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.  
 

Common Low Back Pain

 Low back pain is so common, yet when it hits people cannot help but worry that they  have a serious problem.  They notice the ache, and their initial reaction is to ignore it, hoping, it will go away.  But the reality they live, an insidious underlying stress that grows daily as the pain persists.  They notice the limp in those first few steps when they stand after sitting for a while, but assume no one else can see it.  Sitting is not what it used to be, once restful, now that nagging pain in the buttock and leg.  Their beds are suddenly uncomfortable.  Walking is ok, for a while, as long as they are not carrying anything, or stopping and starting too often.  But it is nothing, really.

Four to six months later they think maybe something might really be wrong.  Now there is some serious leg pain, at times maybe some tingling or altered sensation in the buttock and or leg.  The middle back aches and feels weak.  They feel tired and grouchy.  They consult a doctor for help with their “sciatica” and after careful evaluation the well-meaning practitioner confirms the diagnosis, or may even, with great concern hearing how long the issue has existed, suggest a more serious issue such as disc disease.   

The pain from true sciatic nerve compression will look like this:

When the sciatic nerve is compressed significantly and the fibers irritated enough that their function becomes compromised, one will experience symptoms along the entire course of the nerve. 

The pain from a disc injury will look like this: One will experience pain in a particular area depending on which disc is affected.  There may be tenderness over the area of the disc initially when a disc is injured but most disc injuries heal over 6 weeks (approximately). 

More common than these, people experience pain from gluteal strain.  The gluteal muscle that sends pain to the leg is the gluteus minimus and pain from gluteus minimus strain looks like this:   

Now at four to six months, one thinks, sure, I have that pain, but I have so much more than that.  My ENTIRE BACK aches.  There is sharp, stabbing pain that could not possibly be the result of simple butt sprain. 

And sometimes, that is the case.  

Thankfully, it is not usually the case.  A good majority of low back pain is muscle pain.  There are more muscles involved than just gluteus minimus.  Gluteus maximus, gluteus medius and quadratus lumborum account for a significant percent of back pain.

Gluteus Maximus Pain:

 

Gluteus medius pain:

  

Quadratus lumborum pain:

These are the usual suspects, though there are a few more but no need to overwhelm you with details.  The point is to understand that pain originates from numerous structures.  Your healthcare practitioner will recognize the pattern of the pain, the quality of the pain and your functional deficits and from these identify what has been injured.  And yes, it is important to make sure there is no nerve, disc or bone damage because these, left unrecognized can result in serious consequence.  But the major source of low back pain is some injury to the soft tissue structures, the muscles, their tendons, ligaments or the surrounding support tissues. 

Lower back pain that lasts for more than two weeks can lead to muscle weakness (since using the muscles hurts, the tendency is to avoid using them). This process leads to disuse atrophy (muscle wasting), and subsequent weakening, which in turn causes more back pain because the muscles of the back are less able to help hold up the spine. This is another reason why more than one single area feels pain.  Beyond the original strain or injury, additional structures become affected and become symptomatic.  It is wise to acknowledge any persistent ache or pain that exists for longer than a few days. 

 

The initial treatment for any pain in the back is to rest the injured structure.  48 hours should be sufficient to allow recuperation for any mild overuse.  If pain persists after this, there is most likely some degree of true injury.  Next gentle use, and not stretch is the best way to rehabilitate an injured structure.  The goal is to allow ample blood flow to injured tissue to enhance the healing of injury without adding to any strain or tissue damage.  In physical therapy terms, this is known as therapeutic exercise and it entails movements that include simple exertions, usually much more simple than any functional motions involve; something as simple as contracting and relaxing a muscle a few times with rest periods in between, for example.  Once the symptoms are diminished you can advance to trying more functional motions and exercises.

You will find an abundance of therapeutic exercises available to help relieve low back pain.  There is no single right one.  The best depends on your particular problem and your specific abilities (flexibilities, coordination and strengths).  But exercise of some form is usually the best cure.  The back requires motion. 

Physicians will suggest diagnostic tests as needed to ensure your safety.  They will prescribe medications to temper your pain and prevent subsequent injuries to the rest of your body, to keep you moving as normally as possible and prevent overall deconditioning.  The ultimate goal is always to identify the specific cause of the pain, target a therapeutic program that will restore normal motion as quickly as possible to enhance healing. 

 

How We Learn, Literally.

