easier; management of the patient rather than management of the condition. Both are needed, but it’s the emphasis that may need looking at! Please remember, hurting more does not necessarily equate to damage!

Of course, there are risks, but with proper guidance from your Osteopath, Physiotherapist or health advisor and in conjunction with your trainer, doing damage or causing any permanent worsening of symptoms is unlikely.

The trick is to take the right amount of time for the individual and this is where group classes can be weak – frankly, even the best trainers can’t be expected to tailor programmes for each person in a class of 20+. Don’t blame the class leader though, take personal control and think of how you get around the issue.

So, what is the answer? Well, one answer is to take personal tuition to begin with. Yes it can be expensive, but at say £35 to £40 per session over say 4 weeks, it’s cheaper than an overnight stay in London. Put bluntly, I know plenty of my chronic back pain patients do that fairly regularly ‘as a treat’. So treat yourself to being well and it may improve your mood and mental well being as well – radical stuff, eh?

Probably sounds smug, but it’s what I did. I took a couple of 1-1 lessons and was joined by a friend for a further 2, (price went down for 2 by the way), then another friend for two last sessions. Then I felt ready to join a group class. Let’s face it, most blokes don’t want to look like they don’t know what they are doing and most women don’t like to be stared at!! No doubt that sounds somehow sexist, but I hope you know what I am getting at.

The basic form is the TWO HANDED KETTLEBELL SWING. I won’t describe each exercise in detail, but the kettlebell swing is where it all starts and the technique must be good to both protect your back and get the most out of the exercise.

The swing mainly targets  the legs and abdominal muscles, the back, (BUT NOT WHILE BENT),the hip rotators and increases cardiovascular endurance. The swing element comes from contact with the inner arm as it meets the inner thigh and the thrust generated by a crisp forward thrust of the hips/pelvis.

The aerobic nature of the exercise is what startled me most when I started.

The next technique to master is the CLEAN.

Clean 1st Pos - Photo Christian Vila

Clean 2nd Pos - Photo Christian Vila

The kettlebell design allows for the weight to roll around the hand and wrist as you lift into the clean, keeping it balanced and ‘close packed’.

Once again, the power is coming from the thighs, abdomen and to some extent the lower back, dynamic, fluid and using the whole body to distribute any stresses. However, you can see that the back is held in a neutral or slightly extended position.

The lifting arm is held close to the body to protect the joints in the arm and shoulder. This is crucial, as injuries to the rotator cuff are common when weights are used with the arms extended or stretched out.  The loose arm is used for balance and seems to help focus the dynamic nature of the move.

PRESS - Photo Christian Vila

The next move is a continuation of the CLEAN; the PRESS can be seen in the image here. Particularly good for shoulder, shoulder blade and upper back muscles, it is once again using the whole body, flowing from one structure to another and while the joints are used throughout their range.  There are few static moments during kettlebell moves, the time when soft and bony structures are most stressed, and so helps in reducing the risk of damage.

While excellent for promoting mobility in the joints at each end of the collar bone, the upper ribs and neck, this exercise needs to be done with good technique. This often means using an approriate weight. I have seen people struggling with too much weight, the technique suffers with the consequent risk of neck strain.

I should also say that the leaders of the class that I attend are very hot on this and encourage swapping weights during a set – the emphasis is on keeping going safely rather than emulating Atlas.

The static presses and exertions of  ‘regular’ gym weights, fixed or free, do, in my view, carry the risk of overextension of the joints and point pressure on vulnerable structures such as the rotator cuff insertion, acromio-claviclular joint,  knee and shoulder cartilages.

There are plenty of other basic forms, but check those out on the kettlebell sites, (see examples below), as there are variations and styles that should suit most needs.

So, after all that, is it good for your back? Please remember that the back, (or spine), to physical therapists also includes the neck.

Succinctly, if you are well but unfit and want to become so, then yes. If you have back problems, then proceed with some caution!

However, as with all exercise forms, make sure that you seek out well qualified trainers and yet be strong enough in yourself to proceed at your own pace. Their job, in my view, is to provide the knowledge, support and skills, plus the encouragement to keep going and to draw out your motivation.

