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  Prevention of injuries in young competitive orienteers Workshop presented in Andalo, Trentino, Italy on 2 July 2024 by Martin Krause (Musculoskeletal Physiotherapist) hosted by Joergen Moertenson (legendary Swedish Orienteer and PWT owner) Orienteering, especially at an elite level, requires a combination of physical, mental and cognitive agility. Essentially, its a task which requires the ability to move 'fleet of foot' through uneven terrain at optimal speed, whilst navigating sequential 'check points' using a detailed map (1:2500 -> 1:15000) and reading a compass. The following discussion aims to enlighten young orienteers and their charges, to the first principles of competitive training and injury prevention. Evidence for my proposals are found throughout the over 500 pages of this website. Essentially, whilst an anecdotal presentation, it is based on the life-time 'wisdom' which I have gained, both professionally (working over 38 years in musculoskeletal and sports injury management including elite and professional athletes) as well as my personal sporting experiences across many disciplines, with orienteering, cycling and soccer being my favourite..  Physical attributes required for orienteering include foot/ankle, knee, hip and body stability balanced 'inverse dynamics' from the ankle to the torso and arms endurance - resistance to fatigue 'slow twitch' muscle fibre stability (Work = Power x Time) agility - co-ordinated power (Power = Force x Velocity)  strength - ability to produce force (Force = Mass x Acceleration) Good training techniques, need to be achieved for competitive results, This involves cognitive goal setting, using mental and physiological considerations, that result in the avoidance of injuries and the minimisation of lost training days through ill-health. Endurance : 'resistance to fatigue' and hence reduced risk of movement breakdown and injury : Work = Power x time Power : ability to produce movement under load without compromising stability : Power = Force x velocity Force = muscle mass and cross sectional area : mass x acceleration Acceleration = change in speed in varying terrain : velocity/time Velocity = displacement/time Physical attributes should be differentiated from the physiological and neuro-immune attributes required for elite sporting performance. Categories of injury  Adverse biomechanical conditions as a result of misuse, disuse, overuse, abuse results in damage which can cause a vicious reciprocating cycle of muscle-tendon atrophy, degenerative changes, and immune-metabolic dysfunction. Misuse - poor technique e.g. asymmetrical push off, from previous ankle sprains, resulting in Achilles Tendonopathy Disuse - prolonged periods of rest as a result of illness or injury Abuse - trauma such as ankle and knee sprains, muscle strains Overuse - poor periodisation of training volume resulting in over-loading. Usually as a result of over-reaching. Fail to plan, then plan to fail. Use a training diary for transparency and accountability, which should avoid over-training syndromes including mood disturbances (3 bastards in a day) Causes of injuries Injuries in orienteering can occur within and without competition. Generally, athletes feel that injuries occur due to 'bad luck'. If we consider the inverse 'good luck', then consider it's definition 'when good preparation meets opportunity'.  Injuries occur as a result of  fatigue (mechanical and metabolic) lack of co-ordination and strength inexperience - lack of technical and physical experience in various terrain and cognitive loading conditions Fatigue can be  metabolic - insufficiently trained oxidative capacity cardiac - output as a result of heart rate and stroke volume mechanical insufficient hypertrophy of 'passive' soft tissue and bony structures  insufficient muscle adaptation of contractile and synergistic systems immune - under appreciating the importance of considering muscle as one of the most important organs of the immune system gut - energy species and biome interacting with muscle in a symbiotic relationship Cognitive adaptation to physical and mental stress through training (not over-training) map reading and other psychological conditions to perform functionally in both sport specific and non-sporting environments Injuries can be avoided by adaptive loading the body through sports specific Periodisation of training Nutrition - both energy, immune and anti-oxidant considerations Specific exercise tasks Progressive resistance gym training Plyometric exercises  Races are won and lost by the ability to run quickly downhills and traverse steep terrain. Learning to master these biomechanical attributes, not only optimises performance, it reduces the risk and probability of injury. Considerations in the young female athlete Young female athletes may be dealing with their menstrual cycle for the very first time. Things to consider are the menstrual cycle itself - is it regular the onset of menstruation (menarche) Delayed onset of the menstrual cycle or irregular menstruation can be the result of over-training. Consequences can be multifactorial. In terms of the musculoskeletal system, reduced bone density can occur, which may lead to stress factures. In countries with poor access to sunlight, these factors can be exacerbated by the lack of Vitamin D. Additionally, if the winter ground is frozen the heightened risk of stress fractures is compounded. If the menstrual cycle is regular, please consider excessive blood loss - need to check ferritin and hence iron levels the luteal phase, where muscle reaction times may be reduced and when ligaments might not be as stiff as usual Investigators have found that aerobic athletic performance is compromised during the mid-luteal phase compared with the mid-follicular phase of the menstrual cycle (Freemas JA et al 2021 Med Sc Sp Ex, 53, 2, 442-452).  Researchers looking at US insurance claims between 2007 and 2017 found that women on the pill were less likely to have an ACL injury whilst playing sport. Reconstructive knee surgery was performed on 569 out of 82874 women who were not on the pill versus 465 out of 82874. Thus the synthetic oestrogen and progesterone hormone were considered protective against knee injuries (De Froda et al 2019,The Physician and Sports Medicine, April). Interestingly, high specialisation in female youth soccer players is associated with the increased likelihood of sustaining a serious injury (Xiao et al 2021, Med Sc Sp Ex, 53, 10, 2086-2092).Current youth soccer players are specialising earlier and committing to play college soccer at a younger age compared with when current college and professional soccer players did. Suggestions are that a youth soccer player shouldn't spend more hours training per week than their age. Additionally, issues of 'burn out' may also occur.  Growth Spurts - earlier in life in girls than in boys This can be a very important factor when applied to power and flexibility. The bones can grow 18 months in advance of your muscles. This could mean feeling very stiff. Additionally, certain biomechanical features can become unstable, such as the patella (knee cap) tracking, within the quadriceps, as well as excessive hamstring tightness. Girls can be more affected than boys, as their growth spurt and adolescence frequently occur 2-4 years before boys. Importantly, the overall maturity of the body, muscle mass and life experiences, are less developed in the female, if their adolescence comes so much earlier. Menarche and growth spurts appear to occur so much earlier than in past generations and it's not uncommon for a 10 or 11 year old girl to experience her first menstruation.    Morphometrics Morphometrics describes a person's body type. It's not uncommon for 'chubby' mid teens boys to turn into 'bean poles' in their late teens. Training and movement patterns will vary, purely due to the centre of gravity and length of the body levers. With longer levers, the bigger the inertia, and the more there is to control. Endurance training Orienteering is an endurance sport. Coaches as well as individuals will place a lot of emphasis on the physiological requirements (Heart Rate Max = 220 - age) which makes an endurance athlete. These zones are taken from road and track cycling programs in the 1990's. Zone One (<70% HR max): very low level light exercise, too low in itself to induce physiological adaptations. Minimal sensation of effort or fatigue. Easy to hold a conversation. Used as a recovery strategy between bouts of exercise (intervals) or as a recovery strategy after a hard training session or long race. Zone Two: (endurance 71-80% HR max): classic long slow all day long distance training. Good for gaining and endurance base. However, if too much time is spent training slow, you become slow. Recovery from 2 hour sessions should be quite rapid, whereas longer sessions with some moderately fatiguing climbs may take 1-2 days to recover Zone Three (tempo 81-85% HR max): intensity as a result of speed. Frequent sensation of fatigue, concentration required, conversation becoming difficult. Daily sessions possible so long as adequate energy requirements are met. HR recovery may be a good test to indicate how well you have recovered. Zone Four (lactic threshold 86-94% HR max): efforts similar to time trials on a bike. Continuous conversation very difficult. Continuous sensation of effort or fatigue in muscles being exercised. Mentally very taxing and generally performed in blocks or repeats of exercise with some recovery between bouts but not too long e.g. running 1-3 minute blocks with 1-3 minute rest in between; cycling 10-30 minutes with 10-30 minute recovery between blocks of exercise. Consecutive days of training possible, but check HR recovery every morning and also maintain an immune enhancing diet. Not wise to do just before a big race. Also unwise to do if there is a lot of other stress in your life. Recovery is super important. Zone Five (95-120% HR max): short intense bouts of activity. Running 10-30 seconds, Cycling 3-8 minutes. Strong to severe sensation of fatigue. Laboured breathing. Repeated consecutive days of training not recommended and considered undesirable  You want to get to a point in your training and elite sporting career where lactic acid is not a performance limitation but a useful energy substrate  Elite Swiss orienteers run 5000m track at under 15 minutes. Matthius Kybutz qualified for the Paris 2024 Olympics running a marathon in sub 2hrs07mins. You need to be fast to be an elite orienteer and elite performance takes time. Goal setting can be a weekly, monthly, yearly or even something which evolves over a decade. Most successful elite sports people knew what they wanted to achieve as teenagers. It takes 10000 hours of quality practice to reach expertise. Take home message : high metabolic intensity of training needs to be met by good preparation. Warning : if training in heart rate zones, make sure your day isn't stressful in itself, creating a high resting heart rate, because you have too many things to do!! A by-product of physiological loading is mechanical loading of muscles that activate an inflammatory - immune response Metabolic fatigue can lead to immune compromise : These extreme physiological training principles of zone 3 -> 5, carry the risk of severe metabolic over loading unless prior muscle conditioning has been achieved. Well prescribed exercises can 'fine tune' muscle immune responses. Conversely, over-training, from poor preparation, can lead to immune and mechanical compromise within muscles, leading to under-performance, lost training opportunities and potential injury. Heat shock proteins (HSP's) as well as several immune substances and neuropeptides (TNF - Tumour necrosing factor, IL - Interleukins, IGF - Insulin Gene Related Factor, NK - natural Killer Cells, T - lymphocytes, etc) reside within muscle and it's myo-fascia. These substances are released during physically demanding activities, due to mechanical and/or metabolic strain/stress to induce, either a positive (anabolic) or negative (catabolic) training impact, Therefore, the response can be 'fine tuned' depending upon the appropriateness of loading and recovery, based on the preparation, stage and stability of the athletes mechanical and metabolic conditioning.   It is important to understand that the immune system is stimulated during exercise, but undergoes a compensatory 'blunting of immune response' in the 2-4 hours post exercise. During this period it might be wise to avoid crowded spaces, as well as try to consume a carbohydrate-protein drink, such as a 'banana smoothie', immediately following exercise. Cortisol - a natural anti-inflammatory stress hormone reduces, as do lymphocytes and natural killer (NK) cells Take home message : consider how to optimise the immune response. Immune highs and lows in reaction to the metabolic and mechanical demands placed on  muscles, must consider recuperation between bouts of exercise. Warning - after intense exercise, try to ingest carbohydrates and protein within 2 hours of cessation of exercise. Also, avoid crowds 2-4 hours after intense exercise, as your immune responses go from a high during exercise to a post exercise low, before returning to normal. Additionally, the structure of training camps may need to take into consideration minimising the exposure to crowds in confined spaces, as well as the 'periodisation' of training (explained below). It may be prudent to do the volume and intensity training initially, whilst using the latter stages for technical training, planning, cognitive and psychological exercises, if aeroplane or train travel is going to occur, for the trip home. My anecdotal experience was that a 10 days training camp was OK, whereas a 2 week training camp resulted in a lot of athletes getting sick, generally with Upper Respiratory Infections. Delayed Onset Muscle Soreness (DOMS) - overuse Mechanical fatigue can lead to immune compromise : Muscles contract using a sliding filament mechanism, whereby two filaments - actin and myosin use a 'ratchet' 'cog and rack' like mechanism to shorten and lengthen muscles. These filaments are held together by various cross bridges. DOMS can occur, when unaccustomed exercise is introduced to the training program. Frequently, these are activities which involve muscle contractions whilst the muscle is lengthening (eccentric contractions). Running downhill would be a good example of quadriceps controlled lengthening through muscle contraction. (later it will be explained why running downhill using the hamstrings and gluteal muscles as a synergy to the quadriceps is so important). One simple theory behind DOMS is the 'broadening and streaming' of the Z discs. This can lead to swelling within muscles as a result of the release of inflammatory neuroimmune peptides. Microscopic changes to the cross filaments can last 28 days. Whilst it may seem simple to say, avoid such contractions, training to change the mechanical efficiency of muscles does require some 'damage' and remodelling into a more loading tolerant system. To reduce the risk of mal-adaptive changes, specific functional exercises that involve components of, as well as, entire muscle synergies are required. These exercises should introduce optimisation of the mechanical loading of the entire limb, ideally for downhill and uneven terrain running. Take home message : high metabolic demands of training is accompanied by high mechanical demands depending on which type of training is used (e.g. contrast the (low) mechanical demands of bike riding training in a transition or preparatory phase to the (high) mechanical demands of downhill running training during a competition phase Oscillatory systems - the rate of relaxation Importantly, muscle contractile efficiency, in endurance sports, is determined by how well muscle relax and how few motor units are recruited to perform the optimal function. This is partially why muscles become stiffer as we fatigue, which sets up a cycle of less relaxation and more fatigue, being rate limiting and a protective aspect, by the body, to prevent catastrophic failure (Rhabdomyolysis). The better prepared the athlete, the more fine tuned and appropriate, the response. In endurance sports, a muscle never contracts 100% of it's motor units - there is always redundancy in the system. Furthermore, there is frequently an asynchronous pattern of motor unit firing. Moreover, when examining this asynchronicity, in terms of 'deterministic chaos', repetition under variable conditions, means the 'outlier' becomes the reference point of what is considered 'normal'. This means that training should include, not only 10000 hours of repetition, but varied qualitative repetition, to not only avoid injury, but to optimise the system to become competitive. Hence, specific exercises below, include oscillatory ones, designed to maximise the contraction - relaxation cycle. These include exercises such as the 'Hammer Head', 'Queen Mum' (rocking), 'Moggie', 'Reverse Needle', 'Hip Hitches', 'Quads Hover' , 'Reverse Lunges' (skating) leading to the plyometrics box, hopping, skipping, and downhill running. Magnesium supplementation Magnesium supplementation (200mg for women, 200mg for men) can aid in muscle relaxation. Magnesium is the counterpart to calcium. Calcium makes muscles contract, leakage of calcium from damaged muscle tissue, means that muscles continue to contract. Magnesium is usually 'the gate keeper' of calcium, helping muscles relax. Additionally, magnesium supplementation also seems to improve glucose balance in the blood stream during exercise. The mechanism may be through better uptake of glucose , by muscles, through Glut-4 pathways. Differentiation of the metabolic and mechanical demands of training for a positive training effect, thereby avoiding or reducing the risk of injury Presentation in Rome 2005 for further reading When considering such a model, ideally the joint loading is minimised through the use of bi-articular muscles. In the case of downhill running, the hamstrings and calf bi-articular muscle 'energy straps' circumventing loading on the knee joint. Additionally, this action simultaneously reduces the loading of the quadriceps near the knee, whilst increasing it's loading in the upper 2/3 towards the hip. Thus a series of stabilising contractions in the lower limb. leading to further mechanical energy dissipation in the gluteal and core muscles of the pelvis. Those athletes who ride a bicycle will know how riding uphill in a seated position tends to load the posterior 'slings', whereas getting out of the saddle has a tendency to increase the loading of the anterior 'slings'. Ideally. a 'sweet spot' is reached between the 'slings'. This stabilisation and optimisation, is particularly important, as the loading around the knee can reach up to 3 - 7 times body weight, when (leaning back whilst) running downhill. Exercises (to balance the slings), involving actions which mimic 'downhill skiing', 'reverse lunges' and 'nose behind toes' plyometrics box activities will be described later in the exercise section.  Leaning forward (in the hip joint) during downhill running, not only lowers the centre of gravity, it allows the conservation of momentum, as well as the engagement of the stabilising elements of the sling configuration, whereby the activation of the posterior 'sling' activates the hip-pelvic-thoracic stabilising mechanisms, as well as proximal quadriceps activation. The amount of forward flexion around the hip joint will vary depending upon the persons anthropometric features (taller vs shorter, skinny vs robust).  Warning : you will get DOMS when initially undertaking this form of exercise. Primarily focus on learning the task on soft ground or comfortable cushioned shoes. Do, the reverse lunges and quads hover exercises described below, as well as plyometrics training as pre-conditioning for forward leaning downhill running. Over time, the DOMS experience will reduce and the type of terrain won't make a difference. Remember, the forward lean occurs in the hip, the back remains straight, and the abdominal muscles along with the posterior slings absorb most of the energy, whilst the quadriceps are performing in a shortened range. Ideally, the foot is flat throughout the landing phase of running. This latter aspect is also useful in preventing ankle twisting injuries in soft and uneven terrain. Landing on the ball of the foot adds to the degrees of difficulty (complexity of stability) and should only be used in terrain which hasn't any 'give' such as rocky ground.  Importantly, there are two types of 'slings'  ones that have a 'bow and arrow' effect whereby the greater joint angle creates the greater tension and hence recoil velocity ones that are stabilising, acting like a 'hammock', cradling body parts into a synchronous harmonic spring like motion Take home message : by differentiating and reducing aspects of training and movement into first principles, will allow the athlete and coach and physiotherapist, to set an appropriate training plan, which is objective, transparent and thereby accountable. Hereby, optimising performance, through a thorough understanding of technique, leading to a reduced risk of injury, with increasing training load. Exercises are used to build individual aspects into a functional comprehensive competitive unit. Mechanical - metabolic - immune conversion Importantly. muscles are an organ of the immune system as well as an organ of locomotion. Beside, optimisation of mechanical loading capacity, protective principles to avoid immune compromise, inflammation and injury include contrast bathing periodisation of training progressive resistance weight training power and agility training using kinetic chain 'sling' synergies and plyometric type exercises environment - don't go into crowded spaces in the immediate 2 hours post training. nutrition - carbohydrate and protein loading before, during and immediately after physical activity. These factors are particularly important during periods of intense training and/or competition. Periodization of training can aid in avoiding 'breakdown' as a result of insufficient recuperation and adaptation to training regimes. Heat and Cold Shock Proteins Saunas and cold immersion baths have been advocated for recovery from training and competition. Both are considered to improve the immune system through the release of either heat or cold shock proteins (HSP, CSP). These basic short peptide chain substances are considered to be the basic building blocks of evolution and the development of multi-cellular life on this planet. Inside our muscles, these can be considered basic building blocks of healing and repair. They form complex synergistic relationships with other longer chain HSP (eh HSP 27 and HSP 72), within muscles (mechanical stress, e.g. delayed onset muscle soreness DOMS) and potentially through oxidative stress (metabolic fatigue) form another synergy with (HSP) immune and energy species in the gut? Furthermore, cold immersion therapy can also be used to potentiate microcirculation, reducing clinical and sub-clinical swelling. Although, the precise relationship is complex and still not fully understood, the fact that this form of therapy has been used for thousands of years, in many parts of the world, at least on the face of it, makes the use of sauna and cold immersion baths, a valid strategy to use Periodisation of training in the prevention of overuse injuries Periodisation of training and correct technique reduce the risk of over-training, 'staleness', immune compromise and injury by considering the importance of rest, nutrition and correct biomechanical and physiological loading. Volume - duration : protective endurance base from which Intensity is developed.  (eg long slow run, multi-sport, vs fast runs such as interval training, Fartlek, sprints, power training in gym) Rule of thumb: don't increase volume and intensity at the same time. If over-training and staleness sets in, do the opposite of what they have been doing. When we were working with elite amateur and professional cyclists, if a track cyclist was going stale, we'd put them on the road, and the opposite, when a road cyclist was going stale we would put them on the track (velodrome) or we send them on holidays, where 'less is more'. Preparatory ; Training phases may be separated into various stages depending upon the age of the athlete and whether the athlete is a novice or experienced. General physical abilities may include multilateral/dimensional development of endurance e.g. using bike riding and swimming or even a team sport like soccer, to develop agility, as an adjunct to running training, to prepare for the volume of training required during sport specific orienteering training and competition.  Specific physical training may mean more time devoted to the particular run e.g. 5000m vs 10000m vs hurdles vs orienteering and less time devoted to other sports. Importantly, these forms of training need to be monitored as their intensity could lead to injury before the competitive season has begun. Competitive : As training proceeds into the competitive phase some athletes place a higher proportion of their loading on intensity whilst reducing the total volume of training.  Cycles such as this one may be biannual or biennial.  Importantly, periodisation and cyclic loading is not restricted to any particular time frame. Although,  it does place  emphasis on incremental loading moreover it places emphasis on optimal regeneration and recovery. Additionally, such a methodology provides a 'base' for the next cycle of training activities. Each macrocycle may be made up from micro cycles which can last days, weeks, months or years. Remember, each time you train to change your bodies abilities you are stressing the system and therefore recuperation and repair is important. Transition : seasonal - 'time out', regeneration/recovery, multi sport during 'off season' or a micro cycle of the low volume/intensity day/week/month, working back into the preparatory phase Training phases Protective exercises can be prescribed for the different training phases. Generally, a good endurance base is considered important to prevent injury from much higher mechanical loads which can occur during power and speed work outs, or during periods of intense competition. Endurance training (volume loading) - periodisation How to develop endurance and volume of training without over-training. Periodisation of training allows the athlete to gradually build up their training volume or intensity, whilst allowing time for regeneration. Gradual increments of loading can occur, whilst reducing the risk of excessive over-loading and hence injury.  Additionally, training of various intensities allows the metabolic systems to develop in parallel.  Thereby the anaerobic and aerobic metabolic systems can be used to drive endurance, reduce fatigue and the risks of injury associated with movement breakdown from fatigue. Lifestyle factors need to also be considered. How much time do you really have for training, work/study, friends/family and recreation? Ideally, when study volume is increased, quality (intensity) of training is high and volume (duration and frequency) of training is low. However, intense training can only occur safely, only a pre-existing endurance base. On a micro level an orienteering competition is similar to periodisation, with intense anaerobic intervals, such as running uphill, requiring a medium or low interval for heart rate recovery, which can occur when running downhill or on flatter terrain. Even after coming out of the forest and spending a short period running on a track or road, may potentially be considered a transition phase? Take home message : the endurance base is like the foundations of a building, where the athlete can soar to new heights, by adding intensity on a robust musculoskeletal structure Periodisation of training and injury - disuse Paradoxically, the more refined your training and competitive regimes, the greater the 'perceived error', Training regimes, to a large extent, can be quite predictable. However, high level sport has many levels of 'randomness', where being on a 'knifes edge' can mean the difference between success and failure. The key element is to have the defined variables distinguished from those seemingly 'random' aspects of competitive sport. By having a solid routine, resilience to changes in expectations/outcome can becoming a solid learning tool, if the appropriate analysis is undertaken. Those 'random outliers' may be an insight into a better training methodology or competitive technique.  Periodisation of training, ideally allows the athlete to avoid injury. Moreover, if an injury or illness does occur, understanding and using the concepts of a 'low' intensity training phase gets the athlete used to building up from an injury induced 'low' training phase. Additionally, the transition and preparatory phases give the athlete familiar alternative sports and exercises to do, during the recovery from injury. Moreover, if sport is the athletes main socialiser, then friends in other sports may become extremely important for mental wellness as well as physical strength. The Kubler Ross model of grief are applicable when it comes to chronic sports injuries. Mental health among athletes is an important consideration that has recently gained more attention. The 2019 International Olympic Committee (IOC) consensus statement on mental health in athletes reported on the high prevalence rate of mental health symptoms in athletes and the relationship of mental health with physical injury and subsequent recovery (Reardon CL et al 2019 Br J Sports Med. 53, 11, 667–699). The IOC urged that mental health is a vital component of athlete well-being and cannot be separated from physical health. Assessment of mental health and subsequent management should be a routine part of the medical care of athletes. The IOC also concluded that cognitive, emotional, and behavioural responses are important factors in injury outcomes, and mental health disorders can complicate recovery. A systematic review of 28 studies reported 65% of those patients not returning to play cited a psychological reason for not returning (Nwachukwu, BU et al 2019 Orthop J Sports Med. 7, 5, 23259 67119845313). Fear of reinjury, lack of confidence in the knee, and depression were the most commonly cited psychological reasons. Take home message :  Periodisation of training should provide the athlete with good time management principles, including time for work/study, family, friends and recreation. These aspects become even more important, as they can act as a 'safety net' during periods of injury and recovery for physical and mental health reasons. Fast and Slow twitch muscle fibres - the 'floppies' and the 'stiffies' Anatomically, endurance muscles are deep muscles, close to the joint, generally only cross one joint and are slow twitch red muscle fibres. Muscles for power are 'fast twitch' white fibres which are more superficial and cross more than one joint and even multiple body segments. People tend to be divided into two categories - the 'floppies' and the 'stiffies'. Floppies tend to be inherently ballistic in their movements - sprinters. Conversely, stiffies tend to be endurance athletes. Frequently, stiffies need to do speed, flexibility and agility training, whereas floppies need to do endurance training, to protect themselves from injury. Importantly, to do these aspects safely, a gym or home exercise program can be employed, where variables can be controlled and good technique is monitored. Hence, prevention of misuse from lack of movement or lack of control of movement should use specific endurance exercises with the principle of 3 sets of repetitions to metabolic fatigue, with a short recovery period between sets, with low loads specific strength exercises involving few repetitions using high loads to mechanically fatigue muscle cross fibres and tendon. Long recovery time between sets plyometrics speed rebounding exercises, for power, which provide a mechanical and immune protective mechanism against the stresses of training and competitions Take home message : floppies naturally have power but reduced endurance from lack of stability, whereas stiffies have enhanced stability but reduced mobility. Plyometrics training for the former involves control of movement during metabolic fatigue, whereas the latter, involves improving range of movement whilst encouraging biomechanical fatigue. The ultimate objective is power through velocity of muscle rebound. See : Ehlers Danlos or Joint Hypermobility Syndrom link for further information  Musculoskeletal stress, cognitive demands and the immune system - misuse An injury can commence in one part of the body and gradually affect other parts of the body, as a redundant compensatory systems become the primary player, protecting the other body part (original injury),  Recovery may involve analysis of technique, examination of training load (duration, frequency, intensity), adequate rest and nutrition, as well as a sound state of mind (mental strength). Redundant compensatory use can eventually lead to fatigue and overuse of those body parts. A classic example is when the hip begins to lose control of rotation, the knee compensates by acting not only primarily as a 'hinge joint' but increases it's function as a rotator as well, which can lead to knee and ankle sprains, Inefficiency of movement can also lead to increased energy requirements leading to premature fatigue, muscle strains, stress and immune compromise. Overtraining - over reaching = immune compromise More isn't necessarily better. How much time do you really have for training, recuperation, work, study, family and friends?  Over-training has been shown, within 4 weeks, after the onset of training, to be associated with increased oxidative stress both at rest and during submaximal exercise in a group of men after they underwent 7 weeks of  intense military training (Tanskanen et al 2011, Med Sc Sp Ex, 43, 8, 1552-1560) A common symptom of over-training is non-restorative sleep, immune compromise and stress fractures. Approximately, 1/3 of young athletes have experienced 'non functional over-reaching (NFOR) or over-training (OT) at least once in their sporting life (Matos et al 2011, Med Sc & Sp Ex, 43, 7, 1287-1294). The rate was higher in individual sports (37%) when compared with team sports (17%). Individual sporting endeavours tended to consume more than 2 hours per day, 6-7 days per week, which was significantly greater than the training volume reported in team sports. Females were more prevalent in the OT cohort (36% vs 26%). Moreover, even in low physical intensity sports such as golf individuals may suffer from NFOR/OT. Training load and volume alone wasn't the sole contributor to OT, as sporting individuals appeared to devote more time to their sport and less time to socialising and other school activities.  Thus, they are at risk of developing a uni-dimensional personality which seems to place them at risk for NFOR/OT. Self esteem, identity and self-worth become intertwined which is fine whilst they are gaining sporting success, however sporting failure may result in stress and anxiety. Hence, young athletes should be encouraged to form multi-dimensional personalities through encouragement of a range of hobbies and interests.  Over training in female athletes can be particularly severe as O-T leads to alterations in the luteal phase of the menstrual cycle which results in dysmenorrhea and potential reductions in bone mineral density and metabolic dysfunction due to reduced Oestrogen levels. Heart rate variability More precise monitoring of the rate of recovery can be achieved by examining 'Heart Rate Variability' whereby the response of the heart from 3 minutes prone to 2 minutes of upright posture is measured. High variability dictates a fresh response - low variability indicates a 'stale response' or high stress related fatigue. This allows the athlete to more objectively determine which days should be recovery days and which ones are days where they can train a little harder. Importantly, chronically reduced HRV is suggested to be a 'red flag' for sudden cardiac arrest in otherwise fit and healthy individuals. Such individuals should have further testing by a cardiologist before recommencing their training regime. Metrics should be used in the evaluation of fatigue, just as they are used in the evaluation of performance. In hypermobile 'floppy' people excessive HR variability can be the problem rather than dampened response. POTS is a condition of exercise intolerance in positions other than the horizontal. Athletes will often present, complaining of symptoms of dizziness in standing, whilst feeling comfortable in sitting and lying down. In the older person it can be a result of cardiovascular deconditioning where the Heart Rate and Stroke Volume do not produce enough cardiac output (CO=SVxHR). In the younger individual, it may present as part of a condition from a different aetiology. In people who have suffered a Whiplash Associated Disorder (WAD) - anterior sympathetic cervical ganglia, or in a person with concussion, POTS symptoms may arise. Additionally in people who have Ehler Danlos Syndrom (EDS) or Joint Hypermobility Syndrome (JHS) POTS like symptoms due to autonomic dysregulation may present with POTS at any stage of life. Any thoracic ring issues which affect the peripheral sympathetic ganglia may also result in POTS like symptoms. Essentially, a person may have low blood pressure and elevated heart rate (Tachycardia) as a compensatory mechanism. POTS is frequently misdiagnosed and requires a tilt table and blood pressure monitoring to aid in the differential diagnosis. further reading : https://www.back-in-business-physiotherapy.com/latest-news/335-postural-orthostatic-tachycardia-syndrome-pots.html Sleep and irritability - the 3 B's Sleep is particularly important for adaptation to training. There are essentially two immune systems adaptive - the one we develop in response to environmental stressors innate - the one we are born with and has a very strong genetic pre-determination One immune system is more active during the day and the other more active at night. At night immune and inflammatory reactions to the physical and mental loading of the day are activated for tissue building, healing and repair. Hormonal balance at night should be anabolic (testosterone, progesterone, oestrogen) muscle building vs catabolic (cortisol), muscle depleting. A sign of overtraining is non-restorative sleep, waking in the morning and feeling tired. This can lead to the 'three bastards in a day phenomenon'. When we meet one person in the day, whom we don't particularly like, we might think that's unfortunate, when we meet a second maybe doubly unfortunate, if we meet a third, then it's not them but you. Overtraining can lead to immune compromise and ill health. Ask your partner, spouse, close friends if you're in over-training. Take home message : when setting out your training plan, ask yourself how much time do you realistically have to train sleep spend time with friends, partners, and family work/study RECUPERATE Periodisation of training should incorporate these aspects of life into your training plan. Don't train when you are sick As already mentioned, muscles have a dual role of locomotion immune conversations   When you are sick, muscle protein and immune substances are required for recuperation. Training isn't only unwise, it's probably a complete waste of time. importantly muscles interact with the gut and it's energy deriving species, as well as with immune substances inside the gut, including heat shock proteins.   It should also be noted that for most common viruses which we associate with 'colds', it can take up to 6 weeks before the immune muscular system is fully recovered.  Nutrition Nutrition should consider energy substrates (carbohydrate, fat and protein) anti-oxidative (Vit C, Blue Berries, etc) pro-biotic (Sauer Kraut, Kim Chi, etc) nitrogen balance Warning : long duration physical activity such as marathons and ultramarathons are known to cause increased protein (especially albumin) excretion in the urine. Additionally, purine, a protein associated with ATP production, which is important for muscle contractions, is known to affect athletic performance. However, too much purine is also associated with gout like symptoms, resulting in joint inflammation, from high uric acid concentration, which can lead to crystals forming within joints. It is probably wise to monitor and even reduce excessive meat, alcohol, spicey food and seafood consumption during periods of intense and prolonged physical activity. Tables of purine rich foods can be found on the internet. Overall, however, good physical conditioning, generally results in enhanced purine modulation. Flexibility Hatha flow yoga is a good form of stretching without compromising stability. Can be done by both 'floppies' and 'stiffies'. A lot of emphasis is placed on the mobility and strength of the thorax through breathing, rotation and side bending movements whilst the limbs are either loaded or unloaded. A general rule of thumb, is that flexible people should draw stabilising forces inwards into the body, whilst stiff people should be mobilising outwards. It should be noted that people can have stiff muscles and loose joints. In many cases this is because the body is trying to protect a weakness. Therefore, with every mobilising exercise, the stabilizing component should also be considered. If nothing else, yoga will teach you to breath properly as well as relax and become more in tune with your body. This should mean that the 'self-awareness' gained by flowing through yoga positions will act like an internal monitoring system, alerting the person about potential problems before they arise rather than the first awareness being that of pain.  Strength : fast twitch mobilizing muscles Strength training usually involves a gym program where the ability to move loads (mass) progressively improves. Benefits can be attained within 6 weeks. Fast twitch muscle fibres tend to cross more than one joint and act as 'energy straps' across different parts of the body e.g. hamstrings cross from the shin to the pelvis thereby transferring energy to the pelvis without compromising/over-loading the knee or hip. These energy straps or slings are very important in the prevention of injuries but also in the approach to rehabilitation. Endurance : slow twitch stabilising muscles Endurance training involves developing 'resistance to fatigue' over a 12-16 week period. Slow twitch muscles usually lie very deep and close to the joint. They tend to cross only one joint and provide localized stability over very long periods of time. Progression of training as well as recovery from injury shouldn't ignore endurance at the expense of 'ballistic power'. Misuse : repetitive incorrect microtrauma through non optimal loading In orienteering and running in general this results in tendonopathy, commonly involving the hamstrings, quadriceps and Achilles. A common example is a chronically unstable ankle causing asymmetrical loading of the Achilles tendon - the latter resulting in tendonosis. Localised (one joint), endurance stabilising muscles can be used to improve the localised alignment around the foot and ankle. Frequently, ankles are unstable due to weakness of hip muscles, as rotation of the limb, as well as sideways stability, is controlled by the (one joint) hip muscles. However, multi-joint energy strap muscles incorporating the 'sling' concepts are trained here, for transference of energy across multiple joints (limb segments). Running slowly in soft sand with good technique can also address stability issues whilst increasing speed and changes of direction can be used to improve dynamic 'ballistic' mobility. The one modality can be used in slightly different ways to address both issues (localised and inter-segmental) whilst improving form and function for better 'flight through terrain' whilst orienteering. Similarly, bush walking with a weighted pack improves endurance stability but also addresses strength (force production), which ultimately improves power (force x velocity). More extremes of desert training, by elite army units, involves a 75km course covered in 15 hours, using a 70kg backpack. Investigations, in the 1980's, demonstrated these athletes to have the highest endurance aerobic capacity, even when compared to other extreme endurance athletes of different sports (marathon runners, x-country ski bi-athletes, etc) Abuse : trauma  Running through uneven terrain can result in ankle, knee and hip sprains of ligaments. Importantly, power and agility training can be used to improve muscular stability, thereby protecting the joints and ligaments. Ultimately, plyometrics can be used to improve stability for uneven terrain. Moreover, muscles need to have other attributes such as mobility (length) to produce velocity, which in turn improves acceleration of mass (body segments) and the contractile muscular force which  ultimately produces 'ballistic' power. Consider a chain which has some 'rusty' links. When you move the whole chain, movement occurs in the non 'rusty' links. Eventually, those loose links, taking all the movement load, will become weak, Similarly, in the body, restricted movement in one part of the body can lead to excessive movement and over-loading in another. Certain joints have a specific movement function in a given kinetic chain. Consider, the ankle and knee to be essentially 'hinge' joints with a small amount of rotation. Generally, when we injure either one of these, it's because of an uncontrolled twisting action. The hip on the other hand, is a 'ball and socket' joint designed to rotate. Therefore, prevention of ankle and knee injuries must consider exercises which stabilise the hip. The other 'ball and socket' joint is in the talo-navicular joint in the arch of the foot. Running bare foot on soft sand can strengthen both the hip and the foot, thereby protecting the ankle and the knee. Failing soft sand, the exercises below are designed to improve kinetic limb co-ordination and hence dynamic stability.   Take home message : "the whole kinetic chain needs to be in rhythm and harmony with each other" like many instruments in an orchestra. Contrasting hip strength and control during landing in women. Women can have an inherently different biomechanical characteristic compared to men, due to a wider pelvis, creating a different lever angle on the thigh bone. This can result in reduced external rotation at the hip, with the consequent increase in internal rotation causing increased forces on the inside of the knee and arch of the foot (prolonged pronation and/or eversion).  Additionally, some females are quadriceps dominant at the expense of the gluteal muscles. It has been shown that female individuals with reduced hip strength have greater pelvic angular displacement, peak velocity, total angular excursion and higher muscle activation of the trunk and gluteal muscles than stronger individuals (Popovich & Kulig 2012 Med Sc Sp Ex, 44, 1,146-153). Lack of control of the inward movement of the knee has been demonstrated to improve with functional hip abductor and external rotator training (Baldon et al 2012 Med Sc Sp Ex, 44, 1, 135-145). They also employed core stabilising exercises for the abdominal region. However, static core stabilising exercises have not been shown to improve knee loading (Jamison et al 2012, Med Sc Sp Ex, 44, 10, 1924-1934). Therefore, dynamic trunk exercises using perturbations of movement need to be incorporated into a rehabilitation program. Pelvic floor exercises are also recommended, as the obturator internus muscle is a hip lateral rotator whose myofascial membrane is continuous with the pelvic floor. Sling like exercises for the optimisation of the two joint muscle 'energy straps' Whilst the joints can be considered like the wheels of a 'pulley' system, the axel as the 'slow twitch stabilizing muscles', whereas the 'fast twitch ballistic muscles' can be regarded as the ropes of the system, conveying tension from one body part to the next, whilst circumventing forces applied to the joints in between the body parts. An example, is the use of the hamstrings to extend the knee (closed kinetic chain such as downhill skiing, reverse lunges, downhill running leaning forward), bypassing forces applied to the knee, whilst transferring energy from the shin/calf to the pelvis/glutes.  The muscular slings can be divided into front and back : quadriceps upper 2/3 with the hamstrings and gluteal muscles as in reverse lunges and reverse squats and quads hover superficial (ballistic energy straps) and deep (slow twitch stabilisers) oblique spiral : abdominal muscles as in planking forwards and sideways, Swiss Ball exercises medial and lateral : hip hitches with the non standing leg in various positions simulating running positions These slings which are created by synergistic muscle action, are designed to protect the joints by 'unloading them' from large forces and misdirected muscle action the hip joint has about 120 degrees of rotation, whilst the knee has only about 15 degrees, whereas the ankle joint itself has almost none. By training the control and range of movement around the hip joint, it not only allows co-ordinated movement across steep undulating terrain, it additionally protects the knee and ankle form twisting actions which could lead to ligament and tendon injuries. The hip hitching exercise is designed to mitigate this. the knee joint is essentially a 'hinge joint', which bends and straightens. To avoid excessive loading of the knee joint and knee cap, try to load the contractile energy absorbing and producing muscles in their bulkiest parts - i.e. in their upper 2/3, by leaning forward in the hip during downhill running. The reverse lunges and the reverse squats are designed to mitigate this. the ankle joint is also essentially a hinge joint, whereas the heel does an inward and outward type of movement together with the ankle. The first joint in the arch of your foot, below the ankle, is a 'ball and socket joint' (like the hip), designed to allow pronation as well as produce the leverage needed for supination and the power of push off. The heel lifting exercise is designed to strengthen this. Better still is running on soft ground, Additionally, skipping and hopping exercises will encourage the energy absorbing (up to 70%) and energy producing elements of ankle control.   Repetitions : 3 sets to fatigue Calf muscles are particularly important for propulsion but also for shock absorption, as they can absorb up to 70% of the forces going into the knee when running down hill. Skipping and hopping can be very useful exercises to improve calf function.  Other examples of sports which can be used to activate neuromuscular 'slings' include indoor/outdoor rock climbing and the bouldering gym. The 'Butt' comes before the core.   Gluteal contractions activate abdominal core muscles as well as enhance the upper limb strength. Core and back exercises The final Fitball exercise is a good example of the differentiation of the internal stabilising muscles versus the external 'sling' muscles. Exercise 22a involves pure hip rotation - meaning that only the leg moves due to the 6 deep lateral and medial rotators of the hip controlling leg movement. These muscles only cross one joint and act purely on the joint in an endurance stabilising capacity. Exercise 22b is NOT a progression of 22a. This exercise invokes the external 'sling' muscles, in a co-ordinated synergistic manner combining muscles that cross the knee, hip, pelvis, low back and lower 6 ribs. Hence, the deep muscles control the axis of rotation around the joint and provide powerful feedback (proprioception) to the brain, whilst the superficial muscles are responsible for 'energy transfer'. One should not be trained to the detriment or neglect of the other. Take home message : Races are won and lost by the ability to run quickly downhills and traverse steep terrain. Learning to master these biomechanical attributes, through targeted exercise, not only optimises performance, it reduces the risk and probability of injury. However, 'transference of learning' through internal visualisation of these specific exercises, to terrain running needs to occur. Similarly, whilst in terrain, think about the exercises, or even execute one or more of them, in terrain e.g. hip hitches or some reverse lunges, and then continue to run. Feel the difference and the 'new spring' in your stride. Progressive Resistance Weight Training  Strength : 3 -> 4 sets of 5 repetitions with several minutes rest between sets. Promoting mechanical fatigue Conditioning -> endurance 3 x 20-30 repetitions with only 60 seconds rest between sets. Promoting metabolic fatigue Power : Proactive potentiation resistance squats followed by box jumps. 2 -> 3 days between workouts. Promoting ballistic mechanical rebounding (potential energy into kinetic energy). a bit like a stretched rubber band recoiling back to the shortened position Generally, muscles who perform an eccentric contraction (jumping down) prior to a concentric contraction (jumping up), enhance the concentric contraction. However, if not conditioned appropriately, athletes will suffer DOMS within 8 hours, which will gradually worsen up to 48 hours post exercise. Doing alternative sports during the transition phase can aid in attaining strength, endurance and power. Such sports need to be ballistic fast reactive multi-directional. Examples are soccer, squash and serious table tennis. Plyometrics : "nose behind toes" Plyometrics uses the physical concept of turning kinetic energy (KE = 1/2mv2) into potential energy (PE =mgh) and vice versa Various heights depending upon size of person and ability to jump : 40 vs 50cm Hands from behind to the front Important to land in 1/4 squat. Hip wide feet - with emphasis on the knees staying above foot/ankle whilst the pelvis stays back on landing   Sideways step ups can be progressed to sideways jump ups as well as 'cross overs' to the other side - good for steep terrain traversing running Reverse lunge step down - pelvis drops and knee stays above ankle and mid foot - emphasis is on the posterior sling : hamstrings and gluteal muscles. No tension in the knee.   loading upper 2/3 of thighs and glutes. Taking the knees back, takes tension out of the knee joint. Note the pelvis dropping vertically Again the emphasis is on the pelvis dropping vertically. Note : the knee moves forwards and backwards horizontal to ground (NOT up and down). Sensation of strain should be in the upper hamstrings, glutes and upper 2/3 of quads (NOT in the knee) Pelvis drops down and back whilst the knee maintains alignment in the hip and ankle. Go down slowly, stop part of the way and return. Vary the amplitude and speed. The slower you go, the greater the amplitude of oscillation. Conversely, the faster you go, the smaller the oscillation amplitude. Hereby, the greater the number of motor units recruited, will enhance the cortical representation and variability of muscle recruitment .Additionally, vary the point where you stop and change direction Thereby optimising the ranges of motion where motor unit firing can occur..  Progression  preloading resistance training weighted vest or ankle weights using a dumbbell in each hand or a kettle bell set up a series of boxes Sports such cycling, cross country skiing, telemarking, and speed skating can have similar effects on activating the muscular slings across the body, when done correctly. Importantly, for transfer of learning from exercise to sport specific task, visualisation and internal mental imagery of the task should be performed. For example, whilst doing the plyometrics box, visualise a forest and the map whilst doing the task. Later in training, whilst running up or downhill, visualise, from within, the plyometrics box. Further reading on mental training and orienteering can be found here : https://www.back-in-business-physiotherapy.com/sports-performance/orienteering.html Summary muscles have a dual function as a mechanical organ of loading and movement as well as an important immune function muscle mass allows for the adaptation to training and sport loads as well as providing a reservoir of protein for immune function muscles have a synergistic function with the gut recuperation is the ultimate goal of any sporting endeavour alternate sports can be used to improve ballistic performance capacity as well as to engage the muscular slings across the body muscular slings are inherently 'innate', they just need to be 'woken up' and activated  They protect the joints from excessive or inappropriate loading. the Glutes activate the core, which gives both upper and lower limb strength by providing a stabilising point of inflection in a system which oscillates elongation through the upper neck (Alexander Technique), broadens the shoulders, lifts the pelvic floor, thereby stabilising the core, opens the diaphragm to lateral breathing, which allows hip flexors to work independently, as well as encourages the pendular movements of the arms which create the rhythm of the legs females have some different hormonal and biomechanical characteristics when considering 'periodisation' and specific exercise regimes (further reading  : females and soccer injuries) Conclusion Injuries can be avoided by adaptively loading the body through sports specific strategies which include Don't train when you are ill Periodisation of training Nutrition - magnesium as well as both energy, immune and anti-oxidant considerations Specific exercise tasks for activating the neuromuscular slings for dynamic stability in uneven terrain Progressive resistance gym training for running uphill Plyometric exercises for running up and downhill, as well as for one legged and two legged jumping, landing and take-off  Train to run and compete uphill for resistance to metabolic fatigue Train to run and compete downhill for optimal biomechanical performance and avoidance of injury Contrast baths (ice bath and sauna) for optimisation of recovery (heat shock and cold shock proteins, as well as micro-circulation) Races can only be won by running fast and especially fast terrain traversing and downhill running. Injuries are more likely to occur as the intensity or volume of loading increase. The same exercises which improve mechanical efficiency and performance are therefore the same exercises that reduce the likelihood of injury. Orienteering races are won, in a fashion, which resembles the 'periodisation' of training - running fast downhill, fighting metabolic fatigue going uphill, recovery on the flats, transition into the next phase of the competition. Further reading on mental and mechanical stress and the immune system can be found here : https://back-in-business-physiotherapy.com/physiotherapy-teaching/rome-presentation.html Uploaded by Martin Krause on 16 June 2024 Updated : 21 October 2024 Read More