Brain neuron

Normal Neurotransmission:  

     The cells in the brain can send signals from one region of the brain to another.   Nerve cells communicate with each other at a region between them called a synapse.  At the synapse, signals move from the one neuron (sending cell) to another neuron (receiving cell).  The small space between the two cells, the synaptic cleft, is where communication takes place.  The cell that will send the message is loaded with sacs called vesicles that are filled with neurotransmitter molecules.  There are many types of neurotransmitters.  The cells that receive the message are coated with receptors specific for a particular neurotransmitter.   An electrical impulse triggers the vesicles to release their content into the synaptic cleft.  Once the neurotransmitter molecules are released into the synaptic cleft, they collide with and lock into the receptor molecules on the receiving cells.  When the neurotransmitter is docked, the receptor sets into motion a cascade of chemical reactions resulting in the production of a second messenger molecule.  Once the neurotransmitter has done its job it is released from the receptor and travels back to the sending cell through reuptake transporters.  It is either repackaged for reuse or broken down.  Back in the receiving cell, the second messenger initiates a nerve impulse which travels down the axon of the neuron.   Once the impulse reaches the end of the neuron, vesicles with neurotransmitter are stimulated and the process starts over again.  The receiving cell becomes a sending cell.  An impulse will stop if there are too few neurotransmitters to bind receptors or if the neurotransmitter is inhibitory in nature, preventing further reaction.   We are born capable of normal neurotransmission.

 

Synapse - vesicles release neurotransmitter

 

 

 

 

 

 

 

 

 

 

 

 

Plasticity

     Plasticity is the capacity of the nervous system to develop new neuronal connections.  This includes the ability to change and adapt, especially the ability of the central nervous system to acquire alternative pathways for sensory perception or motor skills.  Neuroplasticity defines the ability of the nervous system to change its capabilities by experience and plays a major role in compensating for the loss of neurons with age.

 

Nerve cell

 

 

 

 

     Following birth, the brain of a newborn is flooded with information from the baby's sense organs.  This sensory information must somehow make it back to the brain where it can be processed. To do so, nerve cells must make connections with one another, transmitting the impulses to the brain. like a basic telephone trunk line strung between cities, the newborn's genes instruct the "pathway" to the correct area of the brain from a particular nerve cell. For example, nerve cells in the retina of the eye send impulses to the primary visual area in the occipital lobe of the brain and not to the area of language production in the left posterior temporal lobe. The basic trunk lines have been established, but the specific connections from one house to another require additional signals.

 

     Over the first few years of life, the brain grows rapidly. As each neuron matures, it sends out multiple branches (axons, which send information out, and dendrites, which take in information), increasing the number of synaptic contacts and laying the specific connections from house to house, or in the case of the brain, from neuron to neuron. At birth, each neuron in the cerebral cortex has approximately 2,500 synapses. By the time an infant is two or three years old, the number of synapses is approximately 15,000 synapses per neuron. This amount is about twice that of the average adult brain. As we age, old connections are deleted through a process called synaptic pruning.

     Synaptic pruning eliminates weaker synaptic contacts while stronger connections are kept and strengthened. Experience determines which connections will be strengthened and which will be pruned; connections that have been activated (used) most frequently are preserved. Neurons must have a purpose to survive. Without a purpose, neurons die through a process called apoptosis in which neurons that do not receive or transmit information become damaged and die. Ineffective or weak connections are "pruned" in much the same way a gardener would prune a tree or bush, giving the plant the desired shape. It is plasticity that enables the process of developing and pruning connections, allowing the brain to adapt itself to its environment.

 

Plasticity of Learning and Memory

     It was once believed that as we aged, the brain's networks became fixed. In the past two decades, however, an enormous amount of research has revealed that the brain never stops changing and adjusting.  Learning is the ability to acquire new knowledge or skills through instruction or experience. Memory is the process by which that knowledge is retained over time. The capacity of the brain to change with learning is plasticity.  At least two types of modifications occur in the brain with learning.  First, one sees a change in the internal structure of the neurons, the most notable being in the area of synapses.  Second there is an increase in the number of synapses between neurons.

     Initially, newly learned data are "stored" in short-term memory, which is a temporary ability to recall a few pieces of information. Some evidence supports the concept that short-term memory depends upon electrical and chemical events in the brain as opposed to structural changes such as the formation of new synapses.  One theory of short-term memory states that memories may be caused by "reverberating" neuronal circuits.  This means an incoming nerve impulse stimulates the first neuron which stimulates the second, and so on, with branches from the second neuron synapsing with the first.   After a period of time, information may be moved into a more permanent type of memory, long-term memory, which is the result of anatomical or biochemical changes that occur in the brain (ie learning).