In conclusion, I like this regime because it is dynamic, relatively low impact and uses the joints through their whole range. It flows, is as much about balance and technique as it is about strength, yet improves power.

Kettlebell is an excellent mix of aerobic exercise and fat-burning, with muscle toning that doesn’t produce too much bulk.

It is egalitarian and friendly. My experience is that the men and women who go are not there just to look wonderful, but to improve themselves generally. Sounds a bit twee, but I mean it. Posers are at an absolute minimum and overt testosterone is low. There is a good mix of abilities, ages and, lets say, weight categories and there is an old-fashioned helpfulness, at least in the class I attend.

Go on, give it a go. As previously stated, check with someone qualified to judge but you may well be suprised by how much you will benefit!

Andrew Bellamy

Training in the Brighton, East & West Sussex area.

http://www.brightonkettlebells.co.uk/

http://thebrightongirevik.blogspot.com/

Influential figures in Kettlebell:

http://en.wikipedia.org/wiki/Pavel_Tsatsouline

http://en.wikipedia.org/wiki/File:Valery_Fedorenko.jpg

*MMA – Mixed Martial Arts

So, once you get the presents home, they have to be wrapped. This job mostly falls to the women of the house. (Men tend to grudgily buy one present and get the kids to wrap it for them – “but sweetie, you do it so much better than I do“). My experience tells me that most wrapping is done on the floor which gives maximum space, but furthest distance to reach and greatest potential for twisting, the basis of many of the injuries that we see at any time of the year – “now where did that sellotape go?”
Imagine the scene – on your knees, twisting to reach the furthest away item, turning the other way to get the paper off the roll, sellotape pieces stuck to your hand, youngest child begging to be let in the room, or wanting a wee and the dog walking through the whole lot!
It does take longer, but wrap at a table or better a kitchen worktop which is at a better height. Less twisting = fewer back problems. Simple, really.
Now, wrapping over, the big day comes and the bend to put the bird in the oven, (often after a few the night before), and the back ‘goes’. The number of times I have heard this and another Christmas is ruined is not quite countless, but it is very familiar. Do the sensible thing and get someone else to do it for you. Failing that, bend at the knee with a straight or slightly extended lower back and DO NOT TWIST!

Assuming you survive Christmas the next thing is to survive the urge to go to the gym to burn it all off. Just a word to the wise – the gyms will be packed at first, but this settles back to normal in about six weeks when all the good intentions have faded away and other people have forgotten the rash resolutions you publicly announced.
Make your resolution to start at a time that is ‘offbeat’. You don’t have to follow the crowd and if it is your decision made on your terms, you are more likely to stick to it, in my view.
Also take your time to decide which exercise suits you; swimming is a great all round exercise, but if you find it dull and a chore, you won’t keep it up which is a waste of membership fees and achieves very little. Experiment and try and find the exercise that you enjoy – it doesn’t have to be a sport in the conventional sense. What about dancing, walking and cycling?
The thing that matters is to avoid injury in the first place and to keep fit in a way that gives you pleasure. You just have to get out and try a few different things to find which suits best.
Merry Christmas

I sometimes feel that there is a gap in the way that we as therapists and trainers handle the recovery and rehabilitation phase of shoulder injury; that the categories are sub-divided too starkly into black and white, passive and active, low-stress mobilising and strength building. It seems to me that we should more often look at what the individual needs and build in an intermediate phase, where act as guide but let the injured individual be inventive and therefore participatory in their own recovery. They improve faster as a result. Encourage them to clean windows, polish floors, bounce balls against a wall – all low, (or at least controllable), effort activities that help to distract from the discomfort but also gives a sense of achievement.

This is not revolutionary thinking by any means as business management techniques are always telling us that if the employee ‘buys in’, then productivity and contentment rise! Why should patients and sports people be any different?

Each individual is just that, individual, and has different physical structure, varying levels of physical activity, abilities, age, expectations and needs. It seems intuitive, therefore, that while those who are professionals endeavour to tailor recovery regimes, that they should, in part at least, be led by the recipient.