Alaska and the year that was 2022-23 by Martin Krause It's been almost a year since we closed the practice in North Sydney, so I thought I would like to let you know that I'm back in the country for the foreseeable future and would love to treatt your clients once again, albeit from my little practice whci I'm running from home. Below is a little synopsis of what I've been up to since closing the practice in North Sydney and opening in Cremorne II've managed to do a few big trips - one with my father to Germany and Austria, in May/June where we walked 430km in 23 days, which was on the back of a 10 day hiking tour in the South West of Western Australia back in November 2022. Another trip involved 17 days of Pack Rafting and hiking in the wilderness of northern Alaska. 25 days without a bed. Driving a day, and two light planes later, we commenced our trip on the Continental Divide, about 100km south east of the Bering Sea, paddling 400km down the Alatna River, From Arctic Tundra to Boreal Forest. Also hiked into the Arrigetch Peaks of the Brooks Range - described as the Yosemite of Alaska and also known as one of the remotest valleys on the planet. Scaled three mountains and came face to face with the mythical tundra Grizzly on our second night. The myth (we thought to scare Australians) being the cross breeding between Grizzly and Polar Bear. I had to talk it down ('hey bear, hey bear' whilst doing star jumps) as I was nowhere near the bear spray (on my life jacket) whilst the other three, in my party. were in the cooking area some 100m away, with the gun, A Grizzly 30 feet away is on you in 30 seconds!! Amazing looking creature - whitish blond with a golden back (almost like the sun was shining out of it) with these amazing rastapharian like dreadlocks coming off it's back. I always contested every animal understands German - or at least the notion and intent, as he stopped, listened for about 3-5 minutes, then pawed his nose and turned around and walked back up the embankment. My biggesty criticsim - 'no photo!!!' Looking North into the Arctic Tundra - that river flows into the Bering Sea about 100km away The Alatna river from the source we were going to paddle 400km to it's ending in Allakaket - still above the Arctic circle  My new pack raft - internal storage system The boys on the bigger 'mother' ship Arrigetch Peaks - Aquarius Summits and glaceir seen from Aerial Arrigetch meadow with wild flowers. Lower in the valley, we came across Blue Berries, Raspberries and Cranberries, which bears like to eat. Saxon is in his last months of school. All seems to be going well. We celebrated his 18th (with my dad) a few weeks ago!!! Time flies. I'm seeing people every day of the week. However, only in the afternoons from Monday to Thursday whilst all day on Friday.Address is : 19 Ellalong Rd, Cremorne NSW 2090. Telephone : 0490 781 001 Since I no longer have a recpetionist best to book online : https://back-in-business-physiotherapy.square.site/ Due to my reduced overheads (and stress levels) I'm able to spend up to almost an hour with clients. I hope you and your family are all well.  Please don't hesitate to be in touchAll the best for nowMartin Uploaded : 19 September 2023 Read More

OUR TIPS TO IMPROVE YOUR DESK ERGONOMICS Whether you work in the office, from home, or a combination of the two, the setup of your desk is important for your health and well-being. Keep reading for our important desk tips to help you feel your best while you work. Adjust your monitor Having an incorrect screen setup causes you to strain your neck, which may lead to neck pain. Follow our screen setup tips to reduce the risk of neck strain:● If you are using a laptop, invest in an external monitor that you can adjust to the right height.● Adjust the monitor so that it is an arm's length away, directly in front of you. ● When using two monitors, set them up so that they are centered to avoid overturning your head. ● As a guide, the top of the monitor should be at eye level. Adjust your desk chair Having an adjustable chair is VERY important to your desk setup. When set up properly, it will minimize the risk of experiencing back pain and strain. Follow our chair setup tips: Move the height of your chair so that your elbows are resting at approximately 90 degrees. Your hips should be slightly open. Use a foot support if your feet don’t touch the floor (a step or ream of paper may do the trick if you don’t have a suitable footrest). Use an external keyboard, vertical mouse, and headset Keep key objects that you use often close to your body to avoid reaching or straining for them. Your keyboard should be positioned directly in front of you, about 10cm away from the edge of your desk. Your arms and shoulders should be relaxed to avoid any strain. Make sure your mouse is close to your keyboard to limit shoulder movement. Use a headset or earphones if you are often on the phone to avoid holding it in between your neck and shoulders. Take regular movement and stretch breaks! To reduce the risk of injury and strain, remember to get up and move your body often. Aim to get up at least once every hour. Here are some helpful ways to get moving at work: Set a reminder for a quick stretch every hour Go for a walk Refill your water bottle or glass Take a phone call outside Organise a walking meeting Stretch! References: Safe Work Australia (2020). How do I set up a workstation from home? [Online]. Available at: https://www.safeworkaustralia.gov.au/sites/default/files/2020-05/Working_from_home_Workstation_Setup_%20Guide-COVID-19.pdf Office of Industrial Relations (2012). Ergonomic guide to computer based workstations. [Online]. Available at: https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0013/19102/guide-ergo-comp-workstations.pdf MayoClinic (2021). Office ergonomics: Your how-to guide. [Online]. Available at: https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/office-ergonomics/art-20046169 Uploaded : 28 October 2022 Read More

INJURY BLOG: LUMBAR DISC PROLAPSE Did you know that 4 out of 5 people will suffer from lower back pain during their lives? It is a common reason that our patients come to the clinic for physiotherapy treatment. As physios, we want to help to manage your symptoms and improve your quality of life. Read on to find out what causes this condition and how physiotherapy could help. What is a lumbar disc prolapse? Between each vertebra of your spine are spongy, cushion-like discs known as intervertebral discs. These discs provide shock absorption when you run, walk, and jump. They also keep the spine stable, allowing the vertebrae to move. Intervertebral discs have a tough outer shell with a jelly-like centre. The outer shell keeps the jelly in place. Spinal discs withstand lots of pressure and load but sometimes they become damaged and irritated, and the contents push out. This is known as a disc bulge. In the case of a prolapsed disc, the soft centre pushes all the way through. The lumbar spine or lower spine is the area where a prolapsed disc is most likely to occur, making it a common cause of back pain. What are the symptoms of lumbar disc prolapse? The common symptoms of a lumbar disc prolapse include: Inflammation and swelling caused by pressure on the spinal cord Pain that may be persistent, dull and aching, or sharp Numbness, pins and needles, or weakness in one or both legs Tightness that radiates down your glutes and thigh Discomfort that worsens during activity or movement, or when sitting in the same position for extended periods Decreased range of motion and/or stiffness Muscle spasms What causes a lumbar disc prolapse? This condition is commonly caused by natural wear and tear: the amount of water in the discs decreases as we age, and they become less flexible. It is sometimes caused by a traumatic event such as a fall or accident. There are also factors that increase your risk of a lower back injury: Repetitive manual labour and improper lifting techniques increase your risk. It’s important to lift with your legs instead of your back to protect your spine. Being overweight or obese puts more pressure on your spine and increases your risk of injury. A sedentary lifestyle and staying seated for long periods also increase your risk of developing a lower back injury. Can back pain be managed at home? If you’re experiencing mild to moderate muscle strain, you may be able to take some steps at home to manage your symptoms which include relative rest in the early stages, regular gentle movement to promote healing, drinking lots of water and staying off or at least reducing your alcohol intake and smoking habits. How can physiotherapy help? As physios, we are expertly trained to deal with lower back injuries and know when it is necessary to be referred on for further investigations. Most of the time, a disc prolapse can be handled in the clinic. We use a range of passive and active treatment techniques to restore your normal range of motion and function. Initially, we may use techniques such as deep tissue massage, hot and cold therapy, and hydrotherapy to help relieve pain and relax the muscles.As your body heals, we may progress to more active techniques including building core stability, teaching proper stretching techniques to increase flexibility, and muscle strengthening to help prevent future flare-ups. We will work with you at every stage of your recovery and provide advice on how to manage your injury at home. References: 1. OrthoInfo (2018). Herniated Disk in the Lower Back. [Onlinehttps://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/ (Accessed 19 August 2022). 2. Patient (2020). Prolapsed Disc. [Onlinehttps://patient.info/bones-joints-muscles/back-and-spine-pain/slipped-disc-prolapsed-disc. (Accessed 19 August 2022). 3. Spine Universe (2019). Physical therapy for herniated discs. [Onlinehttps://www.spineuniverse.com/conditions/herniated-disc/physical-therapy-herniated-discs (Accessed 19 August 2022).  Uploaded : 26 September 2022 Read More

PHYSIOTHERAPY FOR RIB PAIN   If you’ve injured your ribs while playing a sport like rugby or football before, you’ll know that it can be both uncomfortable and unpleasant! It’s important to seek proper care to reduce your risk of complications. Read on to find out how physiotherapy could help with your recovery. Anatomy of the rib cage The rib cage, or thoracic cage, is made up of 12 thoracic vertebrae, 12 pairs of ribs (lightweight, curved bones), intercostal muscles, cartilage, and the sternum. The thoracic cage provides stability and support for the upper body, protects vital organs including the lungs and heart, and aids breathing. It also acts as an attachment point for muscles in the upper body. What are the common symptoms of rib pain? Symptoms of rib injuries range from mild discomfort that resolves in several days to severe pain that takes weeks or months to heal. Common symptoms include: a sharp or dull pain in the chest that worsens when breathing in, sore and tender ribs that may be accompanied by bruising, and a popping or cracking sound if a fracture occurs. It’s important to seek emergency medical treatment if you experience severe pain or pressure in the chest and breathing difficulties, as this could indicate a medical emergency, such as a heart attack. What are the common causes? The most common causes of rib pain include: Bruised or strained intercostal muscles Broken or fractured ribs Sports injuries Trauma from motor vehicle accidents or falls Severe coughing during illness Stiffness in spine overloading the thoracic cage Rib subluxation or slipped rib syndrome Osteoporosis (increasing chances of fracture) Inflamed rib cartilage, known as costochondritis (inflammation of the cartilage connecting the rib to the sternum). Can rib pain be managed at home? If you’re experiencing a mild to moderate muscle strain, you may be able to take some steps at home to manage your symptoms. Breathe normally and deeply to clear your lungs and avoid chest infections Use over-the-counter medication to manage the pain, as advised by your Doctor Avoid sports or exercises that aggravate the pain Use ice therapy to reduce any swelling Holding a pillow to your chest for support if you need to cough or sneeze Try to remain upright as much as possible, and prop yourself up to sleep Avoid straining or lifting heavy objects How can physiotherapy help? Physiotherapy aims to restore your normal range of motion and function. It could be an important part of your recovery from a rib injury. Treatment may involve breathing exercises and chest stretches performed slowly and gradually. If you’ve suffered a fracture or cracked rib, make sure you get medical clearance from your GP before commencing exercise. As physios, we work with you to understand the cause of your symptoms and come up with an appropriate plan for treatment. We can show you the proper technique for stretches and exercises to ease your discomfort and promote recovery. We can also provide advice on how to manage your injury at home. see : Thoracic Rings section elsewhere on this site Deep breathing for broken ribs Deep breathing is essential to prevent chest infections or pneumonia. A gentle breathing exercise you can start with is to sit upright in a chair or a bed. Hold a pillow over your chest for support then breathe slowly and deeply until your lungs are full. Try to hold your breath for up to ten seconds, then slowly exhale. Repeat five times, several times a day. References: Physio-pedia (2020). Ribs. [Onlinehttps://www.physio-pedia.com/Ribs (Accessed 20 July 2022).Healthline. (2019). What causes rib pain and how to treat it. [Onlinehttps://www.healthline.com/health/rib-cage-pain (Accessed 20 July 2022).NHS (2021). Broken or bruised ribs. [Onlinehttps://www.nhs.uk/conditions/broken-or-bruised-ribs/ (Accessed 20 July 2022).WebMD (2020). Best exercises for broken ribs recovery. [Onlinehttps://www.webmd.com/a-to-z-guides/best-exercises-broken-ribs-recovery (Accessed 20 July 2022). Uploaded : 26 September 2022 Read More

