You Should Not Limp.

   Touted as an excellent form of exercise, walking is something we all do, and that most of us take for granted as an activity we need no training in. But of course we were trained, it was just at a time we no longer remember. 

    More than an exercise, it is a basic activity of daily living. We bear weight, we transport and we maintain our body’s equilibrium. The human gait cycle is more complicated than most of us appreciate, but perhaps that is because few of us take time to think about it. A normal gait supports our weight as we move with minimal energy expenditure. The lower limbs are adapted for stability rather than range of motion and that stability is achieved at the major joints of the lower limb through the use of strong ligaments and tight fitting bony surfaces rather than the expenditure of energy in the form of muscle contraction. 

 

 

 

 

 

 

 

 With each step we shift our weight to an ideal position supported by the surfaces of our bony joints. 

 

 

 

 

 

 

 

 The wide surfaces of the knee joints, and the arches of the foot and ankle bear the majority of the weight. The ligaments stabilize the joints with amazing strength providing support. The goal is to maintain an ideal center of gravity, and this is done instinctually. 

 

     The two main phases of gait are named stance and swing and the structures of the lower limb move differently during each. In stance phase the limb is weight bearing and in swing phase the limb is non-weight bearing. During stance phase, the pelvis moves over the thigh (femur), the thigh moves over the lower leg (tibia) and the lower leg moves over the foot. During swing phase, the motion is opposite, ie the thigh moves under the pelvis etc. 

 

     The muscles act to control the rate of motion and the size of each step. They accelerate and decelerate the bones to maintain the ideal center of gravity and support our weight as we move. Any deviation away from the instinctual pattern increases the work each limb must do at a higher energy expenditure. 

 

    If a muscle is weak, a ligament damaged, a bone misshapen or in the presence of neurologic disease, we subconsciously adjust our gait pattern to accommodate the dysfunctional part. Said another way, we limp. Most people think that if they have an injury limping will protect the impaired body part from further strain and this may be true but consider the rest of the body. For example, if an ankle is sprained, the normal compensatory instinct is to walk on the ball of the affected foot minimizing motion across the ankle joint. But walking on the ball of the foot, eliminating the part of gait when the heel hits the floor, causes excess strain on the calf muscles and hip, knee and toe joints and their ligaments. The time for each step on the injured leg is reduced and the healthy limb must bear weight longer than normal, thus straining the muscles and joints. And the muscles we do not use by walking on the ball of the foot get weaker.

    
   When we limp, protecting the one injured part, we cause strain and misuse of many other portions of each limb. And this strain and misuse happen all the time, with every step. The risks of limping to the entire limb far outweigh any benefit limping might offer a single injured portion of a limb. The damage begins almost immediately so that even a single day of limping may cause substantial injury. When injured it is essential that we adjust the way we walk to maintain a normal gait pattern. Reducing the speed of our walking is one efficient way to restore a normal gait pattern. When this is not enough, using a cane or crutch to reduce our body weight can restore gait to normal.

Athletes' Heart A Benign Syndrome

 

The heart is comprised of cardiac muscle fibers, which differ from the skeletal muscle fibers of the limbs or the smooth muscle fibers of the internal organs. The specialized muscles fibers allow the heart to function as a reliable pacemaker that proves remarkably accurate and strong.
Heart muscle develops as an athlete trains. The changes in cardiac muscle fibers, and heart function as a result of training do not parallel those changes seen in the skeletal system exactly. There are a collection of fairly typical changes that occur that have been named as a clinical syndrome called Athlete’s Heart. Athlete’s Heart is an asymptomatic condition associated with common clinical signs including bradycardia (slow heart rate), a systolic murmur and extra heart sounds that, in an athlete, are usually considered acceptably normal. The vigorous, repetitive training regimens that athletes routinely endure lead to characteristic physiologic and anatomic changes, including enhanced diastolic function, larger left ventricular dimensions and mass, and right ventricular dilatation and systolic dysfunction. These are all basically enlargements of the heart chambers or thickenings of the muscular chamber walls.