I am a great fan of The Rotater and, increasingly, of Kettlebell workouts, but they have very different ‘points of entry’ in the timeline of recovery – the Rotater can be used fairly early in the recovery phase – gently at first, ramping up the intensity as pain reduces and range of motion increases and until it becomes an integral part of any workout, prehab or sporting event. Kettlebell is fantastic as a total body workout that is low impact and wonderful as shoulder mobiliser, BUT is only appropriate rather further down the recovery road!

The following video tries to outline a fairly ‘loose’ approach to mobilising the shoulder – be inventive, work within your means to start with, gradually increasing range and intensity, trust your therapist or trainer, but trust yourself as well.

As with all advice on medical conditions, check with your doctor, osteopath, physiotherapist, chiropractor or trainer before embarking on any new regime.

This is an example of a shoulder dislocation. It is of a rare type, inferior, (or downwards into the armpit), and is caused by hyperabduction and makes up only 1% to 2% of all dislocations. This is a Luxatio erecta type.

So, if it is so rare, why does it matter? Well, it is rare overall, but is relatively common in sporting people who fall!  Mountain biking, moto-X, soccer goalkeeping, equestrian sports and skateboarding.

If YOU end up in the emergency room with your arm stuck above your head, the chances are that they will not have seen it. The key to relocating this joint is to dislocate it again first…..FORWARD, creating an ANTERIOR dislocation, then a more normal reduction to its proper position.

As well as the usual problems associated with dislocations, (AC joint, nerve and blood vessel damage), the inferior type causes damage to the floor of the armpit and can lead to  concurrent fractures of the upper arm, AC joint, as well as injury to the nerves, (brachial plexus), or specifically to the axillary artery.

Recovery can be slow, even with conventional physical therapies, medication and exercises. You will probably have to start with PASSIVE movements, such as pendulum swinging which you can see if you run the video. Remember that passive means just that – let someone else make the movements for you, (physio,osteopath), or use the weight of a tin of beans or can of coke and your body movements to generate the impetus.

Repeat these exercises several times a day and at every opportunity. If you don’t use the range of motion, you may well lose it! Repeat each direction on movement about 30 to 40 times. ie, 30-40 clockwise, anticlockwise, front-to-back, etc.

Good luck with your rehab and make use of all the tools available to you; information, professional advice, devices like the Rotater and, most of all, use your imagination.

We don’t normally endorse products so positively, but this thing really does do what it says on the tin. Take a moment and have a look! If you would like to know more, drop in and see us at the clinic or check  these sites;

Main ShoulderCentric Site

The Blog for shoulder exercise and rehab articles.

Facebook Page for general shoulder information:

Scott Welch - Champion Boxer using the Rotater

The Rotater is used to enhance the process of rehab after surgery and can also be used to improve shoulder mobility that may help your sporting ambitions. Flexibility and improved range of motion, (ROM), for golf, tennis, rugby, baseball, boxing and goalkeeping can all be helped with its regular use.

Some of you may have heard that ‘your author’ was foolish enough to fall off his mountain bike while trying to keep fit and keep the expanding waistline manageable.

This happened on the 16th December, just before Christmas and just after getting back from holiday – excellent timing!

I won’t go into the gory details, but I dislocated my right shoulder and fractured part of the upper arm bone. I can’t fault the Ambulance Service who promptly picked me up from the back of the Downs, but I’m not convinced that ‘gas-n-air’ does more than give you something to do! However, thanks boys for bringing me in, mud and all.

Worthing A&E did their sterling best to put things back in place, but sadly failed. My ‘inferior’ dislocation, (and I can tell you it didn’t feel at all inferior at the time), is apparently rare, but the sight of them checking up on the internet before ‘having a go’ was a bit unsettling, as you can imagine. By now I had had my arm above my head for 6 hours and I was prepared to let them try anything. They told me I wouldn’t remember anything! I’d like to have a word with that very enthusiastic chap sometime.

Next day,after a good, morphine-induced sleep, I was taken to theatre to have the shoulder back in place, discharged later that day with a promise to screw the detached bits back in a few days.