INJURY BLOG: SHOULDER DISLOCATION There is no doubt that dislocating a joint is a painful experience. Whether from a nasty fall, a car accident, or during a game of rugby, the shoulder is easy to dislocate, as it is a very mobile joint. Recovery can take months and after you have done it once, you are more susceptible to it happening again. In this blog, we look at common causes of a dislocated shoulder, and how physiotherapy may help with your recovery. Anatomy of the joint The shoulder is a complex joint that allows for a wide range of motion. It is a ball and socket joint formed where the humerus fits into the shoulder blade/scapula. Think about all the ways that you can move your arms: up, down, side to side, making circles every which way. The complex shoulder joint makes all of this possible. What is a dislocated shoulder? A dislocated shoulder is when the head of the humerus bone pops out of the shoulder socket (ouch!). It can either be partially or completely dislocated depending on whether the bone is all the way out of the socket (double ouch!). What causes a dislocated shoulder? Dislocation is generally caused by a sudden blow to your shoulder. It’s a common sports injury, particular in contact sports such as rugby. Car accidents and falls are also common causes. Hypermobility People suffering with joint hypermobility syndrome (JHS) or Ehlers Danlos Syndrome (EDS) can often spontaneously dislocate their shoulders  https://youtu.be/4rj-4TWogFU  Symptoms It will usually be fairly obvious if you have dislocated your shoulder because you will not be able to move your arm without being in a lot of pain, and your shoulder will look square instead of round. You may also experience swelling, numbness, weakness and bruising. If you suspect a dislocation, you should seek immediate medical treatment from your doctor or a hospital where you will likely be examined and sent for an X-ray to confirm the dislocation. It is important to have a doctor treat you and put your shoulder back in place to ensure that you don’t damage tissues, nerves and blood vessels. Can physiotherapy help recovery? So, you’ve sought medical treatment and had your shoulder examined and put back into place by a doctor, now what? Once the pain and swelling subsides and the doctor has given the all-clear, rehabilitation can commence. Physical therapy is an important part of recovering from your injury. It will help to restore the normal range of motion in your joint, stabilise and strengthen the surrounding muscles, and prevent the injury from reoccurring. We work with you to come up with an appropriate treatment plan to help you regain strength and restore movement as quickly and safely as possible. In the initial stages, you may feel aches and discomfort as you recover. We can recommend stretches and exercises to ease your discomfort and promote recovery. We can also provide advice on how to manage your injury at home. Preventing the injury from reoccurring As your condition improves, we will change up the program to focus on strengthening and stabilising the joint and surrounding muscles. This is an important part of rehabilitation and recovery and will help to reduce your risk of dislocation in the future. Some additional steps you can take to prevent the injury from reoccurring include:● Wearing padding and protective gear during sports● Taking care to avoid falls● Keeping up exercise to maintain strength and flexibility● Avoiding awkward arm positions References1. NHS. (2020). Dislocated shoulder. [Onlinehttps://www.nhs.uk/conditions/dislocated-shoulder/ (Accessed 24 June 2022). 2. Mayo Clinic (2020). Dislocated shoulder. [Onlinehttps://www.mayoclinic.org/diseases-conditions/dislocated-shoulder/symptoms-causes/syc-20371715 (Accessed 24 June 2022). 3. OrthoInfo (2017). Dislocated shoulder. [Onlinehttps://orthoinfo.aaos.org/en/diseases--conditions/dislocated-shoulder/ (Accessed 24 June 2022). Uploaded : 23 July 2022 Read More

INJURY BLOG: THORACIC OUTLET SYNDROME Have you experienced numbness or weakness in the arm and hands that seem to run from your upper chest all the way down your arm? If you also have trouble lifting objects over your head, thoracic outlet syndrome could be to blame! Today’s blog explains thoracic outlet syndrome, the signs and symptoms, and how it is treated. Before we dive in, let’s talk about what the thoracic outlet is. The thoracic outlet The thoracic outlet is the space between the collarbone and ribs in the lower neck and upper chest area. It’s a narrow space that houses nerves, muscles and blood vessels that pass through from your back to your arms. What is thoracic outlet syndrome and what are the symptoms? Thoracic outlet syndrome is the term used when the thoracic outlet is compressed, irritated or injured. Sometimes the thoracic outlet becomes too narrow and can compress the muscles, nerves, and blood vessels (ouch!). It most commonly affects the nerves but can also affect the veins and arteries. What are the symptoms of thoracic outlet syndrome? The symptoms of thoracic outlet syndrome can include: Pain in the shoulders, neck, arm, or hand. Numbness, pins and needles, or weakness in the hand and arm. Swelling, redness of the hand, arm, or fingers. Arm becomes easily fatigued. Limited range of motion in your arm and shoulder. What causes thoracic outlet syndrome? Common causes of thoracic outlet syndrome include: Physical trauma such as a car accident causing whiplash. Repetitive movements from sports such as baseball, swimming, golfing or volleyball. Manual labour - carrying heavy shoulder loads. Weightlifting. Pregnancy Structural abnormalities (e.g. an extra rib, called a cervical rib). The condition can be aggravated by poor posture, obesity, stress, depression, and sleep disorders. Can physiotherapy help to treat thoracic outlet syndrome? Yes. Physical therapy is a common treatment for thoracic outlet syndrome. As physiotherapists, we will conduct an assessment, talk to you about your symptoms and medical history, and come up with an appropriate treatment plan to help to reduce your symptoms and pain. Initial treatment will focus on: Reducing pain. Increasing the range of motion in the neck and shoulders. Strengthening the muscles around the shoulder to better support the whole area. Exercises to improve your posture to lessen the pressure on the area. Physical therapy can assist with recovery, restoring function and strengthening to get you back to your best. Preventing thoracic outlet syndrome It’s not always possible to avoid thoracic outlet syndrome, however there are steps you can take to reduce the risk of recurrence: Practice good posture when sitting or standing to create space in the thoracic outlet. Try to maintain a healthy weight. Avoid heavy backpacks and shoulder bags. Avoid heavy lifting or activities that make symptoms worse. Stretch and strengthen! We can help you with exercises and to master the correct technique. If you are experiencing the symptoms of thoracic outlet syndrome and need help to manage them, come and see us. We will investigate and come up with an appropriate treatment plan to help improve your quality of life. Give us a call or email us or book online to make an appointment. References: 1. Burke, D. (2021). Thoracic Outlet Syndromes. [Onlinehttps://www.healthline.com/health/thoracic-outlet-syndrome (Accessed 23 April 2022). 2. Cleveland Clinic. (2022). Thoracic Outlet Syndrome. [Onlinehttps://my.clevelandclinic.org/health/diseases/17553-thoracic-outlet-syndrome-tos (Accessed 23 April 2022). 3. Mayo Clinic (2022). Thoracic Outlet Syndrome. [Onlinehttps://www.mayoclinic.org/diseases-conditions/thoracic-outlet-syndrome/symptoms-causes/syc-20353988 (Accessed 23 April 2022). 4. OrthoInfo (2022). Thoracic Outlet Syndrome. [Onlinehttps://orthoinfo.aaos.org/en/diseases--conditions/thoracic-outlet-syndrome (Accessed 23 April 2022).  Uploaded : 26 May 2022 Read More

Exercises for hamstrings injuries in sport Hamstrings injuries can take many forms. Acute sporting injuries, in younger individuals, are frequently to the bulk of the muscle belly, whereas more chronic injuries, in older individuals, tend to involve the tendon insertions on the sitting bone. Depending on the type of sport, dynamic sports such as running and kicking tend to involved the contractile apparatus of the muscle, whereas less dynamic sports such as cycling or rock climbing, tend to involving the sitting bones and tendon insertion. Severe traumatic injuries, such as those from water skiing may also involve insertional fractures. Additionally, some sciatic nerve dysfunction from the low back or piriformis can mask as a hamstring injury. Finally, haematomas from a hamstring injury can form around the peripheral sciatic nerve, resulting in sciatic nerve like symptoms. The Hamstrings are made up of four muscles. The Biceps Femoris (outside two muscles), Semitendinosus and Semimembranosus. The biceps can be considered the power mobilisers for bending and extending the knee, whereas the inside two muscles have a greater role in stabilisation, especially of the knee's medial joint complex. The role of musculoskeletal physiotherapy is to make a differential diagnosis. Hereby, ascertaining the appropriate course of treatment and rehabilitation. More can be read elsewhere on the site : Differential Diagnosis of Hamstring Injuries. Exercise regimes should be functional and appropriate to the stage of injury and will often include back-hip and knee exercises as well as the eccentric hamstring programmes promoted by therapists dealing with the latter stages of an injury. Chronic Tendon - sitting bone insertion injuries, should be encouraged to do a lot of gluteal work, to take some of the load off the hamstring as well as enhance the nutrition to the tendon. PRP - involving injections of platelet rich plasma might also be considered and was found to be effective in combination with haematoma aspiration in athletes (Trunz LM et al 2022, Med Sc Sp Ex, 54,1, 12-17). These authors found a significantly shorter return to play and shorter recurrence rate compared with athletes receiving conservative treatment. However, an active recovery program should be an essential part of rehabilitation, as it prepares a framework for the process of recovery, as well as establishes baselines and goals, specific to the stage of injury, which provide a benchmark, as to the rate and extent of recovery, which ultimately determines their return to sport competency. Invasive procedures should be undertaken with care and sometimes it's better 'not to poke the bear'.  Uploaded : 28 April 2022 Read More

The low-down on kinesiology tape Have you ever wondered why your physiotherapist is making you all colourful with stretchy tape during your appointment? Read on for some answers! What is kinesiology tape? As physiotherapists, we use a range of treatment methods to help increase your mobility as you recover from an injury, including therapeutic taping. Kinesiology tape (or kinesio tape) is an elastic, therapeutic tape that we use to provide your joint with support, without limiting movement. Originally developed in Japan as long ago as the 1980's, it only became popular in the West in the late 1990's. Why is kinesio tape used? We generally use kinesio tape to help reduce pressure on damaged muscles and joints, increase mobility, lessen pain, and reduce swelling. We also use it to reduce the chances of further damage to an area that is weak from injury. If you are prone to injury in a certain area, taping may also give you some protection. How does it work? During an appointment, we will assess your condition and determine if kinesio tape is necessary, and then work out the best way to apply it. We apply it in a pattern that will help to support your specific injury. Kinesio tape is stretchy and flexible. It’s designed to be elastic like your skin, so that you can move freely when it is applied. When applied, it lifts the layers of skin and tissue, encouraging blood flow. It has roughly 35% elasticity, whereas semi-rigid sports strapping tape is only around 6%.  There is also some research to suggest that using kinesio tape changes the signals between your brain and the skin over an injured area. The tape helps to strengthen the signals, increasing connectivity between the area and the brain. Skin sensitivity Kinesiotape seems to be better tolerated, by most skin, than the traditional sport stape. However, people have been known to have allergic reactions, to even this mild adhesive. What about the colour of tape, does that matter? No! We think the different colours look cool though, the brighter the better! However, some people suggest the darker colours absorb more heat and maybe better for areas which are feeling cold Other forms of taping Other forms of taping can be read elsewhere on this site : What we do : Taping  and under Patellofemoral Taping or Tape Tape Tape Uploaded : 27 April 2022 Read More

INJURY BLOG: LATERAL ANKLE SPRAIN Are you an avid netball or basketball player? There’s a good chance you have had a lateral ankle sprain (or anterior talo-fibular ligament (ATFL) sprain) at some point! The classic ‘rolled ankle’ is one of the most common sports injuries. However, this common injury doesn’t just occur on the sporting field. It can be caused by stepping awkwardly on an uneven surface, or even wearing high heels. Any action that throws off your balance and shifts your centre of gravity, could result in a painful sprain. What is a lateral ankle sprain and what causes it? The ankle joint is made up of three bones: the talus (ankle bone), the tibia (shin bone), and the fibula (the smaller leg bone). A series of ligaments running in different directions connect the bones and provide stability and support to the joint. There are three lateral (outer) ligaments that help to stabilise the ankle joint, preventing it from moving too much. The anterior talo-fibular ligament, or ATFL is one of them. It is a short ligament that attaches the fibula to the talus. The ATFL is the weakest outer ligament and the most injured. Sports and activities that involve running, jumping, and sudden changes in direction put pressure on the ankle and may cause it to abruptly roll outwards. When this results in overstretching and tearing of the outside ligaments, it is known as a lateral ankle sprain. What are the symptoms of a lateral ankle sprain? If you’ve sprained your ankle you may experience the following symptoms: swelling (immediately or over a few hours); localised tenderness or bruising around the joint; pain when trying to walk, or when you put weight on it. Lateral ankle sprains are graded depending on severity: Grade 1 is a smaller ATFL tear with minimal swelling and the ability to walk with little to no pain. Grade 2 is a larger ATFL tear with bruising, swelling over the outer ankle, inability to walk or bear weight without pain. Grade 3 tear is the most serious with a complete rupture of the ATFL, minimal or no ability to walk without severe pain; swelling and tenderness surrounding the whole ankle.  What can you do about an ankle sprain? RICER protocol is suggested for treatment of a sprained ankle: Rest or reduce activity. Ice therapy (on for 20 minutes every two hours for the first 24 hours). Compress the injured ankle using tape or a bandage wrapped firmly around the joint. Elevate the ankle (above the heart if possible). Refer - if you are unable to walk on the ankle, you should seek medical attention to determine if medical imaging is required. You should also avoid HARM - Heat, Alcohol, Running/exercise and Massage, in the first 48 hours to keep any swelling to a minimum. You should also call your physiotherapist at your earliest convenience. How can a physiotherapist help with a sprained ankle? Physiotherapy can help with rehabilitation as you recover from an ankle sprain. Your physio will work with you to develop an exercise program focused on improving the mobility of the joint and regain movement. Evidence shows that commencing rehabilitation exercises within a week of a sprain speeds up recovery. Your physiotherapist can also help you to strengthen the surrounding muscles to aid your recovery. This is particularly important to prevent the injury from reoccurring. Stabilising the ankle using tape or a brace will allow the ATFL to rest and heal. Your physio can recommend a support or brace as appropriate and teach you the correct technique to ensure the best recovery. Further concepts on stability can be read here : https://www.back-in-business-physiotherapy.com/stability.html When you return to your favourite sport activity, you may need to brace or tape the ankle for extra support. Your physiotherapist will provide advice on whether this is necessary. You should also ensure that you warm up and wear supportive shoes when you get back out there! Lumbopelvic dynamics - core and hip - knee stability on ankle imbalance The entire kinetic chain needs to be addressed when dealing with lateral ankle sprains. In chronic ankle instability, weakness of the gluteal muscles has been found by researchers and clinicians. A challenging high repetition functional exercise program, not only mitigates these deficiencies, it also becomes a tool to assess recovery and eventually integrated into the functional assessment of the sport specific activity. Weber fracture Importantly, with an ankle sprain, differentiation with a Weber fracture, is required. These types of fractures and tears of the syndesmosis require some form of immobilisation, such as a moon boot, for up to 6 weeks, and sometimes longer.. LisFranc's fracture Named after a Napoleonic surgeon who noted a very specific injury when cannons rolled back over artillery soldiers feet, a small ligament on the inside of the foot can become detached, leading to a very unstable mid foot, frequently, but not exclusively, seen as a dropped arch. Imaging should be undertaken to confirm diagnosis. Achilles tendon and lateral ankle instability Achilles tendonosis can arise from altered biomechanical patterns of movement such as ankle inversion or foot over pronation as a result of lateral ankle instability. Addressing the entire lower limb chain, including hip strength and symmetrical calf pull can improve the functional stability in the ankle and thus reduce the strain in the Achilles. Read more : https://www.back-in-business-physiotherapy.com/we-treat/achilles-tendonosis.html References: 1. Better Health Channel. (2014). Ankle sprains. [Onlinehttps://www.betterhealth.vic.gov.au/health/conditionsandtreatments/ankle-sprains (Accessed 19 February 2022).2. Physiopedia. (2022). Anterior Talo-Fibular Ligament (ATFL). [Onlinehttps://www.physio-pedia.com/Anterior_Talo-Fibular_Ligament_(ATFL) (Accessed 20 February 2022). Uploaded : 24 March 2022 Updated : 7 April 2022 Read More

Exercise blog: Stable shoulder workout Whether you are a swimmer, tennis player, builder or simply do the laundry - having a stable shoulder is super important in preventing injury! With repetitive overhead actions, the shoulder can fall victim to overuse, resulting in poor movement, pain and loss of range of motion. Here are some simple exercises you can incorporate into your exercise routine to keep your shoulders in tip-top shape! Scap push-ups Scap (or scapular) push-ups use a small range of motion to improve shoulder stability, by strengthening the serratus anterior muscle (located on the sides of the rib cage). They may seem like nothing fancy, but trust us they are worth your time! ● Start with your hands on the floor. Push back into a plank position (with knees lifted or lowered depending on your strength).● Whilst keeping your arms straight, retract or draw your shoulder blades together. After a pause, protract or draw your shoulder blades away from each other, your shoulders and upper back should look slightly rounded.● Continue to retract and protract for 3 sets of 10 reps. Remember to engage your core, tuck your chin and don’t let your hips drop throughout the entire set! Banded row A banded row uses a theraband (or resistance band) to work the upper back muscles, helping support good posture and lessen the strain on your shoulders. Choose a level of band and give this one a go! ● Secure the band to a tree, pole or any secure anchor point.● Hold each end and take a few steps back so the band is taut and your arms are straight.● Pull your elbows back so they graze your ribs. Squeeze your upper back and pause for 3 seconds (remember to keep your shoulders down and relaxed!).● Slowly return your arms to the starting position (parallel to the floor).● Repeat for 3 sets of 10 reps. Wall circles We love wall circles as they not only strengthen the serratus anterior but also target the deep muscles in your rotator cuff. All you need is a wall (duh!), basketball or light medicine ball and a little bit of coordination! ● Place the ball at shoulder height, with one hand firmly placed at the centre. ● Place your other hand down by your side and keep your shoulders down and relaxed.● Start to make small clockwise circles for 10 counts, then change to anticlockwise circles for 10. ● Once you have got the hang of that, try to advance to figures of eight for 10.● Repeat on the other arm.● Repeat for 2 sets. Are you looking for some extra shoulder support? Want some more guidance on your exercise regime? Give us a call on 02 9922 6806 or book your appointment online https://www.back-in-business-physiotherapy.com/book-now! Further Reading https://www.back-in-business-physiotherapy.com/shoulder.html Uploaded : 25 February 2022 Updtaed : 7 April 2022 References 1. McPhillips, K. (2021). If Your Shoulder Mobility Is the Pits, Meet the ‘Scapular Push up’. [Onlinehttps://www.wellandgood.com/shoulder-mobility/ (Accessed 29 Jan 2022)2. MasterClass staff. (2021). Scapular Push-Up Guide: How to Master Scapular Push Ups. [Onlinehttps://www.masterclass.com/articles/scapular-push-ups-guide#3-benefits-of-doing-scapular-pushups (Accessed 29 Jan 2022)3. Cronkleton, E. (2022). 6 Resistance Band Exercises for Shoulders. [Onlinehttps://www.healthline.com/health/shoulder-band-exercise (Accessed 29 Jan 2022).4. Dale, P. (n.d.). Exercises to Strengthen the Stabilizers in the Shoulder. [Onlinehttps://www.livestrong.com/article/334944-stabilizing-strengthening-shoulder-scapula-exercises/ (Accessed 29 Jan 2022) Read More

Important vascular issues include those of the vertebral artery in the cervical spine. A commonly held belief is that these incidence (-catastrophic or otherwise) are rare with a prevelance of 1 : 100 000. However, the true number may be much greater, as many catastrophic incidents are under - reported due to medico-legal reasons. In my clinical experience, by 2008 I had seen approximately 12 clients with VBI and a further 8 who had petit mal seizures or vaso-vagal syncope with mobilisations to the first rib. The majority of the clients with the 'classic' symptoms of VBI had either a prior incidence from manipulation of the C/S or had a major accident involving the neck - car accidents prior to seat belts, and horse riding incidents were frequently reported. Even a train crash was reported. By 2008 I estimated that I had seen approximately 60 000 clients. Hence, my 20 : 60 000 ratio suggest a 1 in 3000 chance of coming across a client with VBI. A form of pins & needles in the feet during cycling may be due to claudication. Such claudication may be the result of damage to vessels of the abdominal aortic. Additionally the branches of the abdominal aorta descending into the leg as well as the leg vasculature may be damaged by trauma and/or systemic complications (e.g. Marfan's syndrome, vascular diseases, etc). These problems may be a medical emergency whereby immediate consultation with a vascular surgeon is imperative. Virchow's Triad in the aetiology of thrombosis may also be of assistence with differential diagnosis. The 3 variables include Changes in vessel wall (endothelial damage) Changes in blood flow (flow volume/stasis) Changes in blood constituents (state of coagulability) The latter may include screening questions for blood disordes (thrombolytic ones, C-reactive protein , Leiden Factor V, as well as Thalasaemia and Sickle Cell Anaemia), systemic inflammatory conditions (such as Lupus and Scleroderma), the use of oral contraceptives, smoking, diet and frequent flying. Taylor & Kerry (2005) quote a paper from Sise et al (1989) reporting an average 2 year delay in diagnosis in young people where 93% could have been diagnosed with simple palpation of peripheral pulses. from Gray's Antaomy Vascular complications are potentailly overlooked causes of symptoms. This in part may be due to their relative infrequency compared with other conditions seen by physiotherapists. Futhermore, the symptoms of vascular compromise may mimic those of symptoms arising from musculoskeletal structures. Compromise of a blood vessel to the spinal nerve results in radicular pain. A colleague reported the incidental finding of a family friend's teenage boy whose mother was about to take him to the chiropractor for low back pain. What he noted was the boy had 3 socks on his left foot!!! Immediate examination of the lack of pedal pulses and referal to the A+E department confirmed a diagnosis of spinal artery thrombosis. Unfortunately, most peoples friends aren't astute clinicians that recognise "something which doesn't make sense". Arterial kinking of the external iliac artery during hip flexion whilst cycling (and rowing, skatting and Fjell running) have been known to produce pain affecting the buttock, anterolateral thigh, calf and foot with feelings of paraesthesia and numbness in the toes. Cyclists may also describe the feeling of 'fullness' in the leg and lack of power, cramping and/or ischeamic like fatigue. Although anterior/posterior and lateral compartment syndromes are commonly associated with vascular complications in running, similar type (not necessarily area) of symptoms associated with iliac artery, femoral artery and popliteal artery can be missed during the clinical reasoning process. Generally, symptoms are associated with exertion and external compromise of the blood vessel. Apart from the iliac artery already mentioned other examples include the femoral artery in the adductor canal (b/n the adductor magnus and vastus medialis), and the politeal artery interfacing with the medial head of gastrocnemius. Generally, these conditions are associated with anatomical anomalies whereby the external pressure from repetitive movement gradually damages the external lining of the blood vessel. Besides repetitive microtrauma, any external trauma from an accident needs to consider possible vascular damage or the formation of scar tissue and adhesions which could lead to vascular damage. Other clinical examples, include aortic aneurysm which may be due to valsava type maneuvers. Familial history may also be important in differential diagnosis. Additionally, a history of heavy smoking can lead to internal blood vessel pathology. Similarly, women who take the pill may also be at risk. Aortic stenosis may manifest as a result of arterosclerosis or due to underlying congenital defects. These are screening questions which need to be asked during the subjective examination. During the physical examination, the femoral and pedal pulses should be examined at rest but usually need to be assessed immediately after exercise or in the compromising posture where symptoms normally manifest. Further testing should include ankle blood pressure monitoring of each side. Taylor & Kerry (2005) recommend 20 minutes of rest before testing systolic blood pressure in the left and right brachial artery, posterior tibial and dorsalis pedis and then using the "Ankle to brachial pressure index = Ankle systolic BP / Brachial systolic BP". 1 - 1.2 considered normal, 0.75 - 0.9 indicates moderate disease, 0.5 - 0.75 severe disease and <0.5 is limb threatening. (see: Taylor AJ, Kerry R (2005) Vascular syndromes presenting as pain of spinal origin. Ch 36 in Grieve's Modern Manual Therapy: The Vertebral Column. Ed Boyling JD & Jull GA Elsevier Churchill Livingstone). The Upper Limb and vascular compromise from Grays Anatomy The posture of the cyclist (and rower) may also make these athletes particularly prone to upper limb and head/neck vascular conditions. Additionally, one of the most common cycling injuries involves landing on the shoulder or outstretched hand resulting in possible neurovascular traction injury, direct trauma and/or clavicular fracture. The latter has been associated with trapezius muscle dysfunction which can be a precipitating variable leading to Thoracic Outlet Syndrome (TOS). Symptoms of TOS can include typical symptoms of neck, shoulder, elbow and hand pain. Occasionally, people describe a sense of swelling (or fullness) in the arm, with/without concommitant pins & needles or numbness. Vascular components of TOS may be less prevelant than neurological ones. Yet this may be due to mis-diagnosis as the plethora of tests (Adson's, Allen's Halstead's manoeuver, Roos's EAST test) may be falsely positive or negative and variable b/n examiners. Hence, the examination must use the multitude of variables at the clinicians disposal, both Subjective symptoms & Physical signs - inductive and deductive reasoning, to make sense of the clincal picture. When in doubt and further investigations are required, by using the weight of probability from many variables, it may also make the argument for further testing more convincing to a medical colleague. Paget - Schroetter syndrome is a deep venous thrombosis of the subclavian - axillary venous system, also known as "effort thrombosis" (Rutherford 1998, Zell et al 2001) and may account for about 3-7% of all DVT's (Taylor & Kerry 2005). The average patient is in their late 20's to early 30's and males present 3 times more commonly than females. Most commonly complain of quick insidious arm pain (70% in dominant arm), with possible supraclavicular fossa and ipsilateral neck pain. Most commonly occurs in activity with repetitve upper arm, over shoulder height, movements. The usual aetiology is Virchow's Triad which means that specific screening questioning is required. Additionally, other risk factors may include thoracic outlet factors such as cervical rib, anomalous first rib, hypertrophy of the anterior scalene, subclavius or pectoralis minor as well as endogenous factors such as activated protein C resistance and anticardiolipin antibodies (Ellis 2000 in Taylor & Kerry 2005). Taylor & Kerry suggest that observable signs of vascular compromise may include skin pallor or cyanosis - both resting and positional, swelling, and/or superficial venous dilation. Corneal arcus or xanthelasmas (yellowish raises skin changes) around both eyes may be associated with hyperlipidaemia and hypercholesterolaemia. Staining of fingers may be a more accurate indicator of tobacco consumption. Obesity and state of mental awareness may also reflect underlying cerebrovascular state. Hand and digital examination should also include nail squeezing - indicative of capillary refilling time. These should be perfomed in various positions of potential vascular compromise. Nail abnormalities may be present. Pulses should be tested, stethescope auscultation should be undertaken and the pressure cuff sphygmomanometer and hand held doppler or automatic blood pressure monitor used (Taylor & Kerry 2005). Taylor & Kerry (2005) argue quite strongly that vascular examination is such a miniscule part of both under-graduate and post-graduate degrees that we may be implicated in delayed diagnosis and initiating innapropriate treatment. Clinical example : Facial Numbness Blood Disorders Thalassemia (British English: thalassaemia) are forms of inherited autosomal recessive blood disorders that originated in the Mediterranean region. In thalassemia, the disease is caused by the weakening and destruction of red blood cells. Thalassemia is caused by variant or missing genes that affect how the body makes hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen. People with thalassemia make less hemoglobin and fewer circulating red blood cells than normal, which results in mild or severe anemia. Thalassemia can cause significant complications, including pneumonia, iron overload, bone deformities and cardiovascular illness. However this same inherited disease of red blood cells may confer a degree of protection against malaria, which is or was prevalent in the regions where the trait is common. This selective survival advantage on carriers (known as heterozygous advantage) may be responsible for perpetuating the mutation in populations. In that respect, the various thalassemias resemble another genetic disorder affecting hemoglobin, sickle-cell disease. Factor V Leiden, also known as Leiden Factor 5 (and sometimes factor VLeiden) is the name given to a variant of human factor V that causes a hypercoagulability disorder. In this disorder, the Leiden variant of factor V cannot be inactivated by activated protein C. Factor V Leiden is the most common hereditary hypercoagulability disorder amongst Eurasians  Uploaded : 17 November 2017  Read More