 

Injury-induced Plasticity

      During brain repair following injury, plastic changes are geared towards maximizing function in spite of the damaged brain. In studies involving rats in which one area of the brain was damaged, brain cells surrounding the damaged area underwent changes in their function and shape that allowed them to take on the functions of the damaged cells. Although this phenomenon has not been widely studied in humans, data indicate that similar (though less effective) changes occur in human brains following injury.

     We are a long way from being able to safely manipulate neural growth and behavior.  Perhaps the intricacies and complexities of the human neural networks make the task an impossible one. Or if not impossible, perhaps limited.  But there are now known ways to influence, beyond a doubt, improved function to some degree in some systems.  Intuitively we have known this for centuries.  This is why we have practiced anything to become “better”.  Only now we “know” more about why it is worthwhile to practice.  And perhaps we are learning ways to manipulate practice.  The list of clinical examples is long, showing how healing, performance, growth and development can all be enhanced through optimal neural learning.  Do the research if you find yourself intrigued.  If overwhelmed by the concept, well, just keep practicing.  Don’t worry about why it works.   

It’s Pronounced ab DO men

Patrick Helm - SnootyFoxImages

You are told, strengthen your abdomen and you think, no problem, I am toned.  Or you are one of those who feels hopeless, knowing that no matter what you try, that area will never respond to your efforts.   You know, you have tried.  Or maybe you are not quite hopeless, you could build strength and develop great muscle tone, if only you would do the work.  What should you do to strengthen the abdomen?  When did you learn what works most effectively?  What do you know about your belly? 

      The rectus abdominus flexes the trunk (bends it forward).  The internal and external abdominal obliques and transversus abdominis muscles flex the trunk and bend the trunk laterally (sideways).  These muscles are innervated by intercostal nerves 7-11, subcostal, iliohypogastric and ilioinguinal nerves (the rectus receives innervation from the intercostals and the subcostal alone).  When you contract these muscles, it is the obliques and transverus muscles that flatten the abdomen (bring your front toward your back).  The rectus muscle brings the top toward the bottom (the chest toward the pelvis).

        Crunches are popular, portable, affordable and accessible but are they effective?  If done correctly, they can be.  Yet there are limitations.  It is difficult to exercise all the fibers of each abdominal muscle doing only crunches.  The abdominal muscles are large and cover a lot of body surface area.  To exercise them efficiently, one has to accomplish full extension and contraction at some point during the motion to actually strengthen the fibers of the target muscle.  When lying on the floor, the floor itself limits your extension to zero degrees when you might benefit from a starting point of a bit more (slight trunk hyperextension).    One cannot bend back past the floor.   And crunches are not a true functional motion, unless you are a wrestler, or unless you spend an unusual amount of time getting out of bed or up off a floor.  More effective are exercises that work the muscles through longer ranges of motion, against gravity, in more functional positions, such as standing or sitting.  Motion in all planes around a central axis will assure development of all the abdominal muscles as well as the accessory muscles.   The best way to exercise the abdominal muscles is to combine simple single or multiple plane exercises during your normal routine.  You can do the crunches on a stability ball increasing your range of motion beyond that possible on the floor, but you must be aware of your body form!  Then changing your plane of motion, and performing a torso twist will also work the obliques (as well as a few leg muscles).   

     Simple side bending can be done with or without weights (free weights, or at a cable apparatus) to work the internal and external oblique muscles. 

You can use a cable apparatus to perform the torso twist move as well.  There are benefits to varying the way you work the muscles since in life you use the muscles for so many different functions (for motion and for stability). 

     The list of existing known abdominal exercises is long, and most are reasonably effective.  The key is performing any exercise correctly.  Most people do not use their abdominal muscles as well as they should when doing crunches or other “abdominal” exercises, wasting a lot of time and energy and sometimes doing some real harm.  You have to learn to use the muscle you are targeting in isolation when you exercise (when you are weight or strength training, anyway).  This is extremely important when targeting the abdominal muscles.  Otherwise you use the neck, back or legs instead.  If you are unsure if you can isolate your abdominal muscles during a crunch try this exercise.  I call it “Belly, Butt, Back of the Legs” (it is my own creation and could use a better name, I know).  The starting position has you lying on the floor, knees bent, feet flat on the floor with arms at your side.  Take a deep breath, and as you exhale, squeeze your belly, and only your belly sucking it in as deeply as you can toward the floor (nothing else moves), then relax.  Next take a deep breath and as you exhale, contract your buttocks, as tightly as you can (but nothing else moves-keep your legs and belly soft) and then relax.  Finally take another deep breath, and as you exhale, contract the back of the legs (the hamstrings, keeping the buttocks and belly soft) and then relax.  This usually takes some practice, if you have never thought about using these body parts in isolation before.  And if you are having a hard time doing this, you are probably contracting both the buttocks and the back of the legs every time you do a crunch, and this is wrong.  And, you are also probably using the low back muscles for part if not most of the motion of your crunch.    If you are, this would mean that for every crunch you do, you are working your abdominal muscles a lot less than 50% of your effort.    Ok, I am making a lot of presumptions here but this is a general statement and I get no individual feedback through this venue, but I think you get the point I am making?! 