Normal Heart

Athlete's Heart

 These changes allow the heart to beat less to pump out the same or greater amounts of blood to surrounding tissues used in exercise. In the first six to 12 weeks of training, the resting heart rate decreases by five to 10 percent. The resting heart rate slows, a sign that the heart is pumping blood with greater efficiency. The large volume of blood flowing through the heart results in a slower, stronger pulse (which can be felt at the wrist and elsewhere on the body) and sometimes heard as a heart murmur. These murmurs, which are specific sounds created as blood flows through the valves of the heart, are no dangerous. The heartbeat of a person with athletic heart syndrome may be irregular at rest but becomes regular when exercise begins. Premature heartbeats may occur occasionally at rest. Blood pressure is virtually the same as in any other healthy person. The myocardial changes that characterize an athlete’s heart are influenced by the type of sport practiced. The physiologic responses to static and dynamic training lead to different adaptations to sustain the specific compulsory demand During aerobic exercise, the consistent exposure of the left ventricle of the heart to increased volume during episodes of sustained elevation in cardiac output causes the ventricular enlargement. Increased afterload during strength and weight training has a propensity to initiate ventricular wall thickening.

Calf Pain When Stepping

 

Many runners use the elliptical or arc trainers as alternative exercise choices when they are rehabilitating injuries. The indoor training apparatuses allow challenging aerobic workouts without the same potentially harmful physical impact experienced when running. But outdoor runners are practiced at using a normal running “gait” pattern than their colleagues who usually exercise indoors on treadmills, ellipticals and arc trainers. Thousands of people have climbed onto trainers without any “training” in their proper use. Treadmills, ellipticals and arc trainers do not come equipped with instructions attached to each machine as to how your feet should move. Though the physiologic effects of indoor cardio workouts may be very similar to running, the actual leg motions vary in specific ways, dictated by the aparatus being used. With ellipticals and arc trainers, the foot patterns are obviously different from outdoor running since the feet rarely rise off the footplates. Calf fatigue or pain or tingling during a aerobic exercise session on a treadmill or elliptical trainer are common complaints. These specific symptoms result from the way people use their legs when exercising on the machines compared with when they run or walk on the ground.

Normal gait

Running gait

 Usually with walking or running the foot lands on the heel (heel strike) and rolls forward. When you walk faster, your stride length (the length of each step) naturally increases. Your leg muscles prime themselves to extend further and your heels reach farther to take that longer step. This cannot happen natrually on a treadmill or elliptical machine where the distance available for the next step is fixed. Your foot hits the ground prematurely, landing on the ball of the foot instead of the heel, unless you make a conscious effort to place the heel first. With practice the you can and should use the more normal heel strike pattern. Repeated stepping on the ball of the foot will exercise predominantly the calf muscles, the gastrocnemius and soleus muscles, instead of the larger and stronger thigh and buttock muscles (hamstring, quadriceps and gluteal muscles). The calf muscles fatigue quickly and cramp. Lactic acid builds up and you feel painful tightness and resistance as the muscles fight against the work you are asking them to do. Essentially, it is as if you are walking or running on your toes. You want to make sure your weight is firmly on the heel of your foot when you begin stepping down on a leg. This places your body weight properly with your center of gravity more posterior and will use you muscles and energy more efficiently.

An Effective Cardiac Workout

 

As a muscle, a heart needs exercise to remain in conditioned. Exercise helps improve heart health, and can even reverse some heart disease risk factors. As a result of exercise, a heart can pump more blood through the body with every beat and continue working at maximum level, if needed, with less strain. The resting heart rate of those who exercise is slower, because less effort is needed to pump blood.

Exercise benefits the heart and circulation (blood flow throughout the body) by improving cholesterol and fat levels, reducing inflammation in the arteries and helping to keep blood vessels flexible and open. For the greatest heart protection, it is not the duration of a single exercise session that counts but the total weekly amount of energy expended. The American Heart Association recommends that individuals perform moderately-intense exercise for at least 30 minutes on most days of the week (2008 recommendations - now recently updated in 2018 to greater than 150 minutes weekly). Similar exercise guidelines have been issued by the Centers for Disease Control and Prevention, and the American College of Sports Medicine (30-60 minutes 3-5 days/week). These organizations are recommending aerobic exercise, but resistance (weight) training has also been associated with heart protection. It may offer a complementary benefit to aerobics. And studies show that yoga and tai chi, an ancient Chinese exercise involving slow, relaxing movements, may lower blood pressure almost as well as moderate-intensity aerobic exercises. So know that there are options when designing your ideal exercise program.
 