What is Patellofemoral Pain Syndrome? PFPS is an umbrella term for pain in and around the patella (kneecap). It is sometimes called “runner’s knee” or “jumper’s knee” because it is common in people who run or play sports, but it can affect anyone. PFPS is most commonly caused by vigorous overuse of the knee, and jogging, squatting, even climbing stairs can be culprits. Suddenly changing or increasing the amount of physical activity you do can also put excess stress on the knee, leading to PFPS, as can using inappropriate equipment or footwear. PFPS can also be caused by incorrect alignment of the patella. If you’re experiencing PFPS, you’re likely to have pain in your knee that gets worse when you sit, climb stairs, run or squat. The pain can be felt anywhere around the knee. What can you do about PFPS? If you’re experiencing pain in your knee that you think could be PFPS, stop doing the activities that are causing you pain until you feel better. This might mean switching to low impact exercise for a while. Use the POLICE method: Protect – avoid making the painful knee worse by stopping the activity you are doingOptimal Loading – keep moving the joint as pain allows (don’t become a couch potato!)Ice – use cold packs for 20 minutes, two to three times per dayCompression – a knee bandage can help prevent swelling (your physio can advise on the best one)Elevate – whenever you can, rest with your knee supported in a position higher than your heart See your physiotherapist to check the severity and type of the injury and see what needs to be done to help you recover. How can a physiotherapist help with Patellofemoral Pain Syndrome? Your physio will examine you to determine exactly what is causing the pain and where the specific problem lies. As there are a number of tendons and muscles in this area that could be affected, you need to know exactly what the problem is before it can be addressed. Depending on the nature of your problem, there are a range of exercises that your physio might suggest to help strengthen and stabilise the area, as well as helping you regain movement. Manual therapy and massage may also help reduce pain and recover motion. Your physio will be able to advise as to whether you need any bandages, taping or support equipment, and which ones are right for you. They will also advise on whether you’re wearing the right shoes, using the right equipment and following the best training regime to reduce the likelihood of the problem coming back. Frequently, the muscle synergy around the knee becomes altered. The cortical representation of the muscle attaching to the inside of the knee cap (vastus medialis) is frequently diminished and relocated to another aspect of the cortex, making normal muscle contractions very difficult. Retraining the brain becomes important, to enhance the vastus medialis activity. see below for further explanation on Cortical Resource Mapping and Game Theory Exercises which are designed to 'unload' the knee joint become important. These include synergistic loading of the upper 2/3 of the hamstrings/quadriceps as well as gluteal activation. Furthermore, calf strength is of paramount importance, as the calf absorb up to 70% of the load when landing on the ball of the foot. Frequently, continuous hopping and skipping are the last functional dynamic exercise outcomes used to determine full return to sporting activity. reverse lunges sideways lunges Swedish squat quads hover hip hitches core stability and gluteal one legged bridges hopping and skipping Leaning forward, through the rotation in the hip, with a straight back, should take the pressure out of the knee, whilst doing sideways and reverse lunges, as well as the quads hover. Importantly, with the quads hover, the movement of the knee is forwards and backwards, NOT up and down. Perfecting reverse lunges, is the precursor to other lunging activity. Progression, should be reverse lunge, diagonal reverse lunge, sideways lunge. Initially using a slider on the floor and ultimately progressing to a small step. What can you do to prevent PFPS? If you think you might be at risk from Patellofemoral Pain Syndrome, the best things you can do to reduce your chances of injury are: Introduce a new training regime or a change in activity slowly – get physiotherapist advice on putting your activity plan in place Get expert guidance to make sure your footwear is appropriate and supportive, and that you’re using any equipment correctly Maintain a healthy weight to avoid putting excess strain on your knees Warm up thoroughly before exercising Stretch your quads and hamstrings before and after exercise Don’t push yourself – if you’re exercising and your knee (or anything else for that matter) begins to hurt, stop, and get on the phone to us!  Muscle coordination within and between limbs Researchers have demonstrated the importance of intra-limb coordination for the development of peak sequential power from knee to hip to ankle, and the reliance on multiple muscles to produce torque.  At back in Business Physiotherapy, we use a very comprehensive approach to treating the spine and pelvis, whereby, even improvements in areas of the body not traditionally associated with leg dynamics, such as ribcage biomechanics, will improve power output in the legs. Treatment of pelvic asymmetries and low back conditions can frequently relieve recalcitrant chronic knee pain. These issues have been addressed elsewhere on this website. Game theory and the curious concept of immune - muscle synergies It is interesting to speculate that both the novice and elite orienteer are more susceptible to infection because they both have more rigid motor patterns, are less inclined to take risk and therefore are less likely to be confronted with error generating patterns of correctability? The assumption underlying game theory is that there is a resource over which there is a conflict.  A factor which the orienteering paradigm partially defines, and identifies, is the freedom of thought and movement. That fact that many investigations are looking at exercise and the immune system, using captive animals, might be problematic in itself. These animals are in a predictable environment, which for this purpose is ethical, reductionist and conforms with rigorous scientific research protocols, which is practical, as it reduces the number of 'dependent' and 'independent' variables. However, from an evolutionary point of view, and from the perspective of the example used here, where in orienteering, more may be learnt and fine-tuned, in an unpredictable variable environment, whereby the use of caged animals may be limiting the validity of the paradigm (deterministic chaos) which is under investigation. Moreover, in terms of cognition, confinement is a stressor. Moreover, the calmness and clarity of thought needed in the freedom of orienteering (running and navigating) through the landscape can be considered the antithesis of the caged animal.  Our ancestors were striving for energy security through appeasement, subjugation or dominance over other life forms, both internally and externally. In this sense, the 'freedom to navigate and move' paradigm, suggests that our evolutionary forefathers, used their muscles, to propel themselves out of Africa, for 'greener gut biome pastures'. Therefore, maintaining good health in new and potentially 'dangerous environments', involved an unpredictable deterministic variable. As it pertains to cognition, it is an intriguing idea that a motor-sensory curiosity, drove a mechanism, which simultaneously caused muscle hypertrophy, and endowed the muscles with enhanced glutamine and cytokine concentrations, which were needed, if an immune response to pathogens was encountered. Additionally, it is conceivable, that the gut biome was driven by the laws of thermodynamics, in the search for energy. Subsequently, the gut-environment interface provided the interaction needed, to both provide energy for movement, allowed the immune system the encounters needed to flourish, and achieved the abundance of gut species required, in a variety of situations, from feast to famine. Therefore, the gut - muscle - brain cognitive pathway, was driven at a conscious and subconscious level to meet the demands of thermogenesis and immune competency, resulting in collective gain amongst all cells which required energy. Akin to Zen Buddhist philosophy, suggestions are, that the constant sensation of mild hunger, drives the clarity of thought needed, to strive for all encompassing meaning and ultimate enlightenment. Yoga, using animal poses, to stretch muscles and enhance breathing, whilst calming the cognitive state, may be based on the same primeval paradigm, of what is good for muscles is also good for the gut and brain.  The 'dove and hawk' paradigm in game theory is interesting. If a hawk and dove compete over the same resource, direct open conflict of the dove with the hawk would be suicidal. Hence, one would think it's better to be a hawk. However, what if two hawks meet, there will be only one winner and potentially both could be injured for the same net gain. Whereas, if two doves meet, they may postulate and gesticulate and eventually one may retreat or they may even share the resource, with the less risk of injury. Hence, the stakes for the Hawk are much higher. Humans have always been in conflict for resources. Does this mean that the immune system is tuned by adaptation to 'individual' resource dominance? Or, as people developed and evolved as tribes, into communities did our immune systems come to share pathogens, which may have entailed 'herd immunity' but at the same time, gave humans a lack of species variability, making them more vulnerable to 'novel' pathogens? Even more intriguing, is the notion that within a group of similar, the weakest may be driven out, seeking new resources, which in this case means new environments and new pathogens, invoking an 'immune enriching' response?   Continuing with the 'hawk dove' analogy, if we have too many hawks in a population, the consequences are constant conflict. If too many doves, constant compromise. In fact, a single dove in a hawk environment might be totally ignored, as might a single hawk in a dove environment. Thus, the apparent weaker species could be at an advantage when it's the outlier? To carry this further, we could postulate that the hawk is more prone to injury. Does this mean that in humans, the more dominant 'aggressive' individuals have an immune system which is more in demand for potential or actual injury? Whereas, the postulating dove, activates it's immune system minimally when it's performing some form of escape or deception? Interestingly, most animal conflict encounters, go out of their way to avoid injuries to themselves. Regardless, it's likely, that in both 'stressful' situations, the immune and musculoskeletal systems are activated, in a proportionately preparatory manner. Thus, the stronger the variability in the individual, the more proportional, and therefore robust their immune response. Needless-to-say, a balance between hawks and doves needs to be established for mutual gain to take effect. In terms of the human genome, it's very underwhelming, yet it has evolved to a complex multi-cellular life form, still totally dependent upon trillions of unicellular life forms within the individual gut biome. This flies in the face of Darwinian evolution and the survival of the fittest, in that simple life forms keep complex life forms alive. Even, within the gut biome, there appears to be a symbiotic relationship with parasites and a healthy immune system (i.e. parasitic exposure appears to reduce auto-immune disease such as allergies). A 'simple' multitude (gut biome) balanced with a 'complex' minority (human DNA). Humans eat to feed their gut, their gut breaks down energy from food, which in turns propels the human, with the energy gained, to find more food. A net win win situation using the gut-brain-muscle axis.  In terms of muscles, a simplistic view, (using this analogy) would be that the glycolytic (fast twitch) muscles are the 'hawks', whereas the oxidative (slow twitch) muscles are the 'doves'. The glycolytic muscle fibres tend to be ballistic two joint (mechanical) energy straps which propel the body, whereas the oxidative endurance (metabolic energy) muscles are one joint deep muscles tending to stabilise joints and prevent injury. Therefore, the 'hawks' make the large perturbations whereas the 'doves' dampen them. Luckily, there is a muscle glycolytic fibre type which can become more oxidative (endurance power). Hence, 'hawks' which can be tempered towards a 'dove' like mentality....a balance between metabolic and mechanical energy systems, where the mechanical perturbations stimulate the metabolic-immune response. In terms of neurophysiology, this analogy could potentially be taken further, where the sympathetic nervous system is the 'hawk' and the para sympathetic nervous system are the 'doves'. Fortunately, within the sympathetic nervous system there are self modulating ('dove' like) perturbating mechanisms. But it could be envisaged that putting a 'hawk' amongst the 'doves' wakes them up from a state of complacency. Similarly, 'staleness' is an 'existential threat' to any training regime and to any 'immune system'. Read more : Muscles, Deterministic Chaos and the Immune System Cortical 'resource' representation, mapping, in knee muscles, after injury In the context of physiotherapy, a simple model of game theory might be applied to the problem of anterior knee pain. Commonly, this problem is associated with pain at the front of the knee when it is in flexion (a bent position), such as stair climbing, cycling, squats, etc. The conventional wisdom is that the patella (knee cap) is mal-aligned due to a lack of medial (VMO) muscle activity pulling the patella inwards and too much activity of the lateral thigh muscle (VL) pulling it outwards. Game theory could be applied here as the muscles compete for finite cognitive territory to represent their individual (rather than mutual) function, where ultimately neither muscle gains, both loose out to pain generating cortical representations, reducing fidelity and increasing noise in the system. However, if the muscles were to readjust for a functional outcome, they would do so through gaining a synergy of proportionally shared resources (power sharing), hereby a dominance over pain and dysfunction is gained. Physiotherapists, use functional electrical muscle stimulation (FEMS) to give added 'resources' to the VMO, which then can be used during functional exercise training. As the system adjusts, the pain improves and the gain experienced by all the muscles convinces the VL to fire with the VMO, hamstrings and gluteals in a functional synergy for stairs, cycling (see previous), squats, etc. Hereby, game theory would suggest all have won and injury has been avoided. Investigations in Australia, by the Brazilian, Abrahao Baptista (2014), looking at 40-50 year old women with chronic knee pain, demonstrated the significant reduction in the volume of muscle representation in the cerebral cortices, as well as changes in the location of these muscle representations (see below). Moreover, in the context of neurons who 'fire together, wire together' it would be of utmost importance to find exercises that act as functional synergies and relate in a real or a 'virtual' manner to the environmental context in which they need to fire. This also becomes particularly important in psychological behavioural issues of 'fear avoidance' and disuse atrophy. Ideally rehabilitation stimulates 'wiring and firing together' of goal-oriented regions of the brain rather than those which are directed at fearing and avoiding movement. Therapist must instil confidence through their choices of treatment whereby they outline and hence monitor the expectations of outcome. In this picture, it is clear that, the volume of the quadriceps muscle representation in the cortex of people with anterior knee pain (PFP = patello femoral pain) is dramatically reduced. Not seen here, but demonstrated in other research, is the phenomenon of pain processing altering cortical activity in various brain areas (see below).  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036). Physiotherapists use FEMS (30HZ functional electromuscular stimulation) to enhance muscle cortical representation in the brain, which improves function and in turn improves pain. FEMS stimulation readjusted cortical mapping to that seen in asymptomatic individuals.  Alternatively, therapists use trans-cortical stimulation of the pre-frontal cortex to improve 'executive function' and pain.  Brain activation related to spatial discrimination of noxious stimuli is distinct from that related to perceived pain. These images are located at x = 0 mm, x = 30 mm, z = 5 mm, and y = –30 mm in standard stereotaxic space. IPL/SPL, Inferior parietal lobule/superior parietal lobule; GP/PT, globus pallidus/putamen; M1, primary motor cortex; DISCRIM., discrimination. (Oshiro et al 2007 J Neuroscience, 27, 13, 3388-3394) Abrahao Baptista (2020) and his colleagues are conducting research into trans-cortical stimulation and vagal (para-sympathetic) nerve stimulation in the treatment of patients with COVID-19. They are basing their assumptions and working hypothesis on some positive results a rheumatologist has had with this methodology for the treatment of auto-immune inflammatory disease. COVID-19 has many of the hallmarks of an auto-immune disease, including the cytokine storm. This treatise has argued that sympathetic, rather than para-sympathetic, stimulation is necessary to add a deterministic chaotic input which perturbs the immune system into action. It would be intriguing to speculate a large perturbation between sympathetic and para-sympathetic can also activate the immune response. In this case, the illness has already set the sympathetic nervous into a heightened chaotic state, which needs additional buffering (redundancy) from the vagal nerve stimulation.  References 1. Physiopedia. 2021. Patellofemoral Pain Syndrome [Onlinehttps://www.physio-pedia.com/Patellofemoral_Pain_Syndrome2. OrthoInfo. 2020. Patellofemoral Pain Syndrome [Onlinehttps://orthoinfo.aaos.org/en/diseases--conditions/patellofemoral-pain-syndrome/ Uploaded : 23 January 2022 Updated : 7 April 2022 Read More

 What causes hip osteoarthritis? Osteoarthritis is a result of a gradual degeneration of the cartilage that lines the ends of bones that join to form joints. There is no one specific cause. Almost any joint in the body can develop osteoarthritis, but load-bearing joints (such as the knees, hips and spine) are the most susceptible. One in ten people over the age of 65 will experience hip osteoarthritis, although it can develop from the age of 45 (it is highly unlikely, but not impossible, to develop earlier). If you have a family history of osteoarthritis, have had a hip injury or hip function problems in the past, are overweight or have a job that involves long periods of standing or heavy lifting, then you are at increased risk of osteoarthritis. What are the symptoms of hip osteoarthritis? Hip osteoarthritis thins the cartilage of the hip joint and makes the surfaces of the hip joint rougher. This can lead to pain and swelling in the area. People with hip osteoarthritis often experience at least some of the following: ● Progressively increasing pain in the hip● Pain felt with movement (although it may ease off with continued movement) and at rest● Pain that is aggravated by cold weather● Pain in the groin or thigh that radiates to the buttocks or knees● Stiffness of the hip or a “locking” sensation in the joint● Decreased range of motion or an affected walking pattern (i.e. limp) However, approximately 50% of patients with hip osteoarthritis do not have these symptoms, so any changes in your movement as you get older are worth getting checked out, just in case. How can hip osteoarthritis be treated? One of the most effective ways to treat osteoarthritis is with exercise. We can work with you to develop an exercise program that will strengthen the muscles around your hip, stabilise and protect the joint, increase your range of motion, improve your posture and reduce any additional strain on the joint. We will also take a look at the physical activities you are doing day-to-day, and advise you how best to structure them so that you are keeping your hip moving but not overdoing it. It’s important to keep moving when you have osteoarthritis, but breaking up physical tasks into chunks rather than doing too much at once can help to reduce the pressure on your joints. There may also be insoles, walking aids or other forms of supportive equipment that we can recommend to take stress off your hip, as well as changes to your lifestyle and home/work set-up that may help. Manual therapy and massage are also frequently used to reduce pain and increase movement. Massage may include myofascial trains and dry needling to improve the 'slings' across the hip and pelvis. Additionally, Muscle Energy Techniques are also employed aiming to re-align the pelvis and hips. When it comes to osteoarthritis of any kind, the sooner you get treatment, the better. In the worst-case scenario, hip osteoarthritis could require surgery or even a total hip replacement. So come and see us early before the pain gets too severe. How can hip osteoarthritis be prevented? The sooner you start to look after your hips, the more you can reduce your risk of developing osteoarthritis. Here are a few things you can start doing right now: ● Regular exercises to strengthen the muscles around the joint and stretching to improve mobility will help to protect the hip from degeneration. ● Make sure you always use the correct technique to lift heavy items, and don’t lift excessive loads. ● Maintain a healthy weight, as obesity puts strain on your hips. ● If you are sitting for long periods of time, ensure that your chair provides adequate support and that your hips are slightly higher than your knees. Try to avoid crossing your legs. Take regular breaks to move around. Do lots of 'buttock ups' Diet Diet can be very useful in preventing and ameliorating osteoarthritis. Simple weight loss programs such as the 16 : 8 diet (fasting 16 hours whilst eating lunch and dinner), can lead to weight loss, but may also be aimed at reducing cholesterol. As we know cholesterol can block the arteries. As the joints are at the end of the circulatory chain, then even minor blockages can be a problem. we also know that many tendinosis/bursitis in the hip may be due to immune-metabolic compromise. Supplementations have been controversial, however 1000mg of EPA/DHA fish oil have been recommended, as have New Zealand green lip muscles, forest berry and cherry anti-oxidants. Apart from the anti-oxidant properties, fish oil has an effect on blood viscosity. Additionally, if glucosamine is taken, the minimal dose is 1200mg glucosamine with 800mg MSM and 800mg of Chondroitin. However, the latter may have an effect on any thyroid issues. Further Reading : https://www.back-in-business-physiotherapy.com/we-do/nutritional-supplementation.html References 1. Physiopedia. 2021. Hip Osteoarthritis [Onlinehttps://www.physio-pedia.com/Hip_Osteoarthritis2. OrthoInfo. 2021. Osteoarthritis of the Hip [Onlinehttps://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis-of-the-hip  Uploaded : 25 November 2021 Read More

Postural Orthostatic Tachycardia Syndrome (POTS) POTS is a condition of exercise intolerance in positions other than the horizontal. Clients will often present, complaining of symptoms of dizziness in standing, whilst feeling comfortable in sitting and lying down. In the older person it can be a result of cardiovascular deconditioning where the Heart Rate and Stroke Volume do not produce enough cardiac output (CO=SVxHR). In the younger individual, it may present as part of a condition from a different aetiology. In people who have suffered a Whiplash Associated Disorder (WAD) - anterior sympathetic cervical ganglia, or in a person with concussion, POTS symptoms may arise. Additionally in people who have Ehler Danlos Syndrom (EDS) or Joint Hypermobility Syndrome (JHS) POTS like symptoms due to autonomic dysregulation may present with POTS at any stage of life. Any thoracic ring issues which affect the peripheral sympathetic ganglia may also result in POTS like symptoms. Essentially, a person may have low blood pressure and elevated heart rate (Tachycardia) as a compensatory mechanism. POTS is frequently misdiagnosed and requires a tilt table and blood pressure monitoring to aid in the differential diagnosis. The heart plays a pivotal role or orthostasis, where left vetricular untwisting mechanics is critical for tolerating central hypovolaemia (as a result of reduced cardiac filling during orthostatic stress) in both high and low physical fitness people  (Shibata S et al 2021, Ex Sp Sc Rev, 49, 2, 88-98).    Causes of POTS interesting to physiotherapy include cardiovascular autonomic dysregulation, where tachycardia occurs due to decreased stroke volume from low blood volume (hypovolemia). Exercise conditioning results in increased stroke volume. However, all factors of exercise prescription need to be addressed including hydration and diet. sympathetic peripheral neuropathy where the calf blood vessels don't vasoconstrict sufficiently. Additionally, the calf muscles don't produce enough venous return to effectively act as the second 'pump' of the body. Exercise conditioning in supine (Pilates and Yoga) may be particularly useful for the venous return.  hyperadrenergic activity in standing (increased noradrenergic activity).Yoga (stability) and Alexander style activity with a meditation component. Feldenkreis may also be useful for mind-body awareness joint hypermobility (EDS and JHS) with specific physiotherapeutic interventions See Fu & Levine (2019) for a detailed review  The Children's hospital in Philadelphia has simplified the Dallas POTS exercise program to that which follows. Chronological factors in rehabilitation Where a person begins will depend on their current condition. Months 1-4 you should only exercise in a horizontal position, here are examples:o Recumbent bikingo Rowing Ergometero Swimming laps or kicking laps with a kickboard Month 4 you can begin to use the upright bike if it is available Month 5 is when you can begin further upright training (elliptical or treadmill) Use the calendars as a week by week guide. You may need to move training sessions around, but please complete all of the recommended training sessions within that 7 day period. You will need to do this in order to move forward to the next week. One requirement is that after Maximal Steady State’ workouts you must always complete a ‘Recovery’ workout the next day. A ‘Recovery’ workout is when you do anything active, but keep your heart rate below the zone prescribed. Examples of recovery workouts include: low cycling at a low level on the recumbent bike- Using a kickboard to leisurely kick laps in the pool Taking a walk outdoors Playing in the yard Anything active that gets you moving continuously for the prescribed amount of time If for some reason you miss a period of workouts (illness, injury, etc.) then you should go back in the calendar and repeat the workouts. For example: If you miss more than 2 cardio workouts then repeat the full week If you miss a week, back up and repeat 1 week If you miss more than 2 weeks, you should restart from the beginning of the month that you are currently in. If this is too hard then you may need to back up further. The program gets progressively more difficult. When you take time off, you lose some of your hard-earned conditioning so it is important to repeat workouts. You may also need to return to horizontal modes of training (i.e. recumbent bike, swimming, rowing) before moving forward in the program again. TIPS: Use the equipment you have access to and can tolerate training on, but starting with one horizontal mode of training is key. Rowing with the rowing ergometer is preferred because it mimics open water rowing. People who row in the open water tend to have the largest,strongest hearts out of all competitive athletes. Rowing is great to strengthen your heart muscle! If you are unsure how to use it ask someone toshow you. Keep the workouts spread out throughout the week. This is more beneficial than bunching them up and then taking several days off fromexercising. Try not to take more than 2 days off from exercising. This is KEY!! If you cannot complete all the sessions for that week, you need to repeat that entire week again before moving forward. The Basics of the Strength Training The strength training sessions prescribed should take you 20-30 minutes to complete. All weight training should be done using body resistance or onseated equipment. If you are unfamiliar with strength training then you should consult with a trainer to help you use proper form and technique oneach machine. It is recommended that you keep a log of your exercise. The strengthening exercises are mainly for the lower body and core, and thisis intentional. Lower body muscles act as pumps when they contract (as you are walking about in daily life) to return blood to your heart. Increasedmuscle mass in your legs means more blood returned with each step you take. TIPS:  Strength training can make you sore in the beginning (especially 1-2 days after the workout).  Some people find that they can only get to the gym 3-4 days a week. It is fine to do your strength training at the end of your cardio workouts instead of on separate days, if you prefer. If this causes you to become symptomatic then you should try to perform on separate days. Take at least a day off between strength training workouts. You need to allow your muscles at least that day to recover and to build muscle. We do not recommend the use of free weights until you have been able to build your strength and are able to perform with good form. If you have joint hypermobility then you should consult with a physical therapist prior to beginning your exercise program. The therapist can teach you how to protect your joints when you exercise  Exercises The Basics of the Horizontal to Upright Cardio Training Months 1-3 = Horizontal or Seated training When beginning this exercise program you need to use equipment where you are seated or horizontal in position because upright positions will likely make your symptoms worse. Examples include: o Recumbent bikeo Rowing ergometero Swimming (or kicking with a kickboard)o Seated stepper machine Month 4 = Upright bike Month 5= Upright exercise - Elliptical (begin without arm motion and then add after a few weeks)- Treadmill walking (no incline at first) Month 6-8 = Upright Training - Add in use of arm motion on the elliptical and incline on the treadmill- Make more challenging during this time as tolerated Jogging and stair stepping can be tried only after you have performed either elliptical with use of arms or treadmill walking on an incline and did not have an increase in symptoms. You do not ever have to jog if you do not want to. Warm Up and Cool Down: - Can be done on any piece of equipment and should NEVER be skipped.- At the end of your warm up you should have your heart rate approaching the target heart rate range for your workout.- For the cool down, simply remove all resistance from the piece of equipment you are using and slow down. In the beginning, your heart rate will take a long time to recover, but as you train more it will lower more quicklyTry performing stretching during or after your 10 minute cool down is complete. You should hold each stretch for 30 seconds and repeat 3-4 times on each side. Only stretch to the point where you begin to feel resistance. It should feel a little uncomfortable, but it should not hurt. Supine Exercises Exercises lying on your back, allow the blood pressure to remain even throughout the body. It also enables you to be able to build strength without cardiovascular compromise. The standing exercise for calf muscles should be done, when tolerated to aid the calf blood flow pumping mechanism. Mixed Postural Exercises     Upright Exercises Leaning forward, pivoting through the hip in exercise 2 and 3, will lead to better hamstring, gluteal and quadriceps engagement. The Sideways Lunge should only be down once the Reverse Lunge is perfected. The use of a slider on the floor and progressing from reverse lunge, to diagonally sideways lunge and eventually sideways lunge may need to proceed lunges with steps and certainly before forward lunges. Aim, is to re-orient the motor learning systems to efficiency of movement both metabolically and mechanically. Monitoring your Heart Rate We recommend you purchase a heart rate monitor set (a watch with a chest strap) to monitor your heart rate during cardio exercise training soyou can exercise in the proper heart rate zones. These can be found online or at a large sporting goods store. You do not need to purchase anexpensive model. Each cardio workout is prescribed to be within a specific heart rate range (see Training Guidelines sheet from your healthcareprovider), and it is important that you complete the workout in that heart rate range. You may notice that your resting heart rate decreases withtraining. Or, it could be unchanged, but your heart rate response to upright posture is lower.TIPS:• Some monitors work even while swimming in the pool.• If you ever question what the monitor is reading (equipment can go bad or need new batteries), simply feel your pulse at your neck or wrist andcount the beats for 15 seconds and multiply by 4 (heart beats per minute). If you are unsure how to take your heart rate this guide can help you:§ http://www.move.va.gov/download/NewHandouts/PhysicalActivity/P09_HowToTakeYourHeartRate.pdf Long Term Maintenance Cardio Training Months 6-8 of training is different for each person. Some people choose to maintain the level of training laid out in Month 5 forever, but we recommend trying to push forward. After you have completed the program you should continue to exercise to maintain what you have worked for. During this time you can use whatever modes you enjoy most. High intensity interval training, is a fancy name for the training that begins in calendar Month 6. It has been shown to provide great benefits to the heart and lung’s response to exercise for healthy individuals and several patient populations. We have found it to be beneficial to patients with POTS when it is introduced at a time when they are ready for it and responding well to their training. Here is an example of this training- Step 1: 10 minute- warm up to get your HR up to Base Pace zone- Step 2: 1 minute- go “all out”, hard and fast, increasing the resistance and speed on the mode you are using, and trying to get your HR upto your race pace zone- Step 3: 1 minute- remove all resistance, slow down, and actively recover. Take this time to get a drink, but keep moving on the piece of equipment. It doesn’t matter what your HR gets down to.- Step 4: Repeat steps 2 and 3 for two to three more trials- Step 5: 10 minute cool down- Step 6: 20 minute Recovery workout. TIPS: • Begin with the upright bike, rower, or elliptical as these are safer than the treadmill for interval training. Try to treadmill only when you are ready.• You can add any strength training you want, and try other things like yoga, aerobics classes, returning to competitive sports as you feel able (we do not recommend any exercise in the heat).• Consider yourself on a path to wellness and do what you feel you can do! We often hear that symptoms continue to decrease with long term training.• Remember each patient progresses through the program to upright exercise at a different pace and that is okay! What to Expect Getting Started This program is not an easy fix to having POTS, and if exercise made everyone feel better in a matter of weeks, everyone would be doing it. The real results will be seen after several committed months of training. The first month may be very difficult, and you may feel increased fatigue during this month. This is not surprising, so do not give up! You are challenging your system to do things it CAN do, but is not USED TO doing. The second month may still be tough. The hope is that you’ll feel less fatigue, begin to sleep better, and suffer from fewer POTS symptoms in your daily life than you did before beginning the training. This is the goal!!! TIPS: • Your commitment and mental toughness are key.• When you begin with a new mode of training, it is not uncommon to feel increased fatigue. Listen to your body. Push forward when you can, or repeat a week if you feel you need to.• If you are anything like the individuals we’ve met with POTS, you probably do not feel good most of the time, and have tried several other things to make your condition better, Here is the question we are proposing to you: Why not give this program your utmost effort for 3-5 full months before deciding if it helps you or not? Remember the benefits of training occur after months of training and not just days or weeks.• Write down a list of things you want to resume in your life, tape it to your bathroom mirror, and read it every day. Read it especially on the days you do not feel like going to the gym -  allow it to help motivate you to get your quality of life back.• Get a workout buddy if you need one! They can’t follow your heartrate zones, but they can work out with you!• Ensure your family is on board with supporting you in this journey. Help them understand you may feel more tired in the beginning, but the hope will be to feel better in the long run.• Family support is important, but YOU need to be the one to take the responsibility to make this change happen. Exercise as Your Lifelong Therapy If you feel that exercise is helpful for you in any way, maintaining exercise will then be important for you to keep the benefits and continue to see further improvements in your health and quality of life. Furthermore, you will experience the benefits of regular exercise in many other areas of your life and health, as well. Many patients successfully resume caring for their children, full-time work, full-time school, or enter college when previously they thought that these things might be impossible. We sincerely hope that this is the case for you as well. Keep in mind that according to the American College of Sports Medicine (ACSM) every healthy adult should perform 30-60 minutes of exercise more days than not. Most of ourpatients adopt exercise as part of their daily personal hygiene program. Some patients feel that daily exercise is needed to avoid developing symptoms again. If you have an illness, setback, or quit exercise, and realize that you felt better while training, this is actually a good sign! Do not be discouraged. You have a good response to exercise and you know that it makes you feel better! Just start again. You likely need to begin with horizontal modes of training, but you will know how to progress yourself through the program again.  Physiotherapy Physiotherapy can consist of 'hands on' mobilisations of the spine, thoracic rings, myo-fascia as well as guidance and feedback on exercise execution and progression. Additionally, the application of lumbar mechanical traction can lead to mobilisation of the thorax and it's peripheral sympathetic ganglia. Moreover, the post traction exercise protocol, reinforces the mode of action of the postural stabilisers and spinal mobilisers before a person gets up from the treatment table.   Post Traction Exercises are essentially those described above, whereby abdominal and bridging exercise in supine are complemented with oscillations of the pelvis and hips. From Supine, exercises in side lying, then in 4 point kneeling, are followed by isometrics in sitting and finally oscillatory movements in standing, including the wall plank, queen mum and Alexander breathing exercises.  Supine exercises can also include Pilates style hip and core stability, as well as simple cycling. These have some cardiovascular conditioning effect as well as promote blood flow from the calf. Uploaded : 15 November 2021 Updated : 2 February 2022 Read More