           When starting a crunch, or any abdominal exercise from a supine position (lying on your back), you should start by first inhaling, and as you exhale, before you move anything, start contracting the abdomen.          

                Once the abdominal muscles have begun to contract (we in “the biz” refer to this as the muscles being engaged) start moving. In the case of a crunch, the head, neck, shoulders and upper trunk should all fold up off the floor in one piece.  Yes, I said fold, not roll.  The motion is a simple lift upwards.  Okay, I think I have exhausted the crunch in words.  Need anything more and I will just have to show you.  There is more to know but I cannot imagine you wish to read anything more on this subject right now. Come back again!

     

Rolling Along

          Nearly every athletic training room and most physical therapy facilities contain an array foam rollers of different lengths and consistencies.  These serve as tools for hands-on soft tissue care as part of massage therapy in caring for injury.  Techniques like massage, Muscle Activation (MAT), and Active Release Therapy (ART) can work wonders for sore or injured patients.  The foam roller enables one to self treat, manipulating soft tissue yourself in ways a therapist might.  A foam roller is simply a cylindrical piece of extruded hard-celled foam.  They usually come in one-foot or three-foot lengths.  They are also now available in a number of densities from relatively soft foam, to newer high-density rollers that feel much more solid.  The denser the user, the more dense the roller should be.  Large, heavily-muscled users will do better with a very high density roller whereas a smaller, younger user should begin with a less dense product. 



Basic foam roll



The application techniques are simple.  Pressure can be applied to tender areas.  Or the user can roll the injured area over the roller in a sweeping stroke for a massage effect.  The sweeping stroke can act to stretch the soft tissue.  Users are instructed to let the roller search for tender areas or trigger points and to roll these areas to decrease density and over-activity of the muscle (cramping).  Most users, however, require instruction on where to find the tender spots and on the positioning of the roller, such as parallel, perpendicular, or 45 degree angles, depending on the muscle.  There is no universal agreement on when to roll, how often to roll, or how long to roll, but generally, techniques are used both before and after exercise.  Foam rolling prior to exercise can help decrease muscle cramping and promote a better warm-up.  Rolling after exercise may help muscles recover from strenuous exercise.   Foam rolling is hard work that can border on being painful.  It is important that one learn to distinguish between a moderate level of discomfort related to working a trigger point and a discomfort that can lead to tissue injury.  When someone has completed foam rolling, he or she should feel better, not worse.  Rollers should never cause bruising.  Massage therapy remains a better therapeutic option but foam rollers do offer a cost effective alternative.  If you do not have the strength to manipulate your full body weight over a foam roll, consider other manual tools like “The Stick” or “Body Balls”.  These offer the same myofascial release with much less exertion.   Foam rollers can be a very useful tool specifically when treating the spine instead of the soft tissue.   One can achieve gentle spine segmental mobilization by rolling over a medium density roll with no significant adverse effects and good benefits.

Good use - simple spine mobilization

The Dancer's Injury

     Technically, by definition, we recognize Art as the quality, production, expression, or realm, according to aesthetic principles, of what is beautiful, appealing, or of more than ordinary significance¹ , and Sport as an athletic activity requiring skill or physical prowess and often of a competitive nature¹.  Artists and athletes are viewed as being from two distinct subspecies.  Today Dancers perform and compete quite regularly so that boundary between artist and athlete has distinctly blurred.  Professional dancers get hurt just as often and suffer just as serious injuries as athletes in contact sports.  The practices, so often segregate, as performing arts medicine or sports medicine must coalesce when considering a dancer’s care.    For the last twenty years a special group of dedicated clinicians have worked targeting the special needs of the performing artist (See PAMA - Performing Arts Medical Association).