     Consider the logic of this concept, that for optimal cardiac conditioning, creating a routine combining low intensity aerobic, moderate intensity aerobic and resistance training sessions each week provides the most functionally relevant conditioning. The benefits of such a program affords us with a heart that is well equipped to deal with any and all forms of stressors we encounter in our daily activities. Ultimately, this is what we are training our hearts to do.

     With any exercise program safety is an issue. To reduce the risk of injury or complications and make exercise more enjoyable there are a few things we must all do (or at least consider doing if we develop any possible risks). If over 40 years old it is recommended that you speak to a doctor first before starting any new exercise program. Chose a type of exercise you are more likely to stay with over the long-term. Perform your activity at a level in which you can carry on a conversation while exercising. This "talk test" provides a general rule of thumb to help you determine if a particular activity is too strenuous for you (the proper intensity of your workout).
 
     The specific design of an individual exercise program depends on the person, their age, level of fitness, basic health and personal interests. Doing something is proven better than doing nothing at all, so no one should abandon all exercise if they feel they cannot meet suggested guidelines. Knowing the guidelines provides a target for educated structure. Use these to create a program you can enjoy. Run, dance, walk, lift weights, and plan these activities with friends or alone, in a gym, in a park, at a nightclub or at home. Be creative, but be active.

BODY FAT

A body is composed of water, muscle, bone, vital organs and fat.  Adipose tissue (body fat) is a normal constituent of the human body that serves the important function of storing energy as fat for metabolic demands.

There are different types of fat cells that make up fat tissue.  What most people are referring to when they speak about the biology of “fat” are white fat cells, especially those located just under the skin (i.e. subcutaneous fat).

Large white blobs (termed “lipid droplets”) in the white fat cells are what house our triglycerides (TAGs). The lipid droplets grow and shrink as TAGs are used by the body metabolism.   

 

 

 

Chemically speaking, TAGs come in different varieties, but are always made up of a glycerol molecule plus three fat molecules.    

 

You may have heard of Omega-3 Fatty Acids, which have the third carbon from the right with a double bond. To clarify “saturated” versus “unsaturated” fat: This terminology has to do with the “saturation” of hydrogen atoms around the carbon atoms.  Unsaturated fat has double bonds between one or more of its carbon atoms (i.e. the double line things) and saturated fat are those that don’t.

 

 

 

 Know that your body needs both to function properly.

 

 

 

 

 

What causes TAGs to accumulate in lipid droplets within white fat cells?  High blood glucose levels, mainly

In order for our bodies to start pulling TAGs out of lipid droplets, the appropriate signals need to be sent to receptors on the surface of fat cells.  When glucose resources are low, this activates a wide variety of hormones including (to varying degrees and roles) epinephrine, norepinephrine, corticotropin (ATCH), thyroid stimulating hormone (TSH), cortisol, ghrelin, testosterone, human growth hormone (HGH), adiponectin, cholecystokinin (CCK), glucagon, and leptin.

To lose weight all you need to do is keep glucose levels down, make sure that these hormones are triggered effectively, and eat fewer calories than you burn.

 This simple concept would be ideal but a body never functions relying on a single process.   The blood glucose levels alone do not control metabolism.   Everyone has a different “metabolism” (i.e. the rates and efficiencies of the metabolic pathways and biochemistry described above), and these factors always change as we get older.  In addition to how we actively manage glucose, genetic and environmental factors will influence body mass index despite “classic” diet and exercise, and most Americans are destined for an increasing BMI until the age of 60 or so.  Said plainly, by just limiting calories, one will probably still carry excess body weight. 