What is Skier’s Thumb? The terms Skier’s Thumb and Gamekeeper’s Thumb both refer to injury of a ligament at the base of the thumb. The ligament is called the ulnar collateral ligament (or UCL). Whilst Gamekeeper’s Thumb refers to a chronic condition caused by repetitive stress to the UCL (think using a wrench or wringing out cloths), Skier’s Thumb is an acute injury, usually caused by a fall. What causes Skier’s Thumb? Skier’s Thumb usually occurs when a person falls on an outstretched hand whilst holding something - ski poles will do it, which is how the injury got its name. However, football, hockey, basketball and rugby can also be culprits. Falling from a bike or motorcycle is actually the most common cause, and even a firm handshake can sometimes be enough to rupture the UCL! The force of impact while the thumb is extended is what causes the damage. What are the symptoms of Skier’s Thumb? Skier’s Thumb accounts for 86% of all injuries to the base of the thumb, so it’s a common problem. If you’ve developed Skier’s Thumb, then you’re likely to experience the following: ● Pain at the base of the thumb or in the web space between your thumb and index finger● Swelling at the base of the thumb● Tenderness to the touch● Weakness in your grip● Bruising around the thumb● Pain in the wrist (referred pain from the injury site) How is Skier’s Thumb treated? How your injury is treated will depend very much on the severity. Mild injuries may only require stretching and pain relief techniques. More serious injuries might require immobilisation for a period, whilst very severe cases may need surgery. When you come to see us, we’ll assess the damage and determine whether the ligaments have been torn or just stretched - and if they have been torn, to what degree. Elevation and cold compresses can help to reduce swelling and bruising, and if necessary, we will apply a thumb cast to immobilise the joint while it heals. Once the cast comes off, we can show you exercises to help build your strength and flexibility in the joint. If you do require surgery, we will help you afterwards to regain the function in your thumb and grip, and to shorten your recovery time as much as possible. If left untreated, damage to the UCL can lead to long-term weakness and joint instability. So, make sure you get it checked out! How can Skier’s Thumb be prevented? If you’re a regular skier, sports player or (motor)bike rider, there are a few things you can do to reduce your risk of Skier’s Thumb: ● Make sure you’re using the proper technique for any equipment, like ski poles, hockey sticks or carrying a ball - get instruction from an expert● For skiers, you can train yourself to release your pole as you fall, meaning you’re less likely to land on an extended thumb - you can also get special gloves to help with this● Wearing ski gloves or sports gloves can protect your thumb joint in case of impact References 1. Physiopedia. 2021. Skier’s thumb [Online https://www.physio-pedia.com/Skier%27s_thumb]2. Brukner, P. and Khan, K. 2017. Clinical Sports Medicine. Australia: McGraw Hill Education Uploaded : 4 November 2021 Read More

Osgood-Schlatter disease Despite the name, Osgood-Schlatter Disease (OSD) is not a disease at all - it’s a common knee injury that affects children and teenagers. If you thought that “growing pains” were an old wives’ tale, then think again. Growth spurts in adolescence can cause a number of painful conditions, and OSD is one of them. What is Osgood-Schlatter Disease? Children have a lot of growing to do, which means their bones, muscles and tendons have a lot of growing to do too! To enable this process, many of the bones have a growth plate, which is a soft area of cartilage at the ends of long bones. The shinbone is one such bone. During puberty, when the muscles, bones and tendons are all growing at different rates, the tendon that connects the shinbone to the kneecap can pull on the growth plate at the top of the shinbone. Since this is also a time when children are particularly active - playing sports, playing with their friends, and generally running around and jumping about at any opportunity - the tendon can be further stretched by frequent repetitive movements. All of this causes swelling and irritation, known as Osgood-Schlatter Disease. In 1903, an American orthopaedic surgeon called Robert Osgood and a Swiss surgeon called Carl Schlatter both independently described the condition, and it was named after them both. What are the symptoms of Osgood-Schlatter Disease? OSD usually affects children between the ages of 10 and 15. It is more common in boys than girls and can happen in one or both knees. If your child has OSD, they will likely experience some or all of the following symptoms: ● Pain in their knee that gets worse with physical activity● Pain in their knee when running, jumping, squatting, kneeling, walking upstairs, or walking up hills● Tenderness around the knee● Swelling below the kneecap How is Osgood-Schlatter Disease treated? If left untreated, the pain from OSD can last a very long time. The good news is that OSD will go away altogether once your child stops growing, but until then it can cause a great deal of discomfort, so it’s important to give your child the best possible treatment while it’s occurring. Rest is important, and your child will most likely be advised to either limit or modify their level of sports activity for six to eight weeks. After that time, they may continue to participate in their normal activities as long as they rest if the pain becomes too severe and the pain subsides after a day of rest. If it doesn’t, they’ll need to be checked out. You should also watch out for any signs of limping or difficulty walking after activity. Ice application after activities can reduce the pain, and stretching the quadricep and hamstring muscles is important. As this condition is caused by excessive pulling of the tendon on the bone, stretching should be gentle and only done when advised by your physio. Foam rolling may also be effective as a form of self-massage for the leg muscles when at home. Your physio can help your child with exercises to strengthen the quadricep and hamstring muscles, and a stretching and warm-up/cool-down routine for sports activities. Our goal is to keep your child active and moving with as little pain as possible. References 1. Physiopedia. 2021. Osgood-Schlatter’s Disease [Onlinehttps://www.physio-pedia.com/Osgood-Schlatter%27s_Disease 2. Johns Hopkins Medicine. 2021. Osgood-Schlatter Disease [Onlinehttps://www.hopkinsmedicine.org/health/conditions-and-diseases/osgoodschlatter-disease3. Kids Health. 2019. Osgood-Schlatter Disease [Onlinehttps://kidshealth.org/en/parents/osgood.html Uploaded : 23 September 2021 Read More

Orthotics Orthotics can either be “off-the-shelf” standard items that are ready made and adjusted for the patient’s particular size - or custom-made, particularly in cases of more complex injuries or changes to multiple joint structures. Reasons to use orthotics There are a few reasons that your physiotherapist might recommend the use of orthotics. Generally speaking, orthotics are designed to either stabilise a body part, or assist that body part in movement. For example, if a joint is not in a functional position, then orthotics may be used to help it to function better, recover and to prevent further injury during the recovery process. Types of orthotics There are several types of orthotics. Commonly, they can be divided into soft and hard. Both can be molded, but it is more common to mold the hard ones. Both can have inserts, wedges, domes, etc, glued to them. Some are moulded after taking a cast of the foot whereas others are designed after foot platform analysis of weight distribution across the sole of the foot. Commonly, a video is also taken of the rear of the foot at push off. Try soft orthotics first. Inexpensive and frequently enough to fix the problem. Some conditions that might require orthotics include: Back pain - if this is caused by foot or leg problems that are causing uneven gait, then orthotics might help you to walk more evenly and reduce the pressure on your back Arthritis - orthotics can help with positioning of the joints to relieve discomfort Bursitis - when the fluid-filled sacs in the heels and toes become inflamed, they cause a great deal of discomfort which orthotics can help to reduce Ankle sprain – an orthotic might provide support to prevent further injury while you recover and to allow you greater movement Achilles tendonosis - take tension off the achiilles tendon esp at the insertion of the heel and it's bursa Inside knee pain - reduces the amount of rotation on the inside of the knee as the first joint of the foot is a 'ball and socket' joint. Outside hip pain and bursistis - again aids in control of rotation  Common mistakes with orthotics Orthotics can be incredibly valuable tools in your recovery, but only if they’re used correctly. There are a few key mistakes that people regularly make, so we want to help you avoid them! ● You need to wear them in gradually It will probably take two to three weeks to get completely used to wearing your orthotics and, except in serious cases or unless your physiotherapist tells you differently, you will need to gradually build up the amount of time you wear them each day rather than wearing them full-time from the offset. ● You must follow your physiotherapist’s instructionsWe know it can be a hassle to have to put that wrist support on every time you play sport, but it really is important. You need to wear the orthotics in the right way, at the right time, for the right amount of time, or they may not work as effectively as they could. Your physiotherapist has given you those instructions for a reason, so it would be advised to follow them as best as possible. ● Don’t give up on them as soon as you’re feeling betterBecause it can be a hassle to keep putting them on, or because people don’t think they look particularly attractive, or because they might not be incredibly comfortable, many people are keen to ditch their orthotics as soon as possible. But just because the pain has subsided doesn’t mean the problem’s gone away. If you give up on them too soon, the problem might come back or get worse. So don’t put them away until your physiotherapist gives you the go-ahead. When you’re experiencing pain, we’re happy to talk you through all the different treatment options available, including what types of orthotics might work for you alongside our hands-on and movement / exercise-based treatments (but only if needed of course!). Give us a call on or email and we can discuss your choices. Take a look at my research - barefoot running vs orthotics : EMG and joint angle analysis read more.........see link below see https://www.back-in-business-physiotherapy.com/orthotics-and-gait.html Uploaded : 26 August 2021 Read More

The Benefits of Stretching We keep telling you to stretch before and after exercise, until you’re probably sick of hearing about it. But why? Well, there are a whole host of benefits to stretching, and they’re not just limited to exercise. Here are seven reasons to make sure that proper stretching is a regular part of your routine. 1) Reduced risk of injuryStretching warms up your muscles, increasing the range of motion, so they are less likely to be torn or strained during exercise. You are also less likely to experience pain or discomfort after exercise with a thorough warm up and cool down. 2) Increased flexibilityFlexibility not only improves your performance but is good for your overall health. Increasing your flexibility will also help to delay decreased mobility as you age. 3) Improved postureTight muscles, especially in the chest, back and hips, can cause poor posture, which can lead to pain or injury. Stretching keeps your body in better alignment and improves your posture. 4) Reduced stressYour muscles tighten in response to physical and emotional stress, and many of us hold tension in our necks, shoulders and upper backs. Stretching these muscles helps to release the tension and helps you to relax. Stretching also provides an opportunity for a moment of mindfulness to calm your mind. 5) Increased circulationStretching improves blood flow to your muscles and joints, which enables them to get more oxygen and nutrients. 6) Enhanced performanceA flexible joint can move through a wider range of motion with less energy, so stretching makes your body more energy efficient. By preparing your muscles for exercise through stretches, you are improving your performance. 7) Fewer headachesAs a great many headaches are caused by tension, releasing that tension through stretching can reduce the number of headaches you experience. If you’re interested in which stretches will suit you and want help putting a program together to compliment your activity habits, give us a call on 02 9922 6806. We’d offer to do the warm up on your behalf, but that’d be a stretch! See what we did there? Uploaded : 23 July 2021 Updated : 7 April 2022 Read More

Foods for muscle recovery Do you workout a lot and are looking to maximise the effects of your exercise regime by eating the best food afterwards? If you look this up online, you’ll be hit with a million and one pages to read through, with many of them saying different things. It’s a bit of a minefield and can be con-fusing to the average Joe. Fear not, because here at Back in Business Physiotherapy we have great information at our fingertips and want to share it with you. We’ll keep this simple… No fancy scientific words here to confuse the brain. There are a few foodstuffs that are particular-ly important when it comes to improving your muscle recovery following a workout. The key play-ers here are protein, carbohydrates and water. Protein Protein is the building block of every cell in our body (it’s pretty important!). During a workout, the proteins that make up muscle cells break down. After theyhave broken down, the body goes through a recovery process whereby these muscle proteins are repaired, and some new cells are built. This is how our muscles get bigger. Eating a healthy source of protein after a workout can give the muscles the building blocks they need to recover and get stronger. Good sources of protein include eggs, chicken, fish, Greek or other high-protein yoghurts, and cottage cheese. Some people also opt for protein powders and bars to help them reach their pro-tein requirements. Carbohydrates Carbohydrates (aka ‘carbs’) are the body’s main energy source. The movement we do during a workout uses energy. Our muscles store energy so that when we need it to smash out a solid weights session (or any exercise of your choice), we have it there ready to go. After a workout the stores of energy are depleted, and we need to replenish them to ensure we have more in the bank for the next thing we want to do. Good sources of carbohydrate include dark green leafy vegetables (such as kale and spinach), sweet potatoes, fruit, rice, quinoa, and pasta. Water Our bodies are made up of approximately 70% water. It is literally everywhere in the body. For all the crazy chemical process that occur in the body every second, we need water to allow it to happen. During and after exercise, the body loses water through sweating. It is vital to drink plen-ty of water after exercising (as well as before and during… Just drink it all the time, pretty please) to make sure we stay hydrated and to maximise the recovery process. Better still, good sources of water are easy to find! We recommend starting with the tap in your kitchen! 😜 A helpful tip Evidence suggests that eating a post-workout meal combining a 3:1 ratio of carbs to protein will maximise your recovery. Try brown rice with grilled salmon and kale for a powerful, nutritious meal. And drink water before, during and after exercise. We also think you should give us a call to book an appointment, so we can have a more detailed chin-wag about this if you so desire. Call us on 02 9922 6806 today! Link to in-depth analysis on Sports Nutrition - https://www.back-in-business-physiotherapy.com/we-do/nutritional-supplementation.html References 1. Healthline. 2016. Post-workout nutrition: What to eat after a workout. [Onlinehttps://www.healthline.com/nutrition/eat-after-workout. [Accessed 04 June 2020]2. Webster-Gandy, J. et al. 2012. Oxford Handbook of Nutrition and Dietetics. 2nd ed. Oxford: Oxford University Press Uploaded : 29 June 2021   Read More

Shoulder injury blog: Labral tear The shoulder is one of the most complex joints in the body. It is made up of a total of four joints, numerous ligaments, joint capsules, muscles and other soft tissues. Movement at the shoulder is a complicated process and it relies on the controlled function of all the involved muscles and joints for that movement to be efficient and complete. Our shoulders are the most mobile joints in the body which is great for us because it means as humans we get to partake in fun activities like throwing sports, gymnastics and dancing, as well as movements we generally take for granted like being able to do up our bra’s behind our backs. This wide range of movement is only possible because the shoulder is less stable when compared to other joints in the body, leaving the shoulder prone to injury. This blog specifically focuses on an injury that relates closely to the ball and socket part of the shoulder joint. If you are into throwing sports, you may be familiar with it… It’s called the labral tear. A bit of anatomy…There are two main ball and socket joints in the body, found at the shoulder and the hip. Both work where a rounded ‘ball’ of one bone fits into a hollowed ‘socket’ of another. At the hip (the strongest joint in the body), the socket is very deep, and the ball part fits quite snuggly into it. This is a very stable joint. The socket in the shoulder is very shallow by comparison, and the ball part is still quite large. This is what gives the shoulder its lack of stability. Both the shoulder and the hip sockets are deepened and supported by the presence of a labrum — a rounded soft-type of cartilage. In the shoulder, the labrum completely surrounds the rim of the socket creating a ring. The very top part of this ring also acts as the attachment site for one of the tendons of the biceps muscle — a powerful mover of the shoulder and elbow joints. How does a labrum tear? The main ways labral tears occur are: • Repetitive movements such as overhead throwing• Carrying heavy objects• Dropping and catching heavy objects A tear can occur over time as the tissues degenerate over time and become weaker, or it might be from one single, forceful event. In most cases there is usually a combination of both degeneration and a large force which becomes the ‘straw that breaks the camel’s back type of scenario. As the biceps tendon attaches to the socket through the labrum, any large force that pulls on the biceps tendon (like suddenly catching a heavy object) can lead to the tearing of the labrum itself. The most common type of tear occurs across the top of the labrum from front to back, and these are known as SLAP (i.e. Superior Labrum Anterior Posterior) tears. Signs and symptoms If you have sustained an injury to the labrum in the shoulder, you may notice any or all of the following signs and symptoms: • Pain during shoulder movement (especially overhead and behind back movements)• Restricted shoulder movement• Popping, catching or grinding during shoulder movements• Tenderness at the front of the shoulder Depending on how you were injured, how severe your symptoms are, and your personal circumstances regarding work and home life, you may be sent for some imaging to confirm the tear. The tests we perform in clinic when we assess you do not always give us all the information we need to determine the best plan of action. A combination of clinical tests and imaging may give us a clearer picture of what’s going on. Can it be treated by a physio? Yes, but this completely depends on the severity of the injury and what your goals are. In most cases it is recommended that conservative therapy from a physiotherapist is tried first. Many athletes who have a labral tear can return to playing to some capacity with a non-surgical approach. The treatment aims to return the shoulder to full, pain-free range of motion through hands-on massage, mobilisation and rehab exercises that focus on range, control and strength of the shoulder girdle. For severe tears, you may require the opinion of a shoulder specialist. A labrum is not great at healing itself and sometimes needs help from a surgeon to return to normal. A professional athlete wanting to return to sport may choose this pathway, but a non-athlete who has no desire to throw a ball seriously again may be able to avoid surgery altogether. If you have a diagnosed labral tear, or have recently injured your shoulder and need help, we recommend coming to us at Back in Business Physiotherapy where we can discuss the best course of action for you and your circumstances. References: 1. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw Hill Education2. Ireland, M. and Hatzenbuehler, J. 2018. Superior labrum anterior posterior (SLAP) tears. [Onlinehttps://www.uptodate.com/contents/superior-labrum-anterior-posterior-slap-tears. [Accessed 09 May 2020]. Uploaded : 24 May 2021 Read More

Who is at risk from a metatarsal stress fracture? Regular, repetitive motions in the foot are the most common causes of metatarsal stress fractures, making runners particularly susceptible. If you have recently taken up running or are trying to run too far too soon, you are at an even greater risk of developing a stress fracture. Other sports, such as basketball, tennis, gymnastics and dance, that put a great deal of repeated pressure on the foot are also common causes. Whatever sport you are taking part in, you should always ensure you have the correct footwear and that it fits properly – as poor footwear increases the chances you will over-stress your metatarsals. Stress fractures can also occur as a result of a different injury entirely! For example, if you sustain damage to an ankle, knee or hip and don’t seek treatment, you may end up overloading your foot on that side to compensate for the pain elsewhere. Osteoporosis, vitamin D deficiency and certain foot problems can also lead to metatarsal stress fractures. What are the symptoms of a metatarsal stress fracture? If you do develop a stress fracture in your metatarsal you will likely experience pain in your foot that will be worse during activity but will lessen when you rest. You might also notice swelling at the top of your foot, and it may be tender to touch. There could also be some bruising or redness around the area. Some people will have balance problems or an uneven gait. What are the treatment options? If left untreated, stress fractures can develop into a complete break or lead to chronic conditions. If you suspect you have a metatarsal stress fracture, you must rest your foot. You can apply ice to ease the pain and elevate your foot to reduce swelling. Avoid tight or heeled shoes. Then make an appointment with us here at Back in Business Physiotherapy We will look at any immediate interventions that will help the healing process, such as wearing a moon boot for a short period to de-load and allow the bone to repair itself. Then we might suggest footwear modifications or advise on your exercise routine changes to prevent the issue worsening or recurring. If the stress fracture was caused by a previous injury, this will need to be addressed as well. If you’re experiencing pain in your foot, or any unexplained pains following a change in your exercise routine, give us a call on 02 9922 6806 or email us so we can check out what’s going on. See link to a clinical example https://www.back-in-business-physiotherapy.com/latest-news/266-stress-fracture-in-an-adolescent-foot.html References 1. OrthoInfo (American Academy of Orthopaedic Surgeons). 2015. Stress Fractures of the Foot and Ankle. [Onlinehttps://orthoinfo.aaos.org/en/diseases--conditions/stress-fractures-of-the-foot-and-ankle/ 2. Physio.co.uk. 2021. Stress Fracture of the Metatarsal. [Onlinehttps://www.physio.co.uk/what-we-treat/musculoskeletal/conditions/foot/stress-fracture-of-the-metatarsal.php Uploaded : 23 April 2021 ; Updated : 29 June 2021 Read More

5 Physiotherapy Treatments You Can Do At Home Want to look after your body like a physio? Whether you’re currently having treatment and want to complement that work, or you just want to keep yourself in the best possible condition, here are five ways that you can proactively take care of yourself from the comfort of your own home. 1. Stretches Stretching a particular muscle or muscle group improves elasticity and allows you to use the muscle more effectively to build strength. Stretches are therefore very important for increasing your control, range of motion and flexibility. If you are exercising, make sure you stretch before and after to reduce your risk of injury and improve your recovery time. 2. Foam rollers If you’ve developed stiff or tight muscles from exercising, using a foam roller can reduce soreness, release tightness or tension and decrease your recovery time. They can also be used to increase your core stability. You will need to hold your body above the roller, then slowly lower the area you want to target onto the roller. You can then roll gently backwards and forwards. It should cause mild discomfort, but don’t push it so far that it causes real pain as this could lead to injury. 3. Hydration Water plays a pretty important role in your body, enabling you to regulate your body temperature, lubricating your joints, assisting your kidneys to remove toxins, and delivering nutrients to cells to give you energy. Drinking enough water is vital, especially before, during and after exercise. 4. Spikey massage balls These small spikey balls can help relieve trigger points, which are hyperirritable nodules (little knots) in muscles that can occur all over the body. They can be caused by injury, over-exercising, poor posture or joint problems. Pressing the ball into the area and making small movements with it helps to release the trigger point, and the spikes stimulate your circulation. Like foam rollers, it’s important not to push too hard on these areas, so take it easy and book an appointment with us if you suspect you need a helping (physio) hand! 5. Clean diet What you eat has a huge impact on the wellbeing and performance of your body. A clean diet, one that avoids processed foods or those high in sugars or additives, is great for taking care of your physical health. For example, proteins support the building of bone, muscle and connective tissue; vitamin-rich fruit and vegetables support cell function; and omega-3 fatty acids help take care of your joints. When was the last time you took a good look at your weekly food intake to ensure you’re giving yourself a balanced meal each day? (Maybe now is the perfect time!) Want a more personalised plan for your physical wellbeing? Give us a call or email us and let’s have a chat about approaches to support your particular needs. Uploaded : 23 March 2021 Read More

The most common overuse injuries Overuse injuries occur when a particular part of the body is subjected to repeated demand over a long period of time. Activity that involves using the same motions over and over - particularly if these are ramped up too quickly, performed for extended periods or made using an incorrect or unsafe technique - can cause tissue damage. Below are some of the most common overuse injuries in different types of body tissue. Stress fracture A stress fracture is a small crack in otherwise normal bone that occurs when the bone has been subject to repeated impact. Stress fractures are most common in weight-bearing bones, such as the shin or foot. Often seen in runners, stress fractures can be a result of a sudden change in physical activity or increasing training without enough rest or recovery time in between sessions. To avoid stress fractures, follow a sensible training program that increases your activity gradually and allows plenty of rest time (ask a physiotherapist for advice if you’re unsure). You can also look after the health of your bones by eating a diet high in calcium and Vitamin D. Tendonitis or Tendonosis Tendonitis is irritation or inflammation of a tendon, caused by repetitive actions in that area. Activities like gardening, painting, cleaning, throwing a ball and playing tennis can cause tendonitis. To reduce your risk of tendonitis, try to build up your activity levels gradually rather than doing too much too soon. Take regular breaks and limit the amount of force you use in your actions. Tendonosis is considered more like a degenerative condition. Occurring more commonly in middle age and especially in men, due to higher levels of testosterone, leading to to 'drier' collagen fibres. Rather than inflammation, the tendon may show signs of swelling and necrosis. Blisters Blisters form to protect the skin and can be caused by repeated friction from rubbing or pressure. If you have ever had a pair of shoes that didn’t fit well or were stiff in certain places, you might have experienced a friction blister where they rubbed your foot or ankle. To avoid blisters forming, protect your skin from friction where possible (for example, by wearing socks, or wearing gloves if you are using tools that rub your hands). If you do develop a blister, keep it clean and dry and try to leave it alone as much as possible. Resist the temptation to pop it. Strained muscle Overstretching or tearing a muscle, by overusing it or using poor technique, can result in pain, inflammation and limited movement. Any muscle can be strained in this way, but it is most common in the lower back, neck, shoulder and hamstring. To reduce your risk of straining a muscle, warm up and cool down properly before and after exercise and get professional advice to ensure you’re using the correct technique. Poor posture can also strain your muscles, so consider the way you are sitting and standing, especially for long periods of time. Physiotherapists don’t just help you recover from injury - we also try to prevent you getting them in the first place. If you think you might be at risk from overuse injuries, give us a call on 02 9922 6806.  and we’ll discuss whether there are steps you can take to protect your body.  Proactive care may seem unnecessary at times, but it is the most pain-free (and affordable) way to manage injuries before they make themselves apparent. References 1. Oxford University Hospitals. 2018. Bone Stress Injuries and Stress Fractures. [Onlinehttps://www.ouh.nhs.uk/patient-guide/leaflets/files/41517Pfractures.pdf 2. WebMD. 2018. Tendinitis. [Onlinehttps://www.webmd.com/fitness-exercise/arthritis-tendinitis 3. Healthline. 2018. Muscle Strains. [Onlinehttps://www.healthline.com/health/strains#_noHeaderPrefixedContent Uploaded : 22 February 2021 Read More

How can physiotherapists help with headaches? You might be surprised to learn that the answer is, quite possibly, yes! It just depends on what type of headache you’re experiencing - and there are a lot more than you might think! What different types of headache are there? There are more than 150 types of headache! What type you’re experiencing depends on the cause, the symptoms, the location and how often they occur. Some of the most common headaches include: ● Tension headache Usually caused by tension in the muscles of the shoulders, neck or face, tension headaches usually give a sensation of pressure all the way around the head, and can cause nausea and light sensitivity. ● Sinus headache These headaches are usually felt as deep, constant pain in your forehead, as well as your cheekbones and/or the bridge of your nose. Caused by sinus infections, they’re usually accompanied by symptoms like a runny nose, blocked ears, swelling in the face, fever and sinus pain. ● Dehydration When you become dehydrated, the brain temporarily contracts because of the lack of fluid, causing it to pull away from the skull. Which hurts. The pain can usually be felt all over the head and can be anything from a dull ache to an intense throbbing. So, keep up your water intake. ● Cervicogenic headaches These are caused by pain referred from tissues in the neck. They usually cause pain on one side of the head, from the base of the skull to the temple of the eye, and are aggravated by neck movements. ● Migraine If you’ve ever had a migraine, you’ll know it’s way beyond a standard headache. As well as a pounding, throbbing pain in the head, sufferers can experience vision disturbances, sensitivity to light, noise and/or smells, nausea or vomiting, dizziness or stomach pain. Migraines can last for several hours, or even days. ● Cluster headaches Causing intense burning or piercing pain behind or around one eye, cluster headaches can be so overwhelming that sufferers can’t sit still during one. They may cause swelling, redness or tears in the eye affected, and nasal congestion on that side. They’re called cluster headaches because they occur in groups - one to four times per day (lasting 15 minutes to three hours each time) during a cluster period, which can last from two weeks to three months. What can you do to reduce headaches? Depending on the type of headaches you are prone to, there are a few things you can do to try to reduce the frequency and intensity: ● Drink plenty of water● Make sure you’re getting enough quality sleep● Try to reduce your stress levels and make time for relaxation● Don’t skip meals and make sure to eat regular, healthy snacks to maintain your blood sugar levels● Notice if there are particular foods, drinks, smells or environmental factors (such as lighting conditions) that trigger headaches so that you can avoid these in future● If you are sitting at a desk for long periods of time, stretch your neck, shoulder and back muscles regularly● Warm up and cool down properly after exercise How can a physiotherapist help? The two main headaches that physiotherapists can help you with are tension headaches and cervicogenic headaches. In the case of tension headaches, a physio will relax and unlock the muscles, releasing the tension that is causing the pain. They will also look at lifestyle factors that might be contributing to the problem, such as stress, and help you to manage these. For cervicogenic headaches, the goal will be to address the neck issue at the root of the problem. This could involve manipulation, massage or mobilisation. They will likely teach you exercises to perform regularly, which will help to relieve the problem. Poor posture is a common cause of cervicogenic headaches, so your physio will also look at your posture and ask about your living/working space to address that problem. References 1. WebMD. 2020. Headache Basics. [Onlinehttps://www.webmd.com/migraines-headaches/migraines-headaches-basics2. Headache Australia. 2020. Headache types. [Onlinehttps://headacheaustralia.org.au/types-of-headaches/. [Accessed 19 Dec 2020] Uploaded 28 January 2021 Read More