Three weeks later, it was expertly done, leaving me with three shiny screws, a lovely scar and a lot of physio to look forward to.

Physio was an experience, I can say. As an osteopath and with a now-long-ago background in the NHS, I did have some apprehensions, but they were completely unjustified. I won’t mention her name so as to avoid embarrassment, (after all, her colleagues might blackball her for treating ‘the enemy’), but I had expert, professional and effective treatment and I like to thinkthat weboth learned somewhat from each other.

Weekly treatments for 5 weeks, with lots of self-torture at home meant that I was back at work part-time 6 weeks after surgery. I was also aided by a device that I ordered from the US, called the ‘ Rotater ‘, which proved to be a huge benefit. It is a simple device that gives control to the user and lets you relax the shoulder while in use. It’s is so easy to fight the therapist and ‘cheat’, thinking you are getting more improvement than is real.

I was discharged after about 10 weeks post-op and now comes what I think is the really hard part. I and most of my friends and relatives have become bored with the whole thing. It is now, back on my mountain bike, SCUBA diving and working full time again, that it is so easy to stop doing the exercises and stretches – I’m coping OK, aren’t I? Well, yes, but it isn’t better yet and it is easy to avoid doing the things that still hurt or are difficult. Please take my word for  it, keep it up – shoulder injuries, including frozen shoulder, sub-acromial impingement problems, rotator cuff tears and dislocations take a long time to really heal – think in terms of at least a year!

Looking on the positive side, I have learned a great deal both about my specific injury type, as well as shoulder injuries in general. I hope that I will be both more sympathetic and empathetic toward my patients in future – but beware, I have also learned that a I have been too soft on them in the past………

Andrew

WHAT IS THE ROTATOR CUFF?

A group of 4 muscles in each shoulder, named for its vague similarity to a short sleeve shirt cuff. Damage to the cuff may be referred to as rotator or rotater cuff tear, rotater cuff strain or rotator cuff injury.

• These muscles are the supraspinatus, the infraspinatus, the subscapularis and the teres minor muscles. These muscles start on or under the shoulder blade and their tendons wrap around the shoulder joint and the tendons attach to the humerus, or upper arm bone. Their job is to stabilise the joint while it goes through its many movements.**
• The most likely point of injury is to the tendons of the muscles and can range from microscopic tears to large holes in the cuff.
• The supraspinatus tendon is the commonest site of tearing.
• The size of the tear and the amount of pain suffered does not correlate well. Large tears can be seen on scanning that are symptom-free!
• Rotater cuff tears can happen at any age and may from sporting activities, such as throwing sports, traumatic injuries like dislocations and fractures, but are most common in older age. Degeneration of the tendons, abrasion under the acromio-clavicular joint, (the bony knob on top of your shoulder) and postural problems, (being increasingly round shouldered), are all causes.

WHAT ARE THE SYMPTOMS?

• · Pain often starts around the upper, outer arm
• · Pain gets worse when you lift the arm and try to use it above your head
• · A painful arc of movement – i.e. lifting the arm, initially without pain, until you get a sharp pain, which you might be able to go through with effort, when it then eases again
• · Pain when turning the arm out to the side when the elbow is bent, (external rotation)
• · Waking at night with a dull, persistent ache or just when you are resting
• · Pain over the front and side of the shoulder when you lean on the arm of a chair
• · Pain when you push the arm sideways against a resistance (the ‘impingement sign’)
• · Weakness, especially overhead or out to the side
• · Poor range of motion – can’t do up bra, reach back pocket, brush hair and so on
• · Crackling (crepitation) and creaking when you do move

HOW IS THE ROTATER CUFF INJURED?

• · Shoulder dislocation from sports injuries
• · Lifting or catching something heavy
• · Falls on to an outstretched arm
• · Overuse, especially new activities or sports – perhaps soon after retiring from a sedentary job
• · Age-related degeneration of the shoulder tendons and impingement, (pinching)
• · Poor posture, (round-shouldered), which reduces the amount of room under the acromion, especially the supraspinatus muscle

WHAT TREATMENTS ARE AVAILABLE FOR ROTATER CUFF TEARS?