In Lyn Genet’s work, she explains how inflammation affects metabolism, influencing weight gain and loss.   Her book, The Plan is an excellent resource for details.   Paraphrased from her blog; ‘elevated cortisol produces glucose, which leads to increased blood sugar levels. This will start to increase yeast growth as they have specialized glucose sensors and their growth in population will alter gut flora affecting your body’s defense system.  A high yeast population means never ending sugar and carb cravings (and high sugar and carb intake is definitely a factor behind the high rates of type 2 diabetes in the US).  Altered gut flora leads to a weakened immune response as the balance of our intestinal bacteria is thrown off’.   Here you have just a single example of the multiple factors working to manipulate glucose metabolism.

Fat metabolism is defined as the biochemical process by which fats are broken down, incorporated, and used by the cells of the body. Fats provide more food energy (9 kcal/g) than carbohydrates (4.1 kcal/g). Fat catabolism begins with the hydrolysis of fats (triglycerides) into glycerol and fatty acids.

Losing one pound of body fat is equivalent to 3,500 calories. To lose two pounds per week, you must eliminate 1,000 calories per day (all approximations).

The concentration of glucose in your blood is the critical switch that places your body into a “fat-storing” or “fat-burning” state.

As you eat carbohydrates, you metabolize them, and eventually store them as fats.  With energy expenditure, your body will draw on the fat stores, and you burn fat.  If your intake of carbohydrate is lower than your fat burning energy expenditure, then overall you will lose fat. 

 

In general though cardiovascular exercise rarely has a significant impact on the overall quantity of TAGs in your fat cells because  while  you expend energy and burn through glycogen and fat when you workout for long enough , your body adjusts for this via increased hunger and consumption of carbohydrates, fats, proteins, etc.   Building muscle does  raise your basal metabolic rate (so it’s a good idea to weight train). But again, your body adjusts to this new rate by compelling you to eat more.  In fact, in order to gain muscle you need to be in energy-positive situation and let insulin do its work of bringing in energy and amino acids in for “muscle building.”   It is essential to eat smart for exercise to assist with fat burning.   Selecting foods to eat with lower glycemic indices  may help a bit with balancing the caloric need/energy expenditure.   The Glycemic Index (GI) is a relative ranking of carbohydrate in foods according to how they affect blood glucose levels.  Carbohydrates with a low GI value (55 or less) are more slowly digested, absorbed and metabolized and cause a lower and slower rise in blood glucose and, therefore insulin levels.  There exists an exhaustive set of resources  presenting foods and their glycemic ratings  to assist in making smart food choices.   

 

Normal healthy values usually quoted for total body fat are 15% (12-19%) of body mass for young men and 27% (25-30%) for women, both increasing by about 5% from late teens to sixties.  Essential fat in the tissues and organs (including bone marrow, nervous system and muscle) averages 3% body mass for men and 12% for women (extra related to reproductive function); it is not a labile energy reserve, but a vital component for normal structure and function. Storage fat represents the energy reserve that accumulates as adipose tissue beneath the skin and in visceral depots, averaging 12% body mass for men and 15% body mass for women.  Methods most commonly used for estimating percentage fat are: measurement of skinfold thickness at prescribed sites, body density measurement, usually hydrodensitometry (the Quetelet index) and bio electrical impedance analysis.  None of these methods provides a precise indicator of body composition, but bioelectrical impedance is the simplest, least expensive, and most nearly accurate.

Understanding body fat empowers one to manage their metabolism, weight and health more realistically and responsibly.  There is so much more at stake than the prefect bikini body.  Lower body fat has been associated with lower risks of diabetes, cardiovascular and heart disease.  Improved metabolic rates  enhance energy, improve mobility and strength reducing the effects of osteoarthritis and osteoporosis.  Overall, we just feel better with lower body fat percentages and idealized body fat ratios mainly because we are using more efficient energy stores. 

Sacroiliac Joint Dysfunction

Low back pain is fairly common. Successful eradication of low back pain requires an accurate diagnosis of the underlying source of that pain.  Numerous anatomic structures may be the source of pain due to injury or degeneration (wear and tear or overuse).  There are joints, ligaments, muscles and tendons and nerves interacting, moving and where there is expected normal function, there exists the potential for dysfunction.  Identifying the source of dysfunction becomes a challenge in a smaller targeted area when the symptoms are vague, or when symptoms have existed for a longer period of time.  Older, longer lasting pain and dysfunction promote the potential for multiple existing problems contributing to a clinical scenario of low back pain.  But it is very common for people with low back pain to experience mild symptoms initially, and wait a while before actively seeking to correct for them. 