  Reflections over 35 years on the development and set backs in musculoskeletal physiotherapy by Martin Krause (December 2020) Having graduated from Cumberland College Health Science, Sydney, Australia in 1986, I was fortunate. We had a burgeoning profession in the art and craft as well as the embryonic science of Musculoskeletal Physiotherapy. At my time of graduation there wasn't a single Physiotherapy PhD at the College. The college wasn't yet affiliated with Sydney University. However, it turned out, that what we were learning in Australasia, was at the forefront of physiotherapy worldwide. These included  Wet cadaver labs for training in anatomy. Post graduate Manipulative Physiotherapists teaching us, under graduates, Manual Therapy. Based on Post Graduate Biomechanics qualifications, Jenny McConnell and Robyn Grote were commencing their careers, with new concepts such as patella taping, tendon proprioception, and motor control. Janet Carr and Roberta Shepard were describing the conundrums of movement control, Bernsteins degrees of freedom and Kugler and Turveys oscillatory control systems, We still learnt PNF (Proprioceptive Neuromuscular Facilitation), massage and movement analysis. World acclaimed professors, the late John Sutton and Greg Gass were teaching us work physiology. Neurophysiology was taught with an over-whelming emphasis on pain and motor control. We were some of the first graduates in a new form of teaching which involved continuous learning, project based and experiential assessment and competency criteria. Clinical reasoning was used for the first time, which meant placing value on clinical signs and symptoms, rather than a diagnostic medical lead referral system, thus leading to Australasian physiotherapists being some of the first primary practitioners in the world. Researchers and clinicains from South Australia (Geoff Maitland, David Butler, Michael Sherlock, Pat Trott), Curtin University (Bob Elvey, Brian Edwards, Lance Twomey, Max Zusman), University of Queensland (Julie Hides and Gwen Jull) were changing the world in terms of our understanding of Manual Therapy The journey This is one of the first website on physiotherapy to ever exist. Originally published in 1998, it came about after a culmination of a decade of teaching and presenting workshops around the world. These were often countries who had little to no access to Australian Manual Therapy. Although I no longer teach, I continue to regularly update this website, hoping to make an impact on my profession and all the people my profession treat. My philosophy in teaching was to 'train the trainers'. Although each update has only a hand full of readers, I had the experience, whilst cycling across Argentina, that one newspaper and radio interview with me, about my interpretation on life, can led to a film, which was presented at the Cannes Film Festival in 1992. From that moment on, I realised even an impact on just one person, may have multiplier affects, beyond our wildest imaginations. In November 1990, four friends set out on a 6 month journey, from Buenos Aires to the Chilean coast at La Serena, Ushuaia to the Bolivian Alti Plano and later the jungles of the Amazon, wetlands of the Pantanal and the Littoral of Uruguay. We were in for a few surprises, including an attempted coup d'etat and hyperinflation. This meant we needed to sleep 'wild' including staying under bridges and making use of abandoned homesteads. Luckily, the truck stops became a haven for food, as the only thing which was affordable were the parrilladas. Drivers would tell people that we were coming, in return for what seemed like bigger and bigger servings of meat, potatoes and salad, they wanted me to tell our story. Of our adventure, where we were from, Australia, and where we were going - to Patagonia!!! We were often accompanied out of town by convoys of excited people. Not only, the people of the truck stops, but journalists wanted our story. These were the days, before the internet, where story telling and the bush telegraph reigned. They were also the years immediately after the 'dirty war' (la guerra sucia), where knowledge was considered dangerous and the memories of the 'disappeared' (desaparecidos) were fresh. The interviews were sometimes quite simple, whereas at times, nothing was off limits, from philosophy to politics. Literature included 'The Kiss of the Spiderwoman' by Manual Puig, Eduardo Galeano (Age of Fire) to Jorge Luis Borges, Gabriel Garcia Marquez (100 Years of Solitude, Love in the Time of Cholera, The Genral in his Labyrinth) to Pablo Neruda and Mario Vargas Llosa (City of Dogs, Aunt Julia and the Script Writer) with the metaphorical images from the deep dark forests of the Chilean Lakes District to the Afro-Caribbean mysticism of Colombia. Politics, included contrasting Peron with, the famous son of Argentina, Che Guevara to the Sendero Luminoso in Peru. One interview, stood out in particular, where all these topics were covered, including metaphors, in the conditional subjunctive vernacular of the Argentine narrative, broadcast on the radio and written up in the newspaper. Two years later, in 1992, in the 500th year since Columbus discovered America, I was sitting in a cinema, in Basel, Switzerland. The movie, El Viaje, was showing. It was about a boy called Martin, who was cycling around South America. The opening scene was in a secondary high school, in Ushuaia, where the teacher says 'sit down Krause'. I, and my friend were stunned!!!! I cannot take the credit for the artistic brilliance of the film. I'm not even sure if I ever met with Fernando Solanas, so I'll never know if I germinated the seed of the ideas portrayed in the film, or whether he just needed a central character to have a name. Critical appraisal of El Viaje On the way to Passo de Aguas Negras and La Serena, Argentina/Chile, 1990 Oscillations - manual therapy and motor control I spent 1986 delving into the conundrum of shoulder stability - the control of a system with almost an infinite number of movement permutations. Here, some of the giants in human movement research were using the oscillatory pendulum and Hooke's mass - spring as an explanation to motor control. An inflection point of stability, weighted by muscular tone and balanced forces allowing for the ranges of movement needed, in the shoulder, for the huge range of activities, we as humans, put our shoulders through. Similarly, I used an anatomical dissection to explain knee stability. Three and half decades later I examined the same principle of oscillatory systems but now with an emphasis on deterministic chaos theory, redundant systems and their interplay based on physiological, neurophysiological and immune 'outliers'. The outlier which dampens, modulates and moves nearby oscillatory systems. Oscillations continued to fascinate and impress. Australian Manual Therapy had been derived from the Grand Masters, James Cyriax (London, UK), James Mennell, Alan Stoddard and Greg Grieve (Norwich, UK). There was a famous meeting in St Thomas's, London, in 1967 where the greats of physiotherapy met and discussed the later creation of IFOMT (International Federation of Manual Therapy) in 1974 (Montreal) and the first meeting in Gran Canara in 1975 . People in attendance included Geoff Maitland, Freddy Kaltenborn, Stanley Paris, and Robin McKenzie. The first home office of IFOMT was by Ian Searle, a New Zealander. Later, other greats such as Bob Elvey (Western Australia) became involved. Although, this appears like a coming together of 'minds', there was a fundamental clash between the biomechanics based sustained stretch of Kaltenborn and their Nordic Technique (OMT), with the oscillatory movements, advocated by Geoff Maitland in Australia. When I arrived in the UK in early 1988 I found a job, at the Norwich & Norwich hospital, where Greg Grieve had been working. Physiotherapists were the main 'port of call' at A&E.  I learnt a lot from the physiotherapists as well as guest international speakers. The NHS was a great place to learn and work in a collaborative manner. A responsibility seldom given to physiotherapists at that time.  Later that year, whilst in Switzerland, I was fortunate enough to gain invaluable experience at the Medizinisches Zentrum, Bad Ragaz, where I met Geoff Maitland and was able to attend courses with Peter Wells, where spinal manipulations were taught. Maitland examination procedure circa1986 - 1991 The Maitland technique, chased the pain, whereas Kaltenborn chased the biomechanical dysfunction. Both were very precise and both had their merits and limitations. Luckily, in Bad Ragaz I was able to work with OMT trained physiotherapists and learn from them, combined movements, 'locking off and adjusting' spinal joints. Later, in 1991, I had the opportunity to attend a course with David Lamb (Canadian, previously from the UK) where i learnt the OMT method of cervical manipulation. Meanwhile, the Post Graduate program of Manipulative Physiotherapy had been developing in Australian Universities since the early 1980's and was a much sort after qualification, which I completed in 1994. Later, in 1995, I was able to learn mobilisations with movement (MWM) from Brian Mulligan (a New Zealander). He was a very pragmatic and very funny fellow, whose niece I happened to meet, serendipitously,  as a client many decades later. All these encounters allowed me to mix and match the best of all worlds and eventually impart that knowledge in the form of Manual Therapy workshops in Chile, Brasil, Japan and Europe. Teaching in La Serena, Chile 1996 Adverse Neural Tension : passive to the active By 1988, I was seriously interested in the nexus between the assumingly 'passive' manual therapy approach and their amazing results (with very little, almost imperceptible loading), and active approaches using motor control and exercises. Bob Elvey and David Butler came onto the scene with Adverse Neural Tension (ANT) whereby mobilisation of nerves improved clinical signs and symptoms. Remarkably, a very 'passive biomechanical' explanation was used. My Masters Treatise, in 1995, was examining the immediate effects of Mechanical Traction on ANT within a very precise dosage range, using a 'descending modulation' neurophysiological argument. In the early 1990's I attended the International Association Study Pain (IASP), in Paris, where the seminal work of French researchers, on the descending modulation of pain, took the emphasis away from the 'pain-gate' Wall and Melzack theory of peripheral - spinal cord modulation and added an extra dimension of descending noradrenergic pathways.  This was the first time the pain brain function was being imaged using the new technology of PET and MRI scans. This made a lot of research, in manual therapy, using double blind studies redundant, as it became increasingly obvious that the patient is actively involved in recovery, even when a passive device such as Mechanical Traction is applied. In fact, Geoff Maitland was thought to have said that 70% of the examination process was the 'subjective' examination, with it's inductive and deductive reasoning, 20% the physical examination and the remaining 10% treatment. Luckily, I had close interactions with Bob Elvey, Max Zusman, and later David Butler where ideas and visions could germinate further. Proprioceptive Neuromuscular Facilitation (PNF) and functional movement control by Klein Vogelbach (FBL) Bad Ragaz, also gave me exposure to PNF trained physiotherapists. These were a generation of physiotherapists, on the cusp of retiring, who'd gone to Vallejo, California in the 1970's to learn PNF and become teachers in their field. Simultaneously, another group of physiotherapists, in Bad Ragaz, were involved in teaching FBL, where movement analysis and the ability to describe in words what was being seen 'statically' or 'in action' determined specific choices from a plethora of exercises. Primarily, only known in Switzerland, some of these exercises became world famous in the form of the Swiss Ball. Although PNF techniques were originally designed for neurological patients, these strengthening and mobilising methods were morphed into musculoskeletal injury management, where PNF techniques were often combined with Swiss Ball and FBL techniques to optimise (sporting) outcomes. Teaching in Salvador da Bahia, Brazil 1998 PNF techniques morphed into Muscle Energy Techniques (MET), as learnt from David Lamb. MET, I still use today for the treatment of pelvic, hip and back dysfunction. Concepts of form and force closure and the influence of the thorax were later developed by Canadian Physiotherapists Linda Joy Lee and Diane Lee, both of whom I attended courses with. The latter had worked closely with David Lamb earlier in her career. Research, publications and presentations Stabilometry, EMG and kinematic telemetry in Achilles and ACL surgical post operative rehabilitation Magnesium and Multodextrene supplementation in elite athletes Immune compromise in Swiss Female Elite athletes Dysmenorrhea and stress fractures in Swiss Female Elite athletes Improved range of movement of upper limb tension testing after anteroposterior cervical spine mobilisation Cognitive and physical dimensions in elite orienteering Cycling kinematics, bike fit and EMG activity Publications in the International Journal of Manual Therapy on Mechanical Traction and the Chilean Journal Kinesiolgia on neurophysiological considerations when using clinical reasoning in Manual Therapy Sarcopenia - muscle as an immune organ Presentations from 1993 - 2001 in Switzerland, Germany, Portugal, Spain, Holland, Japan, Zimbabwe, Brazil, Ecuador, Chile and the USA on Clinical Reasoning in Manual Therapy. Including key note speaker addresses at IFOMT of WCPT in Yokohama, Japan, La Serena, Chile and New Master Rome, Italy. Taught functional anatomy and biomechanics on the Diploma of Massage course of TAFE NSW Cycled South America which may have inspired a film? Three TV interviews -  -Workstation Ergonomics with Ms Megabyte Morning Show Channel 9, Sydney 2001 - VHS video only - Early Treatment intervention - Prime 7 TV Country NSW 2010 (https://m.youtube.com/watch?v=I_WqKpsTaf8) - Peptides and doping in sport - Sky News, 2014 (https://m.youtube.com/watch?v=0rppkK_j0CA&t=21s) Therapeutic application of Whole Body Vibrations - book co-authored with Alfio Albisini Technology This was one of the first website in world on Physiotherapy. Some of the content from that 1998 website can still be found here. At the time, the URL was www.acay.com.au/~mkrause/welcome.html ,which represented my practice in Wentworth Falls in the Blue Mountains as well as my International Teaching. It was born from a clinical reasoning software (CAI) which I had developed the previous year, during my Post Graduate Health Science Education course. I had undertaken a DOS 5.0 programming course in 1993, whilst using Word Perfect and Harvard Graphics and Lotus 123 during my research at the Rennbahn Klinik, Basel, Switzerland. 40mB hard drive with 5'1/4'' inch 'floppies' and 4mB RAM. That was my first computer and preloved by one of my clients.  At the time, word processing required meta-tags, which meant that by 1998, HTML tags and creating a website were almost second nature. I supplemented my knowledge with Java 1.0 and javascript. The Computer Aided Instruction (CAI) was based on website design and Desktop Publishing. The latter was a TAFE course I undertook, during the last year of my Masters in Manipulative Physiotherapy in 1995.  Interestingly, in the early years of this website, it was possible to see where the people were, who were reading it. Readers included people on US Battleships and even a person from HR in the US State Department got in touch!!! Teaching, Sports and Travel I left Australia in 1987 to pursue a job in Switzerland. During 1986-1987 I worked in the Illawarra Area Health System, where I met a British Physiotherapist, Bridget, who had worked so closely with James Cyriax, that she was able to apply shoulder injections. She had also worked and travelled with the Royal London Ballet. Fortunately for me, she put me in contact with a Rheumatologist in Basel, Switzerland, who sent my CV to Bad Ragaz, where I was offered a position, starting in April 1988. This left me with 6 months to travel in South America, where I wanted to learn Portuguese and Spanish, with the ultimate aim of working there or in Mozambique or Angola. At the time, Spanish was the only viable option to learn in Australia. I did this, via correspondence, which the NSW Department of Health paid for. I had a friend, Beatriz Oliviera Gomez, who had just graduated from medicine, in Rio de Janeiro, and I figured Spanish would become a conduit to learn Portuguese when I was in Brazil. School French, Spanish, Portuguese, German and later Italian and some Dutch became very useful for working in Switzerland, later teaching, in some of those languages, around the world.  When I arrived in Bad Ragaz, I was almost immediately asked to teach. I had no more than 16 months clinical experience. This became a recurring theme, where Rolf Baeni and I would give workshops in South America and in particular Chile, but also Brazil and Argentina in Spanish and Portuguese. These workshops included Jenny McConnell's methods, Clinical Reasoning and the Maitland techniques, Neural Mobilisations, Muscle Energy Techniques, Bad Ragaz Ring Method for Hydrotherapy, conference presentations, etc. This reflected the high standing Australian Physiotherapists had in the world. Bad Ragaz was a place famous in the 'old world' for the thermal springs. Prior to the war, aristocracy would come to spend 3 weeks recuperating and rejuvenating in the springs. Even, in the late 1980's 'the old world' living in the 'new world' would arrive from far flung places such as Tel Aviv, Buenos Aires, Montevideo, Santiago and New York. Bad Ragaz was also famous in the physiotherapy world for the Jim Halliwick hydrotherapy program. He worked with astronauts and cosmonauts on their rehabilitation after extended space missions. Combining the buoyancy and resistance of water for mobility and strength. Bad Ragaz also had a school for physiotherapy workshops and training which had been set up by Dr Zinn. Furthermore, Dr Hohmeister was treating Pope John Paul's knees, as well as other celebrities, including people who would later facilitate us getting contacts in South America, of physiotherapists, who would host our workshops. These were pre-internet days and we needed to 'train the trainers' in order to change the world. A colleague and friend, Pia Baake was a student supervisor in Bad Ragaz, when a young Swiss Italian speaking student named Alfio Albisini turned up. Together we taught him clinical reasoning in the Maitland methodology, as well as neural mobilisations, in Italian and German. He was almost expelled from his school, in Basel, as a heretic, when he described what we had taught him!!!! We were also reprimanded for teaching avant guard methodology to a student from the Nordic School of Manual Therapy.. A few years later, whilst living in Basil, I encouraged Alfio, to pursue the Australian way, where he went to Curtin University in 1995. He met Bob Elvey, Tobby Hall, Kim Robertson and Max Zusman there. Together with Peter Michel, my old boss and colleague whom I'd introduced the McConnell method to, Alfio became a McConnell instructor which he taught all over the world in multiple languages, including some Arabic.  He convinced me to come to a conference in Rome, in 2005, where he invited 'the who's who' of musculoskeletal physiotherapy, including all the famous Australian presenters (Gwen Jull, Jenny McConnell, Bill Vincenzino, Michael Shacklock, Tobby Hall) as well as Freddy Kaltenborn and Ron Melzack, The latter was famous for the 'pain-gate theory'. This was a culmination of his teaching of the McConnell technique as well as his interaction with Tobby Hall and Kim Robertson. Later, he was able to teach the Mulligan technique and with Michael Shacklock the ANT methodology. Alfio has taught these courses for a greater part of two and half decades all over the world. The countless physiotherapists whom he taught and who in turn used their knowledge for the betterment of their clients is hard to imagine. He continued to work as a physiotherapist in his own clinic, whilst still teaching. An amazing achievement. I went to Switzerland to compete in Road Cycling and Orienteering. I managed to do that as my prime objective for being in Europe. However, the great people around me, especially Pia Baake, Peter Michel and Rolf Baeni, they seriously encouraged me to be more than just an athlete who happens to be a physiotherapist. I liked the travel with Swiss National Teams, working and training with professional athletes, mixing languages, becoming involved with Reto Wenzil and psychological team building, Olympic development, biomechanics research (Stabilometry, Telemetry, Force Platforms and EMG analysis in Knee and Ankle surgery, as well magnesium and carbohydrate supplementations) at the RennBahn Klinik, Basel, Switzerland and in Magglingen. The Rennbahn Klinik was the conduit to players from AC Milan, Lazio Roma, VFB Stuttgart, Werder Bremen, and FC Basel. We were even made an offer to set up a physio clinic in Milan. These were halcyon days, of a young professional, as well as the climactic ones, where the sky seemed to be the limit. Dr Bernhard Seggesser was the Olympic team doctor and a well known orthopaedic surgeon seeking out perfection. Although a self admitting flawed personality, it was interesting to be working with a genius....and like Bad Ragaz, people would come from all over the world to see us. Underbelly On the darker side, I saw the underbelly of the Sydney Olympics. Coaches, managers and athletes having nervous breakdowns before or after the Olympics.....some people (including a doctor) committing suicide, coaches being committed after being found running around the forest stark naked and seeing 'demons' or to the more mundane psychological depression 'let down' after such a major event. The re-adjustment to normal life and the need to re-define themselves and finding new meaning in life was a terrible thing to see. Working with Tour de France cyclists, National Gymnasts, Olympic Skiers, Rowers, Soccer Players we had seen the impact of anabolic use in the 1980's, yet we turned a 'blind eye' to EPO doping in the 1990's as it was seen as oxygen supplementation where the prevailing attitude was that everyone else is doing it. Later. similar arguments were made with 'recovery' and peptide use. The latter, frequently involved substances which weren't banned but also weren't approved for human use.  Sadly, there was a medical doctor, who missed a pre-existing knee injury, in a very expensive soccer transfer. He had a fatal car accident.  Whilst teaching in Zimbabwe, the lady who hosted me, agreed to treat two journalists who had been tortured by Robert Mugabe's henchmen. They were so brave and for the first time in my life I actually encountered real fear. The fear that we could all be dragged out of beds in the dead of night, the gnawing tightness in the stomach and the tremor in my hands. On the same trip, a few weeks later, a similar experience, where the night watchman, shot dead an intruder. The intruder and the night watchman happened to be brothers of leaders of two opposing gangs in the local Favela (Brazilian slum). Cover up of where it happened, and to whom followed. to prevent escalation of the situation.  After these two closely followed events and witnessing the AIDS ward, with it's smell of death, in Harare General Hospital, I decided to stop teaching. Sport Thanks to my own involvement in high level Cycling, Mountain Running and Orienteering I had the opportunity to cycle with TDF cyclists and thanks to my job, I was taught to ski by Swiss National Ski Team members. Training and interacting with high performance individuals made me understand the process and pitfalls of training from a personal and professional perspective. At one stage I even managed some significant time out, where I cycled a mountain touring bike around 2/3 of South America in 1990-91, so that the altitude and endurance training would change my physiology for life. Demographics What is surprising is how demographics can influence your specialisation. Whilst teaching in Japan, I noted that a lot of people have 'frozen shoulders', whereas in Switzerland I didn't see a single 'frozen shoulder' but it seemed like everyone had Scheuermans Disease. Whilst working in the Blue Mountains, people were generally Blue Collar workers and out door types, pulling sleds to the South Pole or climbing Mt Everest, whereas in the early days in North Sydney, the predominant white collar IT workers had very little muscular physique. Sports specific injuries and physiques are also an interesting variation, where I seemed to generally see people from 'individualistic' type of sports, with the exception of soccer. Interestingly, when working with elite and professional athletes, I'd often come across people who were in the latter part of their career and who had never really been injured enough to see a physiotherapist. This was the case with a tennis player, who at the time was playing doubles with Boris Becker. he was in his late 20's and came to see me with some hip pain. He was such a natural talent, that his abilities were serendipitously discovered, whilst playing ice hockey, with a friend, at 13 years of age. He managed to be ranked 14th in the world rankings and never have an injury! We often aspire to be an elite athlete and we look at them for perfection, yet in the science of physiotherapy, we are frequently trying to establish a norm. What is it that these 'outliers' can tell us, for the treatment of the general population? Many programs have now been set up, for injury prevention. An example includes FIFA 11 Plus in soccer as well as the modification of sport such as the reduction of ball heading to prevent concussion like injuries.  Since, deterministic chaos uses 'outliers' as does game theory, I formed an interest in these areas. Health advocacy Even whilst still at school, I lobbied for cycling infrastructure and recognition as an equal road user. Back in the 1970's, where the car was king, we cyclists were a fringe community, who generally knew someone, or knew of someone, killed on the road whilst cycling. As such, I cycled all over the world and saw how things were done elsewhere, I was also a part of the fledgling mountain biking and pack cycling scene. Additionally, road cycling gave me the opportunity, to work and ride with Tour de France cyclists as well as Swiss National Team track and road cyclists.  Whilst visiting Montreal for a Biomechanics conference, I discovered the Route Verte of Quebec, with my life long friend and famous Belgium physiotherapist, Jean Louis Thonnard (Catholic University of Louvain, Belgium). This was 1998 and I was living in the Blue Mountains, west of Sydney. We had one of the busiest highways, in Australia, crossing the Blue Mountains, which was getting an upgrade and it followed the railway line. Next to the railway line and through various National Park tracks, there was the opportunity to develop a Trans Blue Mountains Cycling Trail. I created a small group of advocates where we defined our submissions to government, based on the health and economic value of cycling to the community. One quarter of a century on, we're still fighting and gradually getting results. Read more : the Sea to Sky Cycling Trail. Muscles and the immune system Having worked at the highest level of sporting endeavours I noticed the link between muscles and the immune system. Moreover, an older person asked me "why are my muscles falling off me?" When I didn't know the answer, as I'd always done in life, I went looking for the answer. The answer was Sarcopenia. In 2002, I had never considered the muscle anything more than a prime mover, but suddenly it was a protein sink for hormones and immune substances. The most important organ of the immune system! The nexus was now complete, muscle-immune-neurophysiology, pain and inflammation. I'd examined hormones and exercise in regards to the thyroid gland, pro-opiomelanocortin, and the locus coereleus back in the day in Bad Ragaz in the late 1980's. One of the first courses I'd ever attended, was on myofascial releases, with Francine St George, where I felt a serious immune reaction to such techniques. Years later I learnt about Myofascial Trains and in 1998 I started Dry Needling. Later, in the mid 2000's, Jay Shah, demonstrated fibroblastic movement activity during dry needling and the release of immune substances!! Anecdotal clinical observations were followed by the scientific evidence, not the other way around! Paradigm shifts The paradigm on graduation in 1986 was that physiotherapists don't massage, we do joint mobilisations and use electrotherapy modalities. In 1987 I learnt the power of massage from Francine St George and her myofascial release techniques. Trigger point massage followed. Australian Physiotherapists weren't particularly good at exercise prescription, whose void was filled by the introduction of Exercise and Sports Science courses around that time. However, the manual therapy approach was being blended with concepts of motor control by Jenny McConnell. The passive treatment approach paradigm was further confronted when i reached Switzerland, where German speaking physiotherapists had a Krankengymnastic (Remedial Gymnastics) background, where exercise was used for all forms of musculoskeletal dysfunction. As the Iron Curtin fell, the East German physiotherapists, who were frequently graduates of the Sports Science Academy of Moscow added to the strong exercise treatment philosophy.  They wanted to learn from me, whilst I was learning from them, functional stabilisation and mobilisation was being used, which for all intents and purposes was core stability. A concept, later made famous by Queensland University researchers (Paul Hodges and Gwen Jull) in the mid 1990's. Classification of low back pain, based on movement disorder, was further developed, by Peter O'Sullivan at Curtin University, in the late 1990's. I was teaching in Japan, in the mid 1990's, where I saw Kinesiotape for the first time being used. Later, whilst teaching in Portugal, I met physiotherapists researching the effect of Kinesiotape. In many countries, whilst teaching, I learnt that many physiotherapists had never used a tendon hammer, yet we could all learn from one another, different approaches to similar problems. In the 1980's, the concept of University training, in many European countries, was embryonic, let alone the use of clinical reasoning, where medical practitioners dictated diagnosis and treatment prescription. In Switzerland, some friends and colleagues undertook Osteopathy training to make up for this lack of autonomy and lack of University education. Some Chilean colleagues became chiropractors. By the early 2000's, muscles became an organ of the immune system, which could be stimulated through exercise, myofascial releases and trigger point dry needling. The imaging of pain which had begun in the early 1990's was being taken to the ultimate level by Lorrimer Mosely and his treatment of Sudek's Atrophy (CRPS). In the 2010's, functional cortical stimulation was being used for the treatment of chronic knee pain by my friend and ex-student Abrahao Baptista in Brasil. By 2020, those oscillatory systems of joint mobilisation and motor control from the 1980's were being taken, by me, to the level of 'deterministic chaos' where the 'outlier' defines the health of the system.  An incredible journey from the passive joint oscillations to the immune system and eventual 'deterministic chaos theory' in 2020. The best profession ever!!!...at least for me it has been such....and added to these major developments, in thought and knowledge, have been all the positive experiences, I've had with teachers, colleagues and clients, whom I've taught and treated along the way. Uploaded : 29 December 2020  Updated : 31 August 2022 Read More

Tennis elbow vs golfer’s elbow - what’s the difference? Tennis elbow and golfer’s elbow. Two causes of elbow pain that are associated with sports, even though you don’t ever need to play either sport to experience one of these conditions. Both involve inflammation of the tendons that attach to the elbow, and are caused by repetitive motion of the arms and wrist. But what are the differences between them, and how can you tell which, if either, you have? Below we have shared the main attributes, symptoms, causes and treatments for each elbow condition, as well as what you can do to help prevent both. What is tennis elbow and golfer’s elbow? The most noticeable difference between the two conditions is the area of the elbow that they affect. Tennis elbow causes pain in the outside of the elbow and forearm. This is due to strain to the extensor carpi radialis brevis and extensor digitorum tendons of the forearm, which extend and stabilise the wrist. Golfer’s elbow on the other hand, will cause pain on the inside of the elbow and forearm as the inside tendons of the forearm (which flex your wrist and contract your fingers when you grip something) have been overused. Tennis elbow is most common in people aged 30-50, whereas golfer’s elbow predominantly affects people over the age of 40. Symptoms Both conditions will cause pain in your elbow that usually radiates down your forearm. In tennis elbow, this pain will begin on the outside of your elbow, whereas in golfer’s elbow you will feel the pain on the inside of your elbow and arm. There are a few other signs and symptoms which are common in each condition: ● Pain when you reach for, grasp or lift something● Weakness in your forearm or a weak grip● A dull ache when resting Causes Both elbow conditions are caused by repetitive movements which overuse certain muscles and tendons. ‘Overuse’ is considered to be high-level activity of 30 minutes or more, performed three or more times per week. However, the movements that cause each condition are different. Tennis elbow can be caused by impact motions, such as hitting a ball with a tennis racket (or badminton racket or baseball bat) and throwing motions (javelin and discus throwers are prone to the condition). Repetitive lifting or turning of the wrist can also lead to tennis elbow, making plumbers, painters, builders and hairdressers particularly susceptible. Regular typing can have the same effect. Golfer’s elbow is predominantly brought on by repeated lifting movements, especially where the elbow is extended and the palm is face down. Gardening, digging, assembly line work and throwing a ball are common causes, and if you are lifting weights with a poor technique then you are more at risk of this condition. The shoulder, neck and ribcage can also contribute to tennis and golfers elbow like symptoms. Neural irritation may require joint mobilisations to the cervical and thoracic spines, as well as a home programme of neural mobilisation exercises. Additionally, altered bone alignment in the elbow and wrist can create dysfunctional biomechanics leading to tennis and golfers elbow symptoms. Mulligans Movement With Mobilisations (MWM) can help eleviate symptoms. Treatments The good news is that both tennis elbow and golfer’s elbow are very treatable. There are a few things that you can do at home to reduce the pain: ● Rest your arm● Apply ice to reduce the inflammation● Take anti-inflammatory painkillers, such as ibuprofen (always check with your doctor first) However, both conditions can take weeks or even months to recover from, and can worsen if not treated effectively. Your best course of action is to see a physiotherapist, who can help you with exercises to stretch and strengthen the forearm muscles and reduce strain on the inflamed tendons. Your physio will also advise you of how you can adjust your arm movements in future to avoid this happening again. Prevention Although we’re more than happy to help you with your elbow pain, we’d ideally like you not to experience it in the first place. Here are a few steps you can take to prevent tennis and golfer’s elbow: ● Regular stretching and strengthening exercises for the muscles of your forearm● If your job involves the kinds of movements discussed above, talk to your manager about safety precautions that can be put in place● Take regular breaks from any repetitive arm motions and stretch your muscles● If you are performing regular sports activities, make sure your technique is correct and seek professional coaching or advice to improve your movements and check that your equipment is appropriate for your needs If you are experiencing pain in your elbow, do not leave it until further damage has occurred. Get in touch with us straight away by calling 02 9922 6806 and we can start your road to recovery.  References 1. Orthopedic Institute of Pennsylvania. 2020. Tennis Elbow vs Golfer’s Elbow Explained. [Onlinehttps://www.oip.com/tennis-elbow-vs-golfers-elbow-explained/#:~:text=Tennis%20elbow%20presents%20with%20pain,or%20tingling%20in%20your%20fingers. [Accessed 25 11 2020] 2. NY Orthopedics. 2015. Tennis Elbow vs Golfer’s Elbow. [Onlinehttps://www.newyorkorthopedics.com/2015/08/21/tennis-elbow-and-golfers-elbow-the-causes-symptoms-treatments/. [Accessed 25 11 2020] Uploaded : 11 December 2020 Read More