• · Conservative approaches should be considered first as long as the rotater cuff tear is not complicated by trauma or disease
• · Consult a Registered Osteopath or Chartered Physiotherapist or you GP – they will advise you of the best course of action, as appropriate to the severity of your condition
• · Injections of steroids can be very effective for relief of early symptoms and may help in early mobilising of the joint and cuff
• · Non-steroidal anti-inflammatory drugs, (NSAID), are frequently prescribed by physicians – as a result of recent animal research, I am now exercising some caution about NSAID’s. A paper by David B. Cohen, MD, Sumito Kawamura, MD, John R. Ehteshami, MD, and Scott A. Rodeo, MD suggests a hypothesis that suggests ‘traditional non-selective non-steroidal anti-inflammatory drugs and cyclooxygenase-2–specific non-steroidal anti-inflammatory drugs interfere with tendon-to-bone healing’ – a link for the full article is at the end of this blog ***. This is not the same as saying that humans will react in the same way, but I leave you to read and draw your own conclusions

• · Surgical repairs are usually done by keyhole methods nowadays, so the time spent in hospital is short and the initial recovery time is rapid. The post-op exercise regime can be prolonged depending upon age, severity of the tear and other factors. There are many examples if keyhole shoulder surgery on the internet which will give a clearer picture of what happens during the operation than can be explained here

• ·The level of recovery is, in my view, very much down the determination of the patient. Work diligently at the exercises, stretches and strengthening regime that you are given. IT WILL BE UNCOMFORTABLE some of the time, but it is also vital that you don’t shie away from some discomfort because you will almost certainly be let with less mobility than you can expect. Equally, actual pain is not desirable either – to some extent you have to judge this for yourself.

• · One effective method of passive internal and external rotator cuff stretching is to use The Rotater, (yes, this is an advert), a user-controlled device that isolates the muscles that you want to stretch and allows for a ‘pure’ motion around the axis of the upper arm bone, thus reducing the ‘cheating’ effect of hunching the shoulder and lifting of the shoulder blade that so complicates recovery from this injury

SHOULDER EXERCISES – passive phase (PLEASE NOTE THAT THESE ARE EXAMPLES AND MAY NOT BE APPROPRIATE FOR YOUR PARTICULAR CIRCUMSTANCES)

• Pendulum – lean forward, legs apart for stability – loosely hang affected arm down – use good arm to grasp bad arm above elbow – guide pendulum activity in all planes. 2 X per day
• Desk Slide – place bad arm on desk, forearm flat – use good arm to slide arm back and forward. X 20-50 Twice a day
• Overhead Pulley Stretch – repeat sessions as often as possible. There are a number of commercially available pulley systems on the market and they are an inexpensive and effective aid. An example can be seen at this site. http://www.adurosteopaths.co.uk/g_products.htm
• Stand against wall with arms flat to wall – palm facing in or out – lift arms, snow-angel-style, as far as possible, using wall to brace against.
• Scapular, (shoulder blade), exercises are VITAL – there are many ways to do this, but be warned, many of the internet-based regimes are for STRENGHTHENING using you own body weight. Initially STRETCHING and gentle strengthening are what is required.
• Here are just two examples of scapular strengthening;

Shoulder Roll

• · Stand and relax with your arms by your sides. Slide your shoulders forward, shrug gently up, and move shoulders backward – squeeze your shoulder blades together, pull shoulders downward. Repeat X 5
• · Repeat X 5 in the opposite direction in one slow continuous circular motion.
• · Increase the number of sets as you gain strength and confidence.
• · Rest for 30 seconds between sets.