 What is it really that makes the dancer prone to injury?  Their bodies are conditioned so perfectly to their craft.  Their endurance is profound.    In part it is the need for repetition, the essential mandatory rehearsal of a set of moves performed until the sequence flows from their bodies without requiring thought.  Simultaneously they concentrate on sequence as well as form and music not to mention expression though this is more a feeling than a thought but still, it is part of the dancer’s awareness as they move.  Each element contributes to the motion they produce, to the energy being transferred through the trunk and limb and this is what a dancer must master.  It is so common to hear them say “it was silly really, how I hurt myself” and one will almost always be able to trace a dancer’s injury to a moment of distraction.  The moves themselves are obvious.  The injuries themselves fairly predictable. 

     The statistics do not seem to change over time.  A dancer sprains ligaments and strains muscles. Partners will see disc injuries and more traumatic ligament and muscular damage.   Degenerative changes will plague older dancers, with joint diseases affecting the spine, ankles, knees, hips, feet and shoulders.  In approximately this order one sees clicking hips, hallux valgus (bunion), patella disorders,  stress fractures, scoliosis, coxarthrosis, and spondylolysis as the usual leaders. Competent clinicians know how to treat these.  The trick is realizing that successful treatment of a dancer requires acknowledging more than just the injury as part of the problem to be overcome.  The successful treatment of a dancer involves artful negotiation between the clinician and patient, compromise that will allow adequate healing as well as continuation of their performance.

1.       Dictionary.Com

Workout Basics

     The potential variations are endless, but here are the underlying principles.

Aerobic exercise increases metabolic rate, burns fat and improves cardiac function.

Anaerobic exercise pushes beyond pure aerobics increasing metabolic rate, building endurance, enhancing power and further improving cardiac health (in those who are healthy enough to tolerate this).

    When one performs aerobic exercise for up to about 30 minutes, one taps into purely aerobic mechanisms (as a generalization).  Beyond the 30 minutes one starts tapping into anaerobic metabolism which is a more efficient calorie burner.

Weight training: as a topic can be overwhelming. In an oversimplified summary:

 Lower weight/more repetition:  builds some muscle, builds endurance, burns calories to a lesser degree, increases muscle metabolism.

 Higher weight/few repetition: builds muscle, builds strength, builds power, ultimately enhances the long term metabolic rate.

          Aerobic sessions should be at least 30 minutes long, but 45 – 60 minutes will allow one to accomplish more.

          Weight training sessions should include enough work to fatigue at least 4 major muscle groups.

          You can combine aerobics and weight training through calisthenics…. Call these mixed sessions.  I call them boot camp exercises.

          Abdominal strengthening should be viewed as its own category and should (my opinion) done at every workout.

Aerobic workouts should be vigorous enough to get the heartrate up to at least 130 and no more than 160 for 25 minutes or longer.  You get more cardiac and metabolic benefit from an aerobic workout if the intensity is varied throughout the session (It also makes them less boring). Straining for a few minutes at a higher intensity makes a lower level exertion seem easier.  In this way a medium intensity that seemed hard, done after a few minutes of a really hard exertion, now seems easier…. You end up tolerating a higher average intensity by the end of the session.  Not a bad way to progress your workouts. 

Aerobics:  At least three sessions a week, though 4 – 5 are the ultimate goal.

Walking: Walk for 30 minutes at a medium pace (2.5 miles/hour).

          When this gets too easy, add two to five minute intervals of walking as fast as you can.  Once you can do 3 five minute intervals at a speed pace in a 30 minute walk, increase the length of the walk.  You can also use three levels of intensity, in the same way ( for example: 3 minutes warm up, slow pace, 5 minutes medium pace, 2  minutes fast pace, 3 minutes medium pace, 2 minutes slow pace, 5 minutes fast pace 3 minutes medium pace, 2 minutes slow pace).

          A 30 minute speed walk with no slow intervals is a good “medium to hard” aerobic workout when you don’t have a lot of time.  This would be a session where you do not vary the intensity, but keep it high the whole time, but for a shorter workout time.  This is a good thing to do at least once a week.  When 30 minutes at your highest intensity gets too easy, you’ll need to find something to do that is harder than walking ( ie run, bike, swim or join a gym to have access to other aerobic equipment)

For any other type of aerobic workout, the same system of varying intensity can be applied.

Add calisthenics to a walk:  Add 30 second to 2 minute intervals of lunging steps, or broad jumps or skips.  Walk backwards for segments, jog, or sprint.

An excellent way to build functional power and endurance is to interrupt an aerobic walk with 2-3 minutes of abdominal crunches, pushups, or other stationary calisthenics.