Your guide to a healthy heart We all know how important it is to look after our heart. If you want to live a long and active life, you need to be kind to it every day. But how kind are you to yours? Statistics suggest that many of us need to be doing a whole lot more, as cardiovascular diseases are the number one cause of death globally every year. Nearly 18 million people lose their lives annually as a result of cardiovascular diseases, accounting for approximately 31% of all deaths. Cardiovascular disease is an umbrella term used to describe any disease relating to the heart and blood vessels, including coronary heart disease (CHD) and cerebrovascular disease (e.g. stroke), as well as others. Some of the risk factors for cardiovascular disease are changeable and others are not. These include:  Non-changeable factors • Advancing age• Gender – As this affects males more than females• Having a family history of heart disease Changeable factors • High blood pressure• High cholesterol• Being a smoker• Drinking alcohol excessively• Being overweight or obese• Lack of physical activity• High stress levels Your road to a healthy heart So, what can YOU do about it? The good news is, no matter where you are in life, no matter what age, you can do something today to improve your heart health. The following are some of the most important things to consider when working towards having a healthy cardiovascular system. Mizuno et al (2021) Exercise and Sports Science Reviews, 49, 3, 157-167 Keep a healthy weight Being overweight or obese is one of the modifiable risk factors that is easiest to change. You just need to ensure you are doing two things… Exercising regularly and eating a healthy, balanced diet. How many of us know this, but fail to get on board consistently? We’re all a little guilty from time to time, aren’t we? Exercise has many body-wide benefits that are too long to list in this blog but challenging your heart through exercise regularly each week is a great way to help control blood pressure and cholesterol levels. Did you know that going for a 30-60-minute brisk walk each day is all you need to keep the heart in check? There are so many other options when it comes to exercise though… Cycling, swimming, aerobics, team sports, martial arts. As well as helping you maintain a healthy heart, your body will benefit from increased flexibility and strength, and a clearer mind. see also : https://www.back-in-business-physiotherapy.com/health-advocacy/exercise-and-obesity.html elsewhere on this site Combine regular exercise with a good diet and you will be winning on the weight front if you persist. There are many foods out there that hold ‘cardio protective’ properties. Meaning these foods help you reduce the risk of developing cardiovascular disease if eaten regularly as part of your balanced diet. Some of these foods include: • Those high in Omega-3 fatty acids (including oily fish, walnuts, chia seeds, flaxseed oil)• Red wine (when consumed in moderation)• Dark chocolate and green tea (due to their antioxidant content)• Fruits and vegetables (make these a big part of your diet!) A very strong relationship has been established between the role of perivascular adipose tissue (fat) and exercise on arterial function with obesity (Boateng, SY 2021, Exercise and Sports Science Reviews, 49,, 3, 188-196) meaning exercise induced up-regulation of Nitrous Oxide, Prostaglandin 2, and reduced ROS (reactive oxidative stress) as well as reduced endothelial 1, together result in improved aortic stiffness and endothelial dilation. Other handy tips include: • Replacing salt with herbs and spices during cooking• Reducing intake of foods high in saturated and trans fats which can raise cholesterol levels and lead to clogged arteries. This in turn increases risk of stroke and heart attack. Avoid eating cakes, chips/crisps and pastries excessively. Do not smoke Smoking directly damages your blood vessels which quadruples your risk of heart attack and stroke. Our advice to you is plain and simple… If you do not smoke, keep it that way. If you are a smoker, do whatever you can to begin quitting today. Quitting smoking is tough and needs to be done correctly. Speak to your doctor today for help and advice. The day you smoke your last cigarette immediately decreases your risk of cardiovascular disease and early death. Learn how to manage your stress levels Chronic stress is a major contributor to increased heart rate and blood pressure. Learning to control your stress levels can help to alleviate the effect this has on the cardiovascular system. Physiotherapists can offer advice on ways to manage stress. Some of the most popular forms of stress management include: • Regular exercise• Breathing and relaxation exercises• Meditation (including mindfulness-based cognitive therapy, as well as other forms)• Seeing a doctor, psychologist or life coach Educate yourself and get checked by your doctor regularly as you age The bottom line is your heart health is your responsibility. You must act to ensure cardiovascular disease doesn’t become a part of your life. You have a wealth of resources at your fingertips. We (and other health professionals) are here to help guide you to optimal health. We thoroughly recommend you regularly check-in with your doctor, especially as you advance through to your later years, to make sure everything is functioning well.  References 1. World Health Organisation. 2020. Cardiovascular diseases. [Onlinehttps://www.who.int/health-topics/cardiovascular-diseases/#tab=tab_1. [Accessed 07 Nov 2020https://www.heartfoundation.org.au/heart-health-education/keeping-your-heart-healthy. [Accessed 05 Nov 2020https://www.healthline.com/health/healthy-heart-tips. [Accessed 05 Nov 2020https://www.heart.org/en/health-topics/heart-attack/understand-your-risks-to-prevent-a-heart-attack. [Accessed 07 Nov 2020https://www.heart.org/en/healthy-living/healthy-lifestyle/how-to-help-prevent-heart-disease-at-any-age. [Accessed 05 Nov 2020] Uploaded : 3 December 2020 Updated : 2 February 2022 Read More

Foam rolling: Pros and cons New foam roller and wondering where to start? Have a read of this, and you’ll feel more informed. And if you still aren’t convinced or have more questions, feel free to ask us next time you are in the clinic and we will discuss it with you in person. For now, let’s keep on rollin’. Head into any sports store and there is a good chance they’ll have some foam rollers for sale. Foam rollers are widely available and have been used as a therapy aid by millions of people for years since first coming on the market in the 1980s. What is a foam roller? Foam rollers are usually cylindrical in shape, very lightweight, and range in length and firmness from long to short and soft to hard. Their design and use is simple. You simply lie the roller on the ground, choose a body part, place it on top and start rolling. But what are the actual benefits of foam rolling? Are there any potential side effects? Or negative impacts? Let’s take a look… History Foam rollers were originally used by practitioners that followed the Feldenkrais method of treating the body. Early practitioners used the rollers as a way of providing support to the body and would get their patients to stand on the rollers during balance exercises. Use of rollers progressed over the years. In 1987, their use as a self-massage tool was pioneered by physical therapist, Sean Gallagher. They are now used by millions of people across the globe, including gym goers, weightlifters, gymnasts, athletes and many others, as a tool to massage and release tight muscles. Pros Some of the benefits of foam rolling include: • Reducing muscle pain (including the management of certain pain syndromes like fibromyalgia)• Increasing range of motion around a joint• Making muscles more responsive to stretching• Relaxation• It’s a relatively safe way to self-massage tight muscles Cons Due to their widespread availability, foam rollers can be purchased by anyone, even though they may not be a suitable tool to use for that particular person. There are certain conditions and circumstances where use of a foam roller could be detrimental or damaging to a person’s body. Foam rolling exercises load and stress the underlying tissues, including nerves, skin receptors, blood and lymphatic vessels, as well as bones. People with conditions including advanced diabetes mellitus, lymphedema, varicose veins and severe osteoporosis should avoid this form of exercise, unless advised otherwise by a medical professional. When recovering from a muscle strain, a foam roller may be a handy thing to have around, but rolling over a torn muscle should be avoided in the early stages of injury and until you’ve been given the all-clear by your therapist. Rolling over an acutely torn muscle could hinder the repair of the muscle and at the very least would be incredibly uncomfortable and painful. Please note that scientific evidence supporting the use of foam rolling for therapeutic reasons is sparse and caution should be taken by anyone who uses them. Our advice to you is to ask your trusted physiotherapist if it’s suitable for you. We have the expertise to guide you in the right direction and if it’s a great option for you and your body, we’ll give you the thumbs up to rock’n’ROLL! References 1. Healthline. 2019. What are the benefits of foam rolling? [Onlinehttps://www.healthline.com/health/foam-roller-benefits. [Accessed 06 Oct 2020https://www.health.harvard.edu/staying-healthy/should-you-add-foam-rolling-to-your-workout-routine. [Accessed 06 Oct 2020https://www.researchgate.net/profile/Juergen_Freiwald/publication/308392869_Foam-Rolling_in_sport_and_therapy_-_Potential_benefits_and_risks_Part_1_-_Definitions_anatomy_physiology_and_biomechanics/links/57eb7bee08ae91a0c8d4004b/Foam-Rolling-in-sport-and-therapy-Potential-benefits-and-risks-Part-1-Definitions-anatomy-physiology-and-biomechanics.pdf Uploaded : 17 November 2020 Read More

Hip pain in the elderly Joint pain in the elderly population is a common complaint, with women being affected more often than men. There are several causes of hip pain amongst the elderly. We’ve put together this quick-fire list to inform you of what can cause hip pain in our senior citizens. Joint disease One of the most common causes of hip pain in the elderly is joint disease that leads to degeneration of the joint surfaces and results in a poorly moveable joint. The most common condition affecting the hip is osteoarthritis (OA), affecting approximately 25% of the population. The hip is a weight-bearing joint and through a lifetime has to withstand a great deal of force passing through it on a daily basis. Many factors in a person's life can lead to the onset and progression of OA in the hip joint. An injury to the hip earlier in life can kick start a process of early degeneration leading to poor movement and the development of pain as a person journeys through the second half of life. Other factors that may lead to the development of hip OA include obesity and or poor exercise regimes (or lack of exercise altogether). Other forms of joint disease that can cause hip pain include rheumatoid arthritis (RA), gout and pseudogout. Bursitis The word ‘bursitis’ means inflammation of a bursa. A bursa is a small, fluid-filled sac found throughout the body around joints and areas of high movement to reduce friction. There are several bursae found around the hip. These are usually located between a bone and tendon (or other tissues) and help to maintain smooth-moving joints. Weakness or long-standing dysfunction of the gluteal and other hip-related muscles (often seen in the elderly) can lead to compression of the bursae which increases the load on them. Over time and repetition of movement, the bursae can become inflamed and cause pain, often felt on the bony, outside part of the hip. Bursitis can be treated with hands-on therapy and exercise prescription aimed at strengthening and improving movement at the joint. Frequently, bursitis has a immune-metabolic origin. Clinically, I noticed this when working with young elite Swiss sports people back in the early 1990's, that they could suddenly develop bursitis which invariably involved some sort of predisposing immune compromise. Commonly, this involved a case of diarrhea or a cold or similar, in the 6 weeks prior to the onset of the bursitis. I've continued to notice this trend across the spectrum of ages and physical activity in the decades since. A similar trend exists for tendinopathy as well. where scientific research has demonstrated invasion of immune and fatty substances. Moreover, the bursitis and tendinopathy usually co-exist. Please see the shoulder section of this website for details on the latter and see the section on immune system and chaos for the former.  Importantly, the gut biome should be consider in either case. The use of pro-biotics may be considered, such as sauerkraut, acidophilus, etc  Tendinopathy Tendons join muscles to bones. As we age, the health of our muscle and tendon tissue declines and the efficiency of movement is affected. Similarly to bursitis, long-standing muscle dysfunction because of a failing hip joint can place excessive load on the tendon which attaches the muscle (e.g. the gluteal muscles) to the thigh-bone. If strengthening of the muscles and tendons is not achieved in the early stages of injury or disease, the fibres that make up the tendon become degenerated and deranged, resulting in a condition known as tendinopathy. This affects the tendon’s ability to withstand high loads passing through it and can lead to pain, regularly felt before and after exercise or movement. Long standing tendinopathy can lead to a tear which is common in older persons and can be the cause of much disability. Lower back dysfunction This is a very common cause of hip pain in the elderly population. As we age, our spines and the various tissues that play a pivotal role in its functioning can become degenerated. If a degenerated bone or joint in the spine presses on a nerve coming out of the spine, it can lead to a phenomena known as ‘radicular pain’. This is pain that may be felt in the hip (or other areas of the lower limb) but actually the problem lies in the lower back. Fracture Due to the increased rates of conditions including osteoporosis (loss of bone mass) and sarcopenia (loss of muscle mass), we are more prone to falling as we get older. A fall onto the outside of the hip can easily result in a fracture of the neck of the thighbone, close to where it attaches into the pelvis. As with any bone fracture, pain is a common symptom. A hip fracture may require surgical intervention and can greatly impact the health of an elderly person with increased risks of infection and death posing a real threat. If you have hip pain and are concerned, please call us today on 02 9922 6806 to book your appointment immediately. Stay safe everyone! Uploaded : 2 October 2020 Read More

Sacroiliac Pain - musculoskeletal physiotherapeutic clinical reasoning using imaging and stability testing exercises The sacroiliac joint (SIJ) is designed to transfer the load from along muscle energy straps of the limbs into the torso. The torso, hip and pelvis are constructed into a series of slings (front, back, side, inside and spiral) which supports those structures receiving the load. Consider a person lying in a hammock and you have an analogy, for skeletal support, by the soft tissue structures of the body. Andre Vleeming described these 'slings' in the 1990's and body work practitioners such as Ida Rolf (and Thomas Meiers) referred to myofascial trains in the 1970's. As such, a series of exercises can be used to assess and treat stability across the SIJ. People interested in the 'energy straps' across the lower limb should look at 'inverse dynamics' elsewhere on this site. Inverse Dynamics Those interested in 'hands on' treatment of pelvic dysfunction should look at : https://www.back-in-business-physiotherapy.com/we-do/muscle-energy-techniques.html elsewhere on this site  Uploaded : 19 September 2020 Read More

Hip flexor injury: Contusion vs strain Hey everyone! This month we are drawing focus on injuries that affect our hip flexor muscles. Injury to the hip flexor muscles can lead to pain felt in the front of the thigh region, as well as the hip and groin. Hip flexor injuries are common in sports, including football (all forms), basketball, hockey and athletics. What are your hip flexors? Your hip flexors are a group of muscles that move the thigh forwards and outwards, in front of the body. The main muscles involved in the movement of hip flexion include: • Rectus Femoris (one of the quadriceps muscles)• Iliacus and psoas (pronounced ‘so-ass’ — collectively known as the ‘iliopsoas’ muscle)• Tensor Fascia Latae (or TFL)• Sartorius• Some of the groin muscles known as the ‘adductors’ The most commonly injured hip flexor muscle is the rectus femoris muscle (pictured above). This is the muscle that runs from the pelvis, down the centre front of the thigh, to below the knee. This muscle not only flexes the hip, but also extends (or straightens) the knee. Types of injury The most common injuries of the hip flexor muscles (i.e. rectus femoris) include contusions and strains. Contusion: A contusion is an area of skin and underlying tissue that has been damaged by a blunt force trauma. This may come in the form of an opponent’s knee during sport, or an object like a hockey puck striking the thigh. A contusion is also known as a ‘cork’’. The impact of an object causes the tiny blood vessels under the skin and in the muscles to break and bleed. The blood collects into a space around the impacted muscle fibres creating a pool of blood. A bruise appears on the skin where the impact has occurred. Strain: A strain is a tearing of muscle fibres usually caused by a force too great for the muscle to withstand. This may occur during an explosive movement including kicking, jumping or running. Strains are either partial (where some muscle fibres tear and others remain intact — known as Grade 1 or 2 strains depending on severity) or complete (where every muscle fibre tears — known as a Grade 3 strain or in the old nomenclature Grade 3 partial complete full thickness tear, grade 4 complete tear. The latter is still commonly used in calf tears). Strains most commonly occur at the location where the muscle merges into a tendon. In the case of the rectus femoris muscle which runs vertically down thigh, strains usually occur at either the hip-end or the knee-end of the muscle. It can be difficult to distinguish between a contusion and a strain as many of the signs and symptoms are similar. A thorough case history which takes down information including how the injury occurred and how it developed over time can help your physio come to an accurate diagnosis. Signs, symptoms and features The following table compares the features seen with a typical contusion versus a strain: Treatment The way we treat a contusion and a strain are very similar. The length of treatment tends to increase for more severe strain injuries, but the principles of treatment are largely the same. As with any acute injury, the first line of treatment is to control the bleeding and swelling under the skin. This includes protecting the body part from worsening injury, loading the part appropriately (i.e. being on crutches vs full weight-bearing), ice, compression and elevation of the affected body part. Gentle stretching and contraction of the affected muscle is allowed if tolerable. The next stage is to get the knee and hip joints back to full, pain-free range of motion. We can help here with some hands-on massage and joint mobilisation. We’ll kick up the stretching and increase the amount of strength training too. You should be able to use an exercise bike and go swimming at this stage, but we’ll advise when you can do it safely. When you are back to full weight-bearing exercises with full range of motion, the aim is to progress strength and flexibility exercises gradually over a period of weeks. These will include a combination of agility, jumping and balance exercises. When you reach your exercise goals, we’ll advise when return to training/full sport participation is appropriate… If that’s what your ultimate goal is. The most important thing is to ensure the return to sport/activity does not happen too soon. Strains commonly recur, usually as a result of rushed or incomplete rehabilitation before returning to the sports field. So… taken a hit or felt a tear? Give us a call on 02 9922 6806. If you need help with a hip flexor injury, please do not hesitate to get in touch immediately. Early treatment is always preferred over the waiting game. With our help, you’ll be back hopping, skipping and jumping your way to a gold medal in no time at all. References 1. Healthline. 2019. Understanding hip flexor strain. [Online]. Available from: https://www.healthline.com/health/hip-flexor-strain. [Accessed 15 Jul 2020].2. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw Hill Education3. Margo, K. et al. 2003. Evaluation and management of hip pain: An algorithmic approach. The Journal of Family Practice. 52 (8). Available from: https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/5208JFP_AppliedEvidence1.pdf Uploaded : 25 August 2020 Read More

The twists and turns of torticollis Hello readers and welcome to our August 2020 blog. This month’s topic is a neck condition known as ‘Torticollis’. You may have also heard this condition referred to as ‘wry neck’.  What is Torticollis? Torticollis is a painful neck condition where one of the strong muscles on the side of the neck shortens, causing the head to twist and tilt out of its normal position. The muscle we are referring to is the ‘Sternocleidomastoid’, or SCM for short. It’s easy to locate this long ‘strap’ muscle… Turn your head to the left and the SCM pops out on the right-side of the neck. Trace a line from the base of your skull just behind the ear, down to the top of your breastbone and you should be able to feel the muscle. Although the name is a bit of a mouthful, it perfectly describes the at-tachment points for the muscle on the body: • Sterno- refers to ‘sternum’ which is the name of your chest / breastbone• Cleido- refers to ‘clavicle’ which is the name of your collar bone• Mastoid- refers to the ‘mastoid process’ which is a bony lump found behind the ear at the base of the skull There is a SCM muscle on each side of the neck. This muscle helps you to:• Turn your head to the opposite site• Touch your ear to your shoulder• Bend the neck forward• Tilt the head backwards• Breathe (it is an ‘accessory' muscle for breathing - kind of like a little helper to the main breath-ing muscles) Types and causes There are two main types of torticollis—congenital and acquired.Congenital torticollis means the condition is present at birth. This problem can develop in the mother’s womb if the baby’s head is held in an awkward position, or if the blood supply to the muscle is disrupted. Sometimes the bones in the neck do not develop properly and become fused together, this can also lead to a rare type of torticollis called Klippel-Feil Syndrome. Acquired torticollis means the condition develops after birth. The condition is common in both children and adults. Acquired torticollis can be caused by injury to the muscle, or the nerve that supplies electricity to the muscle. In the majority of cases, the cause is completely unknown. As with congenital forms, there are some rarer acquired types, including ‘spasmodic’ torticollis. This type is also known as ‘cervical dystonia’ and is a form seen in adults where all the usual symp-toms are seen, but may also come with a jerking type motion of the head caused by spasms in the SCM muscle. Signs and symptoms The signs and symptoms of torticollis depend on the type, but the main features include: • Neck pain and/or stiffness• An inability to move the head in the usual way• A tilted head to one side• Swollen and tender neck muscles• Uneven shoulder height• Headaches Treatment Parents reading this who have experienced torticollis with their newborn or young child will prob-ably remember the stress that comes with seeing their helpless little human with a seemingly un-changeable head position. It really is quite unsettling. The good news is that for the majority of cases, some focused regular stretching is all that’s needed to correct the head position and re-store the muscle to its full length. Young children usually respond very quickly to hands-on treatment. Some of the rarer congenital forms of torticollis can also be treated in a similar way, but these forms may also require the opinion of a surgeon who can perform a procedure to lengthen the muscle. As with a lot of conditions, surgery is a last resort and will only be considered when all non-surgical treatment techniques have failed. Other treatment techniques used for torticollis include:• Massage of shortened and tight muscles• Heat pack therapy to increase blood flow and relax tight muscles• Joint mobilisation and manipulation For people who live with a permanent or chronic torticollis, other complications are common. These include difficulties carrying out activities of daily living, depression, social isolation and chronic pain. Treatment should be from a multidisciplinary approach. This means that as well as seeing your physio for hands-on therapy, your doctor, psychologist, friends and family will all play a part. If you or a family member are struggling with torticollis, or a neck issue of another kind, please call us here at Back in Business Physiotherapy on 02 9922 6806 to arrange a convenient time to come in for a consultation. We’d love to help unravel the twists and turns of your torticollis and get your neck feeling relaxed and happy Uploaded : 20 July 2020 Read More

Shoulder injury blog: Labral tear The shoulder is one of the most complex joints in the body. It is made up of a total of four joints, numerous ligaments, joint capsules, muscles and other soft tissues. Movement at the shoulder is a complicated process and it relies on the controlled function of all the involved muscles and joints for that movement to be efficient and complete. Our shoulders are the most mobile joints in the body which is great for us because it means as humans we get to partake in fun activities like throwing sports, gymnastics and dancing, as well as movements we generally take for granted like being able to do up our bra’s behind our backs. This wide range of movement is only possible because the shoulder is less stable when compared to other joints in the body, leaving the shoulder prone to injury. This blog specifically focuses on an injury that relates closely to the ball and socket part of the shoulder joint. If you are into throwing sports, you may be familiar with it… It’s called the labral tear. A bit of anatomy… There are two main ball and socket joints in the body, found at the shoulder and the hip. Both work where a rounded ‘ball’ of one bone fits into a hollowed ‘socket’ of another. At the hip (the strongest joint in the body), the socket is very deep, and the ball part fits quite snuggly into it. This is a very stable joint. The socket in the shoulder is very shallow by comparison, and the ball part is still quite large. This is what gives the shoulder its lack of stability. Both the shoulder and the hip sockets are deepened and supported by the presence of a labrum — a rounded soft-type of cartilage. In the shoulder, the labrum completely surrounds the rim of the socket creating a ring. The very top part of this ring also acts as the attachment site for one of the tendons of the biceps muscle — a powerful mover of the shoulder and elbow joints. How does a labrum tear? The main ways labral tears occur are: • Repetitive movements such as overhead throwing• Carrying heavy objects• Dropping and catching heavy objects A tear can occur over time as the tissues degenerate over time and become weaker, or it might be from one single, forceful event. In most cases there is usually a combination of both degeneration and a large force which becomes the ‘straw that breaks the camel’s back type of scenario. As the biceps tendon attaches to the socket through the labrum, any large force that pulls on the biceps tendon (like suddenly catching a heavy object) can lead to the tearing of the labrum itself. The most common type of tear occurs across the top of the labrum from front to back, and these are known as SLAP (i.e. Superior Labrum Anterior Posterior) tears. Signs and symptoms If you have sustained an injury to the labrum in the shoulder, you may notice any or all of the following signs and symptoms: • Pain during shoulder movement (especially overhead and behind back movements)• Restricted shoulder movement• Popping, catching or grinding during shoulder movements• Tenderness at the front of the shoulder Depending on how you were injured, how severe your symptoms are, and your personal circumstances regarding work and home life, you may be sent for some imaging to confirm the tear. The tests we perform in clinic when we assess you do not always give us all the information we need to determine the best plan of action. A combination of clinical tests and imaging may give us a clearer picture of what’s going on. Can it be treated by a physio? Yes, but this completely depends on the severity of the injury and what your goals are. In most cases it is recommended that conservative therapy from a physiotherapist is tried first. Many athletes who have a labral tear can return to playing to some capacity with a non-surgical approach. The treatment aims to return the shoulder to full, pain-free range of motion through hands-on massage, mobilisation and rehab exercises that focus on range, control and strength of the shoulder girdle. For severe tears, you may require the opinion of a shoulder specialist. A labrum is not great at healing itself and sometimes needs help from a surgeon to return to normal. A professional athlete wanting to return to sport may choose this pathway, but a non-athlete who has no desire to throw a ball seriously again may be able to avoid surgery altogether. If you have a diagnosed labral tear, or have recently injured your shoulder and need help, we recommend coming to us at Back in Business Physiotherapy where we can discuss the best course of action for you and your circumstances.  Upload : 2 June 2020 Read More

Injury blog: Abdominal hernias Mention the word ‘hernia’ and most people will think of something painful sticking out of the belly region. You’ll be pleased to know this is not always the case. Many cases are completely pain-free and are only noticeable on a person when they are in a particular position. At other times there may be no other visual sign that a hernia even exists! Read on for more information... What is a hernia? A hernia is a protrusion of the abdominal contents (i.e. intestines) through a weakened or damaged part of the muscle or tissue that holds it in place. Hernias are commonly found in the abdominal region of the body; that area between the bottom of the rib cage and the hip / pelvic area. Abdominal hernias can be broken down into two locations: • Abdominal wall location: Hernias that occur through the wall of the abdomen on the front of the belly region• Groin location: Hernias that occur lower down in the abdomen around the groin region  Abdominal wall location There are a few different types of abdominal wall hernias with the most common being: • Incisional: These hernias occur in and around a scar or ‘incision’ left over from a previous abdominal surgery. During surgery, the muscles of the abdominal wall are cut to allow the surgeon to access the inside of the abdomen. This leaves a weakened area of the wall which is a potential site for herniation to occur. This type of hernia accounts for approximately 10-15% of all abdominal hernias. • Umbilical: This is a protrusion at the belly button which is regularly seen from birth. Over time these usually dry up and disappear altogether. It is possible to get these hernias as an adult too, usually as a result of being overweight or pregnant. • Epigastric: There is a tough, fibrous piece of tissue that spans from the tip of the rib cage to the pelvis in the mid-line of the body known as the ‘Linea Alba’. This forms an area of muscular attachment of the abdominal muscles. Due to a weakness in the abdominal wall above the belly button, a hernia can occur. This is common in infants, but again may happen later in life. Groin location • Inguinal: This is the most common type of abdominal hernia accounting for approximately 75% of all cases. The opening for this hernia is a region known as the ‘inguinal canal’ which allows for the testicles and spermatic cord to descend into the scrotum during male development. After this event, the canal should tighten, but in some males the muscles responsible for this do not respond as well as expected, leaving an area of weakness. As females do not forego this part of development, it rarely affects women. • Femoral: There is a space in the floor of the abdomen for a vein and artery to pass through and down into the leg, known as the femoral canal. In females this canal is wider which results in this type of hernia being more common in women than men. It accounts for approximately 10-15% of all abdominal hernias. Treatment Treatment of abdominal hernias depends on the severity and symptoms associated with them. Sometimes with a hernia, the abdominal contents inside them can become trapped and ‘strangled’, ’which can lead to loss of blood supply and ultimately death of tissue. These complications can possibly be fatal if left untreated. In these cases, and with most uncomplicated cases, surgery is the best course of action to ensure a full recovery. There is also a place for physical therapies like physiotherapy. Physio is particularly helpful following a surgical procedure to aid with strengthening of the abdominal muscles and surrounding area, supporting the area and reducing the risk of re-herniation. Scar tissue following surgery can affect our ability to move efficiently, however exercise as well as hands-on therapy can help to reduce the effect of this. If you have an abdominal hernia and would like advice on how to manage it, please get in touch today by going to our online booking website https://www.myhealth1st.com.au/find/physiotherapists/nsw/nsw-region/north-sydney/back-in-business-physiotherapy or by calling us on 02 9922 6806 to book a face-to-face or Tele Health appointment. If you require the opinion of a doctor or specialist, we'll ensure you are placed in the best possible hands. References 1. MSD Manual. 2020. Hernias of the Abdominal Wall. [Online]. Available from: https://www.msdmanuals.com/en-au/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/hernias-of-the-abdominal-wall. [Accessed 08 April 2020]2. Melbourne Hernia Clinic. 2018. What is a Hernia? [Online]. Available from: http://hernia.net.au/what-is-a-hernia/. [Accessed 08 April 2020]3. MedicineNet. 2020. Hernia (Abdominal Hernia) 9 Types, Symptoms, Causes and Surgery. [Online]. Available from: https://www.medicinenet.com/hernia_overview/article.htm. [Accessed 08 April 2020]4. Healthline. 2019. Everything You Want to Know About a Hernia. [Online]. Available from: https://www.healthline.com/health/hernia. [Accessed 08 April 2020] Uploaded : 28 April 2020 Read More