Shoulder Blade Squeeze

• · Standing or sitting – draw your shoulders down and back
• · Bend elbows at 90-degree angle
• · Pull elbows back, squeezing shoulder blades together
• · Hold for 10 seconds
• · Repeat X 3

SHOULDER EXERCISES – recovery/rehab/strengthening phase (PLEASE NOTE THAT THESE ARE EXAMPLES AND MAY NOT BE APPROPRIATE FOR YOUR PARTICULAR CIRCUMSTANCES)

• Use exercise bands http://www.adurosteopaths.co.uk/g_products.htm
• Consider using a device like The Rotater http://www.shouldercentric.co.uk
• Use tennis ball to throw at all angles and vary position – variation, ball of paper into bin. Vary distance and angles.
• Stand against wall with hand in small of back – lean into wall to stretch front of shoulder.
• ‘Pray to Allah’ – concentrate on keeping arms in same orientation.
• Ball Rolling – as in ‘Praying to Allah’, but over exercise ball. http://www.adurosteopaths.co.uk/g_products.htm
• Roll hand/arm over big ball.
• Polish your windows

NB There are many exercises and stretches that will help with rotater cuff injuries and this article is by no means fully comprehensive. Please look at other sources for further information.

Also, when you are sourcing aids and materials, please look at other sites for comparison purposes

**A good set of illustrations of each rotater cuff muscle can be found at this site;

http://www.sportsinjuryclinic.net/cybertherapist/back/shoulder/rotatorcuff.htm

***Traditional non-selective non-steroidal anti-inflammatory drugs and cyclooxygenase-2–specific non-steroidal anti-inflammatory drugs interfere with tendon-to-bone healing

http://cat.inist.fr/?aModele=afficheN&cpsidt=17538154

http://www.jbjs.org.uk/cgi/content/abstract/91-B/2/259

]]> http://www.adurosteopaths.co.uk/wp_blog_aoc/?feed=rss2&p=74 4 http://www.adurosteopaths.co.uk/wp_blog_aoc/?p=50 http://www.adurosteopaths.co.uk/wp_blog_aoc/?p=50#comments Mon, 16 Mar 2009 20:40:18 +0000 Andy Bellamy http://www.adurosteopaths.co.uk/wp_blog_aoc/?p=50

THE NERVOUS SYSTEM; IS IT AT FAULT AND HOW DO WE TREAT IT? By Alex Strach

Please note that the comments in this blog come from many years of clinical experience and practice, combined with details and opinions taken from various sources, including open-source internet articles. Where relevant, links are provided.

Please also note that we cannot comment on individual cases without taking a proper history and conducting a full examination.

WHEN DO WE GET NERVE INJURY

The nervous system, (NS) is a system that can become involved in any injury or over strain. The nerves can be damaged directly or be indirectly affected by other tissues. There may not even be any obvious injury but nerve tissue can be affected by poor posture and/or repeated awkward movements.

Even very minor injury to nerve tissue can lead to scarring and therefore tethering which in turn affects the mobility and glide of a nerve. It only takes a minor injury to make a nerve behave differently.

Even if the nerve tissue is not injured, we have to remember that the majority of tissues in our body have a nerve supply and that ‘error messages’ of any damage, are sent to the brain via the nervous system. These may contribute stimulate our protective mechanisms such as muscle spasm.

The NS is, (in simplified terms), like “one long piece of string” and injury in one area can lead to repercussions in other parts of the body.

NERVE ROOT INJURIES

One of the most common nerve injuries that you hear about is sciatica, which is a complaint which many people visit the Physiotherapist and Osteopaths here at the Adur Osteopathic Clinic to seek help. However, many people do label any pain referred from the spine as ‘sciatica’, which is technically incorrect.

True sciatica involves injury to the root of the nerve in the lower part of the spine and causes referred pain down the back of the leg and often includes sensory, (sensation), changes such as tingling or numbness, and possibly weakness.

The nerve roots a little higher in the spine can send, (refer), pain down the front of the thigh and leg. Pain and symptoms from the trunk level can radiate round the sides or even into the front of the chest. Nerve involvement in the neck region can cause symptoms to be referred down the arms.

PATTERNS OF SYMPTOMS

The nervous system is so widely spread in the body that referral potential is such that no area of the body is exempt; however, there are patterns of symptoms and area distribution, which give us valuable clues to location and nature of injury.

It is when our Osteopaths and Physiotherapists see and hear of symptoms that don’t fit a familiar pattern that they may suspect nerve tissue involvement.

Symptoms can occur in patches or clumps down a limb or spine. For example, tennis elbow can coexist with carpel tunnel syndrome, low-neck pain and then mid-thoracic symptoms can present.