If this is pain pattern is familiar read on:

 
 

 

Unilateral sacroiliac (SIJ) pain pattern. Pain coming from the sacroiliac joint is usually centered over the area of the posterior superior iliac spine (PSIS), with tenderness directly over the PSIS. Lower lumbar pain occurs in 72% of cases; it rarely presents as upper lumbar pain above L5 (6%). It may radiate over the buttocks (94%), down the posterior–lateral thigh (50%), and even past the knee to the ankle (14%) and lateral foot (8%). The affected individual may report abdominal (2%), groin or pubic (14%), or anterior thigh pain (10%).

 

 

 

 

 

 

 

 

One of the less common sources of low back pain, but often left untreated until it has become quite chronic is the sacroiliac joint.  

The sacrum is a wedged shaped bone that provides resistance to both horizontal and vertical shear forces.  The SIJ is a diathrodial joint that contains synovial fluid.  The joint surfaces are different than the other joints in the body. Hyaline cartilage is available on the sacral surface and this surface is flat. The iliac surface is covered with a rough fibrocartilage.  Strong ligamentous structures support the SIJ. Ligamentous structures are effective in creating resistance to shear. The joints are surrounded by some of the most powerful muscles of the body, but none of these have direct influence on joint motion.  The main function within the pelvic girdle is to provide shock absorption for the spine and to transmit forces between the upper body and the lower limbs.

 

 
 
 














Sacroiliac joint (SIJ) pain does not usually present with an acute injury. Ligamentous degeneration, weakness, or recurrent exposure to lower energy trauma are the major causes of SIJ dysfunction. Female hormones are released during pregnancy, relaxing the sacroiliac ligaments. This stretching in ligaments results in changes to the sacroiliac joints, making them hypermobile and this is a common cause of SIJ dysfunction. The sensation of discomfort or pain often begins slowly, with pain radiating down one leg or on one side of the lower back. And much of the time those who experience SI joint pain are using good form when they exercise. Yet pain is present during back extension, squatting, abdominal work, basically pain no matter what they’re doing.   The classic symptoms include pain in the low back, buttock, pelvis ,hips and groin. Pain may radiate up into the middle back.  Pain may be experienced only on one side if only a single joint is affected.  There may be pain on arising from sitting, or  pain with sitting.   There may be the sensation of numbness, weakness, difficulty bearing the weight of your body on one of your legs or the feeling that your leg might buckle out from under you.  The pain of  SIJ dysfunction is usually worse in the morning  and then eases over the day.  These symptoms are similar to most other sources of low back pain so make diagnosing a SIJ dysfunction difficult.  Imaging studies can rule out many of the other sources of possible pathology.  A skilled clinician can identify SIJ dysfunction by performing provocative tests in a thorough physical examination.


To really resolve SI joint dysfunction one has to restore fluid mobility to all the low lumbar and pelvic joints.  Take a moment to re-evaluate your usual patterns of motion, whether these be daily activities or exercise.  Try the simple spine range of motion exercises delineated below and identify those planes of motion that are limited.  Take note of the asymmetries in the way your body moves.  One does not need the flexibility of a contortionist but symmetry is important as is functional strength.
Functional strength is that strength and endurance you require to perform those activities included in your usual schedule.    We do not realize areas of inflexibility and weakness that develop, and we compensate for those using poor body mechanics and we accept these until we note pain, and until that pain interferes with our functioning. 

 

Now back to resolving SIJ dysfunction, the first key to success, as one rehabilitates is to make sure you are working within your limits.  The next most important variable to successful rehabilitation of SIJ dysfunction is moving what’s not moving, and adding more variety of movement to your repertoire.  Now combining the two, limit yourself to move within your present capabilities in all planes of motion.  If you feel any pain in any movement, it’s beyond your current limitations.  Moving exclusively in a single plane is limiting and makes us prone to overuse.  The spine is intended to flex, extend, rotate, and laterally flex. Add variety and change the way you move to help gain ranges of motion. 