KINDS OF SYMPTOMS

Bilateral symptoms, (both sides at the same time), such as bilateral carpel tunnel syndrome or bilateral ‘shin splints’ must immediately raise suspicion of altered nervous system mechanics. There can also be a pattern of symptoms ‘jumping’ from area to area. For example, one day the symptom may be in the lower back and the next day in the knee. People also commonly describe lines of pain and ‘strings pulling’. These are often related to the pain of peripheral nerves.

The kinds of symptoms that people describe with nerve involvement are very varied. However, nerve root damage that can occur with true sciatica is typically very severe, ‘searing’ pain.

Otherwise, pain can be described as ‘aching’, ‘deep’, ‘burning’, ‘heavy’, ‘vague’ to name just a few. Burning is a common complaint but nerve involvement can elicit much more bizarre descriptions such as ‘wooden’, ‘strangling’, ‘dead’, and ‘ants crawling’, even feelings of swelling when there is no visible evidence of this. There may be limited movement which is key to our testing techniques.

Nerve injury may also cause numbness, tingling, (with or without the presence of pain), and weakness. Symptoms may also be worse at night, which could be related to lower blood pressure combined with certain postures that may tension the nervous system.

TESTING FOR NERVE INVOLVEMENT

We test the nervous system using reflexes, sensation testing and muscle testing. With more subtle nerve injuries we also use movement to test the sensitivity and ability of a nerve to glide as an indication of nerve involvement.

The most commonly used ‘mobility’ test for nerves is the ‘straight leg raise’. This test is used mainly for all spinal problems with leg symptoms to assess the nervous system mechanics, but could also pick up NS involvement throughout the body even including headache symptoms.

The Slump test is another procedure used for spine and leg symptoms but can be   used for wider spread or with multiple symptoms.

The practitioner looks for reduced range of movement, symptom reproduction and being able to produce symptoms by moving a distal body part not mechanically related to the symptom area. E.g. if neck bending reproduces calf pain, we reason that one of the only connections between neck and calf is nerve tissue (that ‘one long piece of string’).

We also test the upper limbs by putting tension on the various nerves that travel down the arm. The picture shows an example of one of these.

If the therapist can detect an abnormality in these tests, then they use this knowledge to treat the symptoms.

TREATMENT

Treatment of the nervous system will depend on many factors and can potentially be very provocative. Therefore we would not recommend that these movements and exercises are used as self-treated without prior assessment and advice.

Moving nerve tissue can help to alter pressures in the system and reduce ‘swelling’. E.g. in carpel tunnel syndrome, movement improves blood supply to areas of injury and damaged nerves. Often, when a nerve is damaged the fluid flow within the nerve is altered and again, by moving the nerve we hope to normalise this flow. There is evidence that movement can actually stimulate nerve growth where a nerve has been cut and repaired.

The therapist will carry out repeated movements, usually into some resistance, but the amount of movement, speed of movement and degree of stretch will depend on the severity, irritability and nature of the complaint.

Knowledge of the courses of the nerves is essential to understand positions of tension. If we believe there is tethering of a nerve to surrounding tissue, then repeatedly gliding the nerve should help to release the scarring, and allow the nerve to function normally. If the condition is non-irritable we may push into resistance and even sustain a stretch. Obviously more care is needed with irritable conditions.

The experienced Osteopaths and Physiotherapist will examine and advise on the most useful treatment form for you and your individual case and needs. No advice that we read can be appropriate for all people, but acts as a guide and we hope that we stimulate sufferers to make informed choices and seek the best treatment from the most experienced and appropriate therapist that they can.

Alex Strach

Chartered Physiotherapist

For further information or advice on how, contact us at Adur Osteopathic Clinic, mail us at info@adurosteopaths.co.uk, or call us on +44 (0) 1273 455 775

With thanks to http://www.neurodynamicsolutions.com/solutions-clinical.php and

http://noineurodynamics.blogspot.com/2007/10/reflections-on-upper-limb-neurodynamic.html

for their excellent images and explanatory text.

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