 

That is it!  Mobilizing the SIJ carefully and strengthening the surrounding structures will restore a healthy joint and the pain will resolve.  Ice and medication may assist the process (acetaminophen or anti-inflammatory drugs like ibuprofen).  There are procedures that a physician might assist you with when SIJ dysfunction is severe.  There are diagnostic and therapeutic injections and surgical procedures for pain and instability.  There are numerous resources available detailing these procedures elsewhere.

  

 

EXERCISES:

Simple spine range of motion:

Side bending



 

 

  

 

 



 

 

Alternating toe touches

 

Forward roll/crunch

  











 



 

Wall bends

 

 



Strengthening :

The lateral lunge

You start in the same position as a forward lunge, standing straight up with your feet shoulder-width apart, arms down at your sides. Take a big step to not quite to the side, more to the diagonal, lunging down and putting most of your weight on your leading leg. Lower yourself down as far as is comfortable for you, always keeping your toes pointing forward during the exercise, lead foot flat on the ground. Return to your starting position, then repeat on the other leg.

Bridges with adduction

*Note – these  exercises are among my favorite being most effective and safe, but these are not the only exercises that will recondition the pelvis and sacral region.

Common Postural Neck Pain

 

Tension at the base of the neck, or maybe you feel it across your shoulders but the sensation is one most of us have experienced; Heavy pressure, squeezing and tightness that translates as pain somewhere in the upper or middle back or shoulder.  Often there is radiation up toward the head or down along one or both arms.  You may feel burning or tingling.  You no longer remember the freedom of fluid soft tissue mobility that once existed among the individual structures in the neck region.  Years ago, each vertebra, both collar bones, each shoulder blade moved on its own without disturbing surrounding structures.  Now, when you tilt your head, or raise an arm, it’s as if half of your chest rises.    

       Everything we do is done in front of us.  We use our arms and our hands and watch with our eyes.  Our heads are usually bent forwards.  Our shoulders are rounded, sitting in front of where they should be.  And once we have finished whatever activity we have just completed, we rarely resume a “proper” posture but maintain this forward rounded one.  Gravity and habit brought us to this shape.  Until we feel pain, we have no stimulus to change.  Unless we happen to catch a glimpse of ourselves in a mirror or a photograph and notice how we actually look so hunched. 

Figure 1

     A main muscle that supports the head in its upright posture is the trapezius ( Fig 2).  When the head is bent forward, the trapezius is in essence turned off.  We then recruit muscles nearby to hold the head up instead.  But these muscles are not intended to do this job.  Their fibers are not oriented to create the upward force needed to support our 14 to 20 pound skulls.  The thin strap muscles that surround the neck twist and turn the head sideways, upwards and downwards.  When we clench these muscles to use them as a head support, they fatigue, their fibers shorten, and their metabolic processes are altered causing a build-up of noxious substances.  The soft tissue surrounding these muscles are altered by the changes in the muscles’ function and the entire area becomes dysfunctional.  The neck area changes shape becoming rounder and thicker.There is less motion, so there is less blood flow with less oxygenation and impaired tissue metabolism.  Eventually we experience discomfort and then pain.
 


Figure 2

Figure 3



The muscles most often affected are the semispinalis, splenius cervicus and capitus and the scalenes, especially the posterior scalene (figure 3).  There is not much motion within the fibers of these muscles, even when they work at their maximum potential. 


When the local environment is healthful, circulation is sufficient to clear any toxic byproducts of normal reactions.  In a setting of chronic, unhealthy behaviors, in the presence of soft tissue damage there is a build up of noxious stimuli.  The local circulation becomes overloaded and cannot clear the area.  The tissue becomes further damaged and scar forms.  The process is self propelled to escalate.  We perceive an increase in pain with no additional obvious cause for  injury.   We develop neck, shoulder and head pain.

Referred pain:

    This is pain felt in a part of the body other than its actual source.  A network of interconnecting sensory nerves supplies many different tissues.  When there is an injury at one place in the network, this pain can be interpreted in the brain to radiate to nerves and can give pain elsewhere in the related areas of the network. If this does not make sense, think of it this was.  Embryologically we start with a single cell that divides into two cells, and then those two into four, those four into eight and so on.  The cells differentiate into all of our different structures, and migrate away from each other to their proper places.  As we get more cells, they take up more space and each are located further away from each other.  But cells that were originally linked maintain some connection despite physical distance, perhaps chemical, perhaps neurological.  When one structure is affected by a stimulus or injury, all related structures may be affected and this is a referred response or referred pain. 

 

      Referred pain is an important component of neck pain and headaches.  Much of the pain experienced is a result of pain referred from original sources of injury.  Treatments need to be directed at the injury and not necessarily at the sites of symptoms.  Treatment should be aimed at restoring healthy tissue.  The best way to achieve this is to restore posture and normal motion to the area.  This will take some time.  To retrain any body takes time and effort. Exercise to strengthen the middle and upper back is a long term solution.  Physical therapies including modalities with soft tissue manipulation, transcutaneous nerve stimulation, ultrasound, the application of ice and heat will promote soft tissue health and healing.  For very focal tissue repair, trigger point injections may help disrupt stubborn tissue damage and then promote muscle tissue repair more rapidly than manual work and exercise alone.  Trigger point injections are performed by a specialty trained physician.  This may be a Physiatrist, Orthopedist, Neurologist or Rheumatologist.  They can be repeated often if necessary, or done once.  The success depends on a number of factors; how long the soft tissue injury has existed, the accuracy of the diagnosis for the trigger point injection, the skill of the clinician. 

 

    The success of therapy will also be dependent on numerous factors.  Therapy requires patient participation.  It is an interactive modality that requires homework.    Our soft tissues (our muscles, nerves, ligaments, tendons) have memory and need to be trained and reminded of the proper positions to hold and the proper ways to move.  We must practice good posture and proper kinetics to maintain them.  If we move our shoulder blades regularly they remain loose.  If not, they become stiff and locked within the back muscles (for example).  But this is an important example, because so many of the muscles that control head and neck motion are attached to the shoulder blades, so if they are not moving freely, the head and neck will feel stiff.  Now, this is not something we wish to think about.  We just want to live, and move, freely, without pain. But, and forgive the cliché, use it or lose it.  It is important that people do not underestimate the importance of some form of “exercise” in their rehabilitation when they have neck pain and/or headaches. 

 

   I have purposely delayed discussing medications as treatment.  There is a list of medications used to treat neck pain.  The pain arises from numerous sources: mechanical, muscular, neurological and centrally mediated – especially once the pain becomes chronic.  Medications should be used to help enable one to endure the pain while participating in the mobilization phase of a rehabilitation program.  For the small percent of people with chronic, incurable conditions, medications are used to manage pain appropriately.   What is an incurable neck condition?  Osteoarthritis, yes.  Herniated disc, no. But even those with osteoarthritis do not necessarily require lifelong medication.  Anti-inflammatory medications treat the pain caused from inflammation.  This is pain induced by tissue damage, when there is underlying tissue disease, whether systemic or induced by strain.  These include ibuprofen (motrin) or naproxsyn(aleve).  Analgesics treat mechanical pain caused by things such as joint disease and degenerative conditions or traumas.  Acetaminophen (Tylenol) is an example.  The best class of medication for muscle pain is the muscle relaxing drug and the most popular is cyclobenzaprine (Flexeril) though the one I like best is tizanidine (xanaflex) since this is less sedating.  Finally drugs used to address central pain, that is pain arising from the central nervous system, what is often called “nerve” pain can be varied.  These medications are a bit more complicated.  They are drugs whose main use are to treat psychiatric and neurologic conditions but also have been shown to also temper pain.  Gabapentin (Neurontin) is a popular example.  I am not suggesting a medication regimen here but only explaining how medications might be used.  Every medication plan would be tailored specifically for any individual based on their specific needs.  And usually patients find medications unsatisfactory in treating their musculoskeletal pain. 

The topic of neck pain is vast.  This article just touches on a small component, specifically common musculoskeletal pain.  And even this topic can be expanded.  But we have to start somewhere.  The take home message, if you have neck pain for more than a couple of weeks, mention it to a physician.  Seek assistance in resolving the issue while it is easy to fix.  Chronic neck pain is much harder to get rid of and can lead to significant debility.