Deterministic Chaos Theory, Exercise, Physiotherapy Reasoning and the Immune System  by Martin Krause B.Appl.Sci. (Physiotherapy); M.Appl.Sci (Manipulative Physiotherapy), Post Grad Dip Hlth Sc (Exercise and Sports), Post Grad Cert Hlth Sc (Education) Known Knowns, Known Unknowns, Unknown Unknowns - the latter is what we need to recognise We were born from the chaotic fire of genesis. Laws of thermodynamics dictate our existence. Evolution of heat shock proteins (HSP) means that we are our immune system. Today, human multi-cellular life is still totally dependent on our unicellular ancestors and their componentry. Trillions of species and bacteria in the gut (flora) and skin alone, associated with immune substances, attest to the importance of unicellular life in the immune system. The abundance of energy species in the gut suggests a nexus with one of the organs most in need of energy, the skeletal muscle. Importantly, muscle cells have more mitochondria than most other cells, so they can readily produce work for movement. Consequently, muscles are an energy system and an immune endocrine organ. Notably, the development from unicellular to multi-cellular life needed movement. A commonality of cellular movement and macro-muscular movements exist. Physiotherapeutic and training interventions must consider the health of the immune system and its ability to deploy and be re-deployed. Training should avoid becoming 'stale' by having enough variety (chaos) to create perturbations in the immune system which induce up and down regulation of immune componentry. Physiotherapy should be innovative and creative, whereby the physiotherapist additionally considers immune-cognitive aspects of pain and inflammation, when people seek physiotherapeutic intervention after/during a change in their training regime and/or commencement of unaccustomed exercise, or in the presence of immune compromise. Index 1. What is a stressor?   3. General Adaptation Theory 4. Nasal Heat Shock Proteins 5. Heat Shock Proteins (HSP) pictures 6. Damping Ratios 7. Sympathetic N.S. & Chaos 8. Butterfly Effect & Chaos 9. Chaos theory and Physiology   11.Infection & HSP 12.HSP70 viral response (1) 13.Muscle-Immune response 14.Matzinger's Danger Hypothesis 15.Classes of HSP 16.HSP72 and HSP27 and muscle 17.Extracellular HSP 18.Aging, HSP and CK       22.Exercise & Respiratory Tract 23.Exercise and Resp Tract Infections 24.HSP viral response (2) 25.HSP-90 26.Mechano-transduction & heat 27.Actin-Myosin Cross Bridge 28.Entropy 29.Bicycle Cadence and Entropy 30.Eccentric Contractions 31.Eccentric Exercise & Immune Markers 32.Sarcopenia 33.Muscle Glutamine 34.Muscle Immune Conversion 35.Over-training 36.Chaos Theory 37.Deterministic Chaos & Immune System 38.Maths & Deterministic Chaos  39.Uncontrolled Manifold Hypothesis 40.Game Theory 41.Cortical Resources 42.Exercise induced disease 43.Anti-Carcinogenic Effect of Exercise 44.Allostasis 45.Neural Componentry & Chaos   47.Recovery & Sleep 48.Psychology & Immunity 49.Diet 50.Gut-Muscle Immune axis   52.Dosage of Exercise 53.Motivators to Exercise and to eat  54.Leptin, Diabetes and X's  55.Leptin and Diet 56.Exposure 57.Musculoskeletal Physiotherapy  58 Low Back Pain and Entropy 59.Conclusion 60.Justification 61.Links Oscillatory systems Many of the things an Australian trained Musculoskeletal Physiotherapist does has to do with oscillations. Everything from joint oscillations, therapeutic ultra-sound, to repetition in exercise to Whole Body Vibration (WBV) therapy involves an obvious form of oscillation. Other less obvious forms of oscillations occur within muscles, within whole body immune systems and across body musculoskeletal systems. The following argues that the expression of oscillations can determine the health and well being of a person beyond simplistic notions of biomechanics, pathology and repair. What is a 'stressor' and why is muscle considered an endocrine immune organ? The sympathetic nervous system has traditionally been assigned the responsibility for the 'freeze, fight or flight' stress response. Regardless of mechanism, the call to action goes to muscles. Culturally, we generally consider a muscular person as the 'picture of health'. Yet, what resides and moves within muscle is as important as the work those muscles produce.  When we exercise, the body adapts to a stressor, which is calorific, metabolic, physiological, immune and psychological. Phylogenetically, heat shock proteins (HSP) evolved from uni-cellular to multi-cellular life, and 'exercise' (physical activity) was associated with survival skills, such as food acquisition and defence (self-preservation). Interestingly, those same mechanisms can be 'fine tuned' to improve the age of your immune system. If we can get or maintain muscle bulk, we can maintain a reservoir of protein for immune function. If we can maintain adaptive processes to mechanical trauma and inflammation, we have a fighting chance of using similar processes to launch an appropriate immune response, fight infection, prevent cell death (apoptosis) and muscle-organ failure (cachexia).  What is the mechanism behind an 'appropriate' immune response? What sets the system in motion (perturbation) and what 'dampens' it? How do the laws of thermodynamics and conservation of energy apply? What is the predicted 'chaos' in the system and how do the immune and sympathetic nervous system act as oscillating 'manifold' for chaos to 'unfold' and 'refold'? Stress and the General Adaptation Syndrome The general adaptation syndrome (GAS) model of stress posits three stages to stress: alarm, resistance and exhaustion. In the alarm stage, the nervous system releases stress hormones to facilitate a freeze-fight-flight response. When a stressor is ongoing, like the COVID-19 pandemic, returning to homeostasis is more difficult. In the second stage — resistance — the individual’s allostatic load ideally returns to baseline. But many people will not, especially in the prolonged stress of a pandemic. Physicians should consider that patients reporting symptom exacerbations (of pre-existing issues), during this time, may benefit from stress mitigation techniques, including: Diaphragmatic breathing Guided imagery Mindfulness Limiting media exposure Progressive muscle relaxation Physical activity These techniques may include holistic approaches such as Yoga, Progressive Resistance Exercise (PRE), and endurance training. In the third stage, called exhaustion, people become overwhelmed from the ongoing stressor. This is where prolonged dysfunction can occur, and in which identifying a coping strategy becomes more difficult for the person. One would hope that intervention occurs during the second stage, when acceptance of behavioural modification is more likely. Furthermore, it is hoped that the general population remains active for life, even in the post COVID-19 era. The following is an overview of why exercise is so important, for the immune system, by using a 'deterministic chaos' theoretical approach to protect against chaos. Nasal Heat Shock Proteins Heat Shock Proteins (HSP) are found in virtually all living organisms, from bacteria to humans. They are a class of proteins which react both to heat, cold and oxidative stress. Since unicellular life, these small protein chains, have developed with evolution, and despite the complexity of multi-cellular life, they still have an important fundamental role to play in human survival. Incredibly, this, evolution, means that complex multi-cellular life, can still recognise their unicellular ancestor counterparts! Frequent confrontation of the host (human) immune system, with conserved regions of HSP, which are also shared by various microbial pathogens, can potentiate antimicrobial immunity. However, long-term confrontation of the immune system with HSP antigens, which are similar in the host and invaders, may convert the immune response against these host antigens and promote autoimmune disease. Since COVID-19 is thought to have an 'auto-immune' mechanism and has a profound impact on the airways, in symptomatic individuals, the following is an example of nasal mucosa HSP responding to heat stress. Nasal HSP's 1 hour after heat shock stimuli (Min et al 2020 International journal of medical sciences 17(5):640-646)  Heat Shock Protein - what they look like Small HSP (mycobacterium) by Kim, K.K., Kim, R., Kim, S.H.(1998) Nature 394: 595-599 PubMed: 9707123 DOI: 10.1038/29106  HSP 27 by Michael H. Chiu, Chunhua Shi, Matthew Rosin, Zarah Batulan, Edward R. O’Brien (2019) HSP 72 by Osipiuk, J., Gu, M., Mihelic, M., Orton, K., Morimoto, R.I., Joachimiak, A., Midwest Center for Structural Genomics (MCSG) 2010 Damping ratio To understand energy systems we must also understand 'oscillation control' by examining 'simple harmonic motion' (SHM) in terms of linear dynamics (kinetic and potential energy ) of a mass spring and it's 'damping ratio'. Simply stated, if you hang a mass off a spring and pull down on it and let it go, in the absence of plastic deformation, the mass will 'overshoot' back and forth several times before resuming its original position. That is, it experiences a restoring force proportional to its displacement. Depending on the weight of the mass and the thickness of the spring, the non-optimised system may experience overdamping or underdamping (Wikipedia).    A lower damping ratio implies a lower decay rate, and so very underdamped systems oscillate for long times. Importantly, this model applies to energy systems and hence obeys the law of thermodynamics. Traditionally, health was considered in terms of predictability. Consistent heart rate was considered good, irregular heart rate as bad. Unfortunately, it isn't quite so simple. In fact in terms of training concepts, low resting heart rate and how quickly the heart rate can oscillate with demand is used to diagnose if an athlete has become 'stale' or said in another way is in a state of 'over-training' or enhance physiological and/or psychological stress. Hence, in the light of these confounding 'beliefs', a more complex system (model) needs to be employed, involving random perturbations of an oscillatory system, if random 'outliers' are to be incorporated into our understanding of health. Simplistic versions of sympathetic vs parasympathetic tone balancing the autonomic nervous system do not explain complexity. It is difficult to reconcile that the parasympathetic vagus nerve controls all thoracic and abdominal organ function and alone counters all 'chaos' of sympathetic nervous system activity, where the latter activity has a multitude of redundancy and interacts in multiple dimensions with an interlaced muscle-gut immune system complex. The sympathetic nervous system is the tight rope, the trapeze artist, the dancer, the orchestra, forged from the fire of genesis and the evolution of heat shock proteins. To understand the development of the muscle-gut immune system complex we must understand its uni-cellular componentry. Using Alexandr Lyapunov theory of stability, in non-linear dynamic systems, the oscillations near the point of origin (equilibrium) are determined by exponential decay.  That is, if the solutions that start out near an equilibrium point Xe, stay near Xe forever, then Xe is Lyapunov stable. More strongly, if Xe is Lyapunov stable and all solutions that start out near Xe converge to Xe, then Xe is asymptotically stable (As an illustration, suppose that we are interested in the properties of a function f(n) as n becomes very large. If f(n) = n2 + 3n, then as n increases, the term 3n becomes insignificant compared to n2. The function f(n) is said to be "asymptotically equivalent to n2, as n → ∞". This is often written symbolically as f(n) ~ n2, which is read as "f(n) is asymptotic to n2 "). The notion of exponential stability guarantees a minimal rate of decay, i.e., an estimate of how quickly the solutions converge. The idea of Lyapunov stability can be extended to infinite-dimensional manifolds (chaos theory), where it is known as structural stability (in mathematics, this is a fundamental property of a dynamical system which means that the qualitative behaviour of the trajectories is unaffected by small perturbations), which, in this case concerns the behaviour of different but "nearby" solutions to differential equations. Later, this will be applied, not only to EMG analysis of muscle activity, but also to cytokine interactions, from nearby solutions Sympathetic Nervous System and Deterministic Chaos The sympathetic nervous system (SNS) has, as previously stated, traditionally been associated with the freeze-fight-flight response - you fight the lion or run from the lion. A reaction to a 'danger signal' (Matzinger). However, there is a lot more to it. Never-the-less, this example describes a bi-directional nervous system, one which is driven by 'motor curiosity' and wanting to arouse sensory stimuli, whilst the other is reacting to 'sensory stimuli'. Frequently, these moments are described as an 'adrenalin rush' associated with fear, excitement and tremor. The greater the chaos and tremor in the system, the greater the perturbations and the greater the damping needed in the system. Ideally, what drives the system also dampens it. Otherwise, at 'extremely high frequencies' we would only 'freeze'. Clinically, some people believe, that right hemisphere dominant tremor tend to have a higher component of irrationality and hypervigilance, whereas left hemisphere dominant tremor may have a more rational generator of tremor. However, this simplification ignores cross-hemispheric communication systems. It is important to note that in health systems, it's the odd asynchronicity in the system which attests to it's health. That is the chaos, 'outlier', in the system. This control by chaos is relative, it's a ratio, it's a magnification, it defines itself and it 'dampens' itself. Furthermore, the outliers define what it isn't! Hence, 'deterministic chaos'. When looking at 'fractals', you can have an infinite length in a finite space. Bifurcation upon bifurcations, getting smaller and smaller ad-infinitum but within a finite space! For example, the length of the coastline of the United Kingdom is known to an error margin of + 10-20% depending on how closely one looks at it (ie at what magnification ratio or scale). As we examine the movement system, we frequently see tremor at each end of the spectrum. With fine delicate movements and with movements which require a lot of force we see a tremor.  In scenarios of many repetitions and fatigued muscles, they gradually cramp up and lose their oscillatory fidelity. This can be considered as an energy or metabolic constraint. In novel tasks, we see more rigidity in movements, due to increased muscular activity, resulting in reduced freedom of movement. In the latter scenario, cognitive constraints arise at a conscious and sub-conscious level, where learning becomes important to improve the degrees of freedom, reduce the amount of muscle tension and hence lower the rigidity in the system. Are degrees of freedom, and hence variability, important for the immune system? A system dependent upon ratios of heat shock proteins, pro and anti inflammatory cytokines, immuno-globulins, lymphocytes, neuropeptides, short fatty acid chains, metabolism, descending noradrenergic and serotonergic pathways and even a balance between 'innate' and learned 'adaptive' immune responses, occurring within and acting upon, the largest endocrine organ of the immune system, skeletal muscle. Is it a coincidence that the spinal cord looks like a butterfly?  Butterfly effect and chaos theory - from Wikipedia In chaos theory, the butterfly effect is the sensitive dependence on initial conditions in which a small change in one state of a deterministic nonlinear system can result in large differences in a later state. The term, closely associated with the work of Edward Lorenz, is derived from the metaphorical example of the details of a tornado (the exact time of formation, the exact path taken) being influenced by minor perturbations such as the flapping of the wings of a distant butterfly several weeks earlier. Lorenz discovered the effect when he observed that runs of his weather model with initial condition data that was rounded in a seemingly inconsequential manner would fail to reproduce the results of runs with the unrounded initial condition data. A very small change in initial conditions had created a significantly different outcome. The idea that small causes may have large effects in general, and in weather specifically, was earlier recognized by French mathematician and engineer Henri Poincaré and American mathematician and philosopher Norbert Wiener. Edward Lorenz's work placed the concept of instability of the Earth's atmosphere onto a quantitative base and linked the concept of instability to the properties of large classes of dynamic systems which are undergoing nonlinear dynamics and deterministic chaos.   Chaos theory and physiology What happens if the 'flapping wings of the butterfly' dampen or calm 'the tornado on the other side of the planet'? In terms of the human organism, chaos theory refers to 'deterministic chaos'. This means that if one knows the initial conditions (state) of the system exactly, then the dynamical trajectory will be the same every time it is initiated in that condition (state). If, however, two states are 'infinitesimally' apart, then the trajectories are such that it makes it impossible to predict the future dynamics (chaos).   Oscillatory dynamics is the prerequisite for many complex phenomena and the onset of chaotic dynamics. Chaos refers to complex, apparently unpredictable, dynamics that even simple deterministic dynamical systems can produce. A universal way to achieve chaos is by driving a nonlinear oscillator by an external periodic signal. When the external driving signal has low amplitude oscillations, it can entrain or synchronise the nonlinear oscillator. As the amplitude of oscillations is increased, the range of frequencies for which it can entrain becomes larger—these expanding synchronisation regions of the external amplitude–frequency parameter space are called Arnold tongues. Such entrainment/synchronisation has been observed in many different physical systems, from fluids to quantum mechanical devices, and now also in biological processes, such as cell cycles, and gene (transcription) regulatory dynamics in synthetic populations. The dynamics gets even more complex as the amplitude of the external driving signal increases further. First, Arnold tongues start overlapping, which means the nonlinear oscillator can exist in more than one entrained state with different frequencies (termed modes), and even small amounts of intrinsic or extrinsic noise can cause it to hop between these modes. Such mode-hopping has been observed in immune system (p53 tumour suppressor) and in gene transcription of the oscillatory NF-κB system, when driven by a periodically varying Tumour Necrosis Factor (TNF) signal of sufficiently high amplitude. When the external amplitude is increased even further, then chaotic dynamics is predicted (Heltberg et al 2019 Nat Commun 10, 71 https://www.nature.com/articles/s41467-018-07932-1.pdf) Shareable link https://rdcu.be/b4sU7 Nat Commun 10, 71 (2019). The significance of this is, that NF-κB is a major transcription factor which regulates genes responsible for both the innate and adaptive immune response. Upon activation of either the T- or B-cell receptor, NF-κB becomes activated through distinct signalling components. TNF is a major inflammatory cytokine player, found in skeletal muscle (MSK), produced by macrophages/monocytes during acute inflammation and is responsible for a diverse range of signalling events within cells, leading to necrosis or apoptosis. The protein is also important for resistance to infection and cancers. Furthermore, other immune ratios or interactions, based on maths and physics, are predicted, which will hopefully lead to a better understanding of why physiotherapists should encourage people to exercise muscle as a vaccine for the immune system. This discussion will include interactions between Interleukin IL-6 (pro inflammatory) driving IL-10 (anti-inflammatory) t-cell CD4+ : CD8+ ratio, HSP 27 and HSP72 HSP 10 and HSP 60 HSP 60 and HSP 70 HSP 90 as well as examining the gut biome and muscle - brain axis in terms of energy, resources and game theory.  The following dissertation will consider cytokines (inflammatory substances), platelets and HSP in relation to muscle as an endocrine organ of the immune system and examine the link with the gut biome, and in particular, the energy species within the gut, as it relates to the immune system, but also as those energy species relate to movement adaptation, within the musculoskeletal system. "We are what we eat" and "healthy mind healthy body" are common sayings which will become abundantly clearer when examining the gut-brain-muscle axis. Chaos theory as it relates to ratios, synchronous to asynchronous periodicities, and magnification of movement and inflammatory markers in response to variable 'healthy' physical demands are postulated to act as a 'muscle - immune shock absorber' when confronted by pathogens. Infection - a bimodal HSP reaction of host and pathogen When entering the host from the environment, a microbial pathogen is confronted by several changes, some of which are highly stressful. These include alterations in temperature, pH, and pO2. Moreover, the pathogen is exposed to natural host resistance mechanisms such as phagocytosis by professional phagocytes. Once engulfed by phagocytes, the pathogen is confronted with reactive oxygen and nitrogen intermediates, attack by lysosomal enzymes, and depletion of Fe2+. To protect itself against the host, the pathogen activates various evasion mechanisms including its own HSP synthesis. Infection is therefore a bimodal process determined by the host and pathogen. During infection, the pathogen as well as the host increase their HSP production. Induction of host HSP synthesis in response to an encounter with a pathogen has at least two major causes. First, infected macrophages are confronted with antimicrobial mechanisms which they have activated themselves during infection. Efficient protection against their own effector molecules (e.g., reactive radicals) becomes vital for macrophage survival. Second, once inside a phagocyte, many microbes, especially those which persist in the host, interfere with intracellular host cell metabolism. Not surprisingly, many of these pathogens are potent inducers of HSP synthesis in mammalian cells (see Ulrich Zügel, Stefan H. E. Kaufmann (2019) https://cmr.asm.org/content/12/1/19 DOI: 10.1128/CMR.12.1.19). They say, 'in life we never should forget where we came from'. This appears true for HSP, where the HSP of a multicellular host recognises and react to the HSP of unicellular pathogens. A reflection on the evolution of life on earth. Heat Shock Protein (HSP) 70 and the viral response Virus infections induce heat shock proteins (described in detail below) that in turn enhance virus gene expression. An intriguing concept is that HSP within pathogens activate HSP within the host. This phenomenon is particularly well characterized for 70 kDa heat shock protein (HSP70). However, HSP70 is also readily induced by fever, a phylogenetically conserved response to microbial infections. When released from cells, HSP70 can stimulate innate immune responses through toll like receptors 2 and 4 (TLR2 and 4). In their review, researchers (Mi Young Kim and Michael Oglesbee 2012 Cells. 2012, 1, 3,: 646–666. doi: 10.3390/cells1030646) examined how the virus-HSP70 relationship can lead to host protective innate antiviral immunity, and the importance of HSP70 dependent stimulation of virus gene expression in this host response. Beginning with the well-characterized measles virus-HSP70 relationship and the mouse model of neuronal infection in brain, they examine data indicating that the innate immune response is not driven by intracellular sensors of pathogen associated molecular patterns, but rather by extracellular ligands signalling through TLR2 and 4. Specifically, Kim & Oglesbee (2012) addressed the relationship between virus gene expression, extracellular release of HSP70 (as a damage associated molecular pattern), and HSP70-mediated induction of antigen presentation and type 1 interferons in uninfected macrophages as a novel axis of antiviral immunity. The reported antigen presentation and cross-presentation and in vitro HSP cytokine functions are a result of molecules bound to, or chaperoned by, HSPs but not a result of HSPs themselves (Tsan MF1, Gao B.2009 J Leukoc Biol.85, 6 :905-10. doi: 10.1189/jlb.0109005). Notably, intra- (IC) and extracellular (EC) HSP 72 are thought to have different functions. IC HSP 72 confers cellular protection from subsequent stressors, while EC HSP 72 has a whole-body systemic role in antigen presentation and immunity. An acute exercise bout stimulates an increase in both IC and EC HSP 72. Long-term training and improved fitness increase the rate of availability of IC HSP 72 in response to stress. Other factors that affect HSP 72 production include environmental factors, exercise mode, duration and intensity, age, Estrogen, and anti-oxidant and glycogen availability. Additionally, other HSP such as HSP27 play a role in conserving HSP72 function. Importantly, the functions and roles of HSP 72 depend on the tissue of origin (brain, muscle, etc). Ratios of HSP's will be discussed later in the context of muscle-exercise-immune responses and is represented in the following schematic (bear in mind HSP70 are a class of HSP's which include HSP72) and ubiquitin is from another class of HSP which are very small (8.5kDa) and have been highly conserved throughout the evolution of life. Similarly, the gut biome will be discussed in terms of 'energy species' and a HSP 10 and HSP 60 synergistic function. Ratios of CD4+:CD8+ appear to be critical when discussing health and disease; as will the consideration of how an acute, but not chronic, pro-inflammatory cytokines (IL-6) stimulate anti-inflammatory cytokine (IL-10) response. Muscle-immune response So, what is the role of Heat Shock Protein (HSP) in the immune system? Simply stated, early in life, we have an innate immune system, the one we are born with. It acts to protect us. It's first exposure and reaction to exposure is in the birth canal, where the cervix lining acts to induce a protective mechanism to exposure of the world. Our first 'adaptive immune response'. Antibodies are formed from exposure to antigens. These antibodies are formed from RNA into DNA, by cleaving off small protein chains from long protein chains (telomeres). It's a bit like cutting a small piece of tail off the long protein chain. We do this throughout life, with the  aid of HSP's. However, as you can imagine, those long protein chains eventually become shorter and are finite. Hence, it's important to maintain our protein reservoir in our bodies by finely tuning how much and when proteins are cleaved, unfolded and refolded or deemed as useless by HSP. Since muscle consists of 90% protein, it becomes abundantly clear that we should protect it's bulk and function by training it, when healthy, and using it's reservoir of protein immune components during or after a disease. The above schematic (Krause 2004) illustrates immune reactions occurring within muscles. Immune responses are a complex interaction of cytokine signalling. Cyto = cell, Kine = movement. These signalling reactions occur in the brain, gut, liver, kidneys, thymus and muscle, in response to a perceived-safety danger signal (Matzinger 1994, review by Martin Krause 2004). Fine tuning of the cytokine reaction is important through a direct muscle cytokine 'micro-trauma' mechanical mechanism and indirectly through 'energy cycling' including metabolic mechanisms, including oxidative stress (REDOX) induced HSP. Furthermore, a multitude of cognitive stimuli can also influence (positively and negatively) the immune system. Notable, HSP must respond to the laws of thermodynamics. In the context of COVID-19, it has become apparent that those critically ill patients, have cytokine flooding in their lungs. That is, they have an uncontrolled (auto) immune response which has been referred to as a 'cytokine storm'. Additionally, there also appears to be a delayed immune response in younger individuals relating to inflammation of blood vessels and clot formation. Further, extremely low oxygenation (<50%) has been reported suggesting hypoxic metabolic stress, potentially not to dissimilar to when we exercise, only in the later we can in most cases cease the exercise without undue effects. A notable exception is Rhabdomyolysis (which is a condition in which skeletal muscle tissue dies, from over-exertion or pathogens, releasing substances into the blood stream that cause kidney failure) discussed elsewhere on this site. It will be argued that previous 'fine tuning' of the cytokine response, through exercise induced neuro-immune perturbations, leaves the host, not necessarily less susceptible to infection, but more prepared to deal with heat stress, platelet reactions as well as the infection itself. Matzinger's Danger Hypothesis - from Wikipedia  In 1994 a new immunologic model was suggested by Polly Matzinger. She suggested that the immune system does not distinguish between self and non-self, rather, it discriminates between dangerous and safe by recognition of pathogens or alarm signals from injured or stressed cells and tissues. According to this theory, the most important stimulation of immune response are normal tissues. When tissue cells are distressed because of injury, infection and so on, they start to secrete or express on their surface so called "Danger signals". "Danger signals" are also introduced into extracellular space when stressed cells die by immunologic not-silent cell death such as necrosis or pyroptosis (highly inflammatory form of cell death, as opposed to apoptosis, controlled cell death). This model also suggests that, despite their potential immunogenicity, neoplastic tumours do not induce significant immune responses to induce the destruction of the malignant cells. According to the danger model, the immune surveillance system fails to detect tumour antigens because transformed cells do not send any danger signals which could activate dendritic cells and initiate an immune response. "Danger signals" are normal intracellular molecules that are not found in the extracellular space under physiological conditions. The danger model has evolved over the years. "Danger signals" include DNA, RNA, heat shock proteins (HSPs), hyaluronic acid, serum amyloid A protein, ATP, uric acid and also cytokines like interferon-α, interleukin-1β, CD40L and so on.  The "danger model" suggests that, upon cellular necrosis, cryptic molecules in normal cells might be liberated from the cytoplasm into the tissue microenvironment, new molecules might be expressed on the surface of killed cells, or new molecules might be synthesized by cells undergoing necrosis. In comparison, the damage associated molecular pattern "DAMP model" suggests that any non-functional molecules (regardless of their cellular location; extracellular or intracellular) that were denatured, oxidized, or had disintegrated quaternary structures might have unique biophysical patterns such as low water-solubility or stretches of polyanions on their surface. "Danger signals" and DAMPs are together with pathogen-associated molecular patterns (PAMPs) called alarmins and they are recognized by pattern recognition receptors (PRRs) of antigen presenting cells (APC). PRRs include Toll-like receptors (TLR), nucleotide oligomerization domain (NOD)-like receptors, retinoic acid inducible gene-I (RIG-I)-like receptors and C-type lectin-like receptors.[12] They are not only at the surface of these cells, but we can find them in cytoplasm and incorporated in the membrane of endolysosomes. Stimulation of PRRs leads to activation of APC cell to process antigen, upregulate expression of costimulatory molecules and present antigens to T helper cells. The danger model is a new perspective on adaptive and innate immunity. In the past innate immunity was suggested to be a minor part of the immune system — in contrast, adaptive immunity was thought to be the most important and effective part of the immune system. According to the danger model there is no adaptive immunity without the innate part. This is because APCs like dendritic cells are essential for activation of T lymphocytes and B lymphocytes, which after activation produce specific antibodies. In the case of dendritic cells deficiency, like in common variable immunodeficiency (CVID), patients suffer from hypogammaglobulinemia and from primary or secondary defects in T-cell functions. Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain. or By Mikael Häggström, used with permission. - Image:Lymphocyte_activation.png, Public Domain, Link (Matzinger, P . "Tolerance, Danger, and the Extended Family". Annual Review of Immunology. 12 (1): 991–1045. doi:10.1146/annurev.iy.12.040194.005015. PMID 8011301.   https://www.ohtn.on.ca/polly-matzinger-recaps-65-years-of-immunological-theory-in-one-diagram/ Classes of Heat Shock Proteins (HSP) Heat shock proteins (HSP) play an important role during exercise and subsequently induced immune responses (Krause 2002). Phylogenetically, HSPs are the basic building blocks of life. Small protein chains of around 8–43 kDa for HSP 27 class and 72kDa for HSP 72 ranging up to 110kDa. HSP72 is abundant in muscle. HSP 27 has been shown to be released in response to muscle damage during novel or acute eccentric (muscle lengthening) exercise, whereas HSP 72 is released in response to metabolic and thermal stress, during endurance exercise, in both untrained and well trained individuals. Additionally, HSP 27 is thought to aid in the repair process of HSP 72 as well as in the repair of contractile protein myofilaments themselves (Folkerson M 2018 http://oru.diva-portal.org/smash/get/diva2:1234179/FULLTEXT01.pdf).  The relevance of the latter will become apparent when examining eccentric muscle contractions later in this treatise. HSP 60 is found abundantly in the gut and in the mitochondria of skeletal muscle, in rodents. It has been demonstrated, in rodents that HSP 60 is greater in slow twitch endurance muscle, as well as in the vastus lateralis of endurance trained men (reviewed by Mattias Folkesson 2018). HSP 60 and HSP 10 will be discussed later when considering the immune system, energy species and the gut biome.   Hence, HSP's have an important cellular function, commonly referred to as a 'chaperone'. The fate of proteins with non‐functional conformations after stress exposure may be either to re‐obtain the functional conformation, form aggregations with other misfolded proteins or become degraded. HSP's play a helper role in shifting the equilibrium in the direction of more functional proteins or degradation of damaged proteins. This can occur in an ATP-dependent or independent manner, meaning the latter doesn't require the normal oxidative metabolism to function, as muscle contraction does.  HSP had an important, stress induced, evolutionary and ecological role. As stated, it continues to play a vital role, as it's chaperone function acts to stabilise/modify exercise induced muscle damage, including micro-trauma. Additionally, HSP's play a role in apoptosis or cell death in sedentary individuals. Essentially they react to 'stressors' which can be temperature (hot and cold) and oxidative. Importantly, these ubiquitous molecular chaperones can prevent the irreversible aggregation of denaturing proteins. Specifically, to maintain protein homeostasis, HSP complex form a first line of defence against protein aggregation, with a variety of non-native proteins in an ATP-independent manner and in the context of the stress response. In vertebrates they act to maintain the clarity of the eye lens, and in humans HSP mutations are linked to myopathies and neuropathies (Haslbeck & Vierling 2015 J Mol Biol Apr 10; 427, 7: 1537–1548). Indirectly, HSP's act on the immune system by maintaining muscle bulk, which provides the environment in which cytokines can act and where proteins can be used to build antigens for an immune response. That is, reported antigen presentation and cross-presentation, activation of macrophages and lymphocytes, and activation and maturation of dendritic cells as well as in vitro HSP cytokine functions, are a result of molecules bound to or chaperoned by HSPs but not a result of HSPs themselves (Tsan MF & Gao B.J Leukoc Biol. 2009 Jun;85(6):905-10). Another, more intriguing speculation, is that the HSP of the pathogens themselves activate the innate human immune response in the presence of fever greater then 2-3 C (reviewed by Hasday JD & Signh IS 2000 Cell Stress Chaperones, 5, 5, 471–480). Regardless, an increase in core body temperature, during fever, activates and utilises elements of the heat shock response pathway, to modify cytokine and chemokine gene expression, cellular signalling and immune cell mobilisation, to sites of inflammation, infection and injury (Hasday JD & Signh IS 2013 Intl J Hyperthermia, 29, 5, 423-435). Hence, increases in temperature during exercise may be a mechanism which uses HSP's to preserve and improve muscle fibre protein, protecting it's bulk whilst adaptively fine tuning mechanistic pathways for potential innate HSP-cytokine immune responses.  Muscle and Heat Shock Proteins   (Krause 2005 Rome Presentation) Muscle is an incredible and potent reservoir of protein and immune substances. It is, in effect, one of the most important organs of the immune system. HSP are a multidimensional protein which act as a protein chaperone, an antioxidant and play a role in the inhibition of cell death (apoptosis). They act on muscle protein (actin cytoskeletal) remodelling. In particular, HSP27 has been characterized with the ability to regulate actin cytoskeletal dynamics during heat shock and other stress conditions, functioning both to promote actin polymerization and as an actin capping protein. During, intense exhaustive exercise, in hot conditions, both HSP72 and HSP27 are released into the blood stream (Periard et al, 2012, Cell Stress Chaperones, 17, 3, 375-378). HSP 27 is speculated to also have a HSP 72 preserving function. Presumably, these HSP, together, have HSP and cytokine protective roles, at certain stages in the immune-inflammatory cycle. Extracellular HSP 27 and HSP 72 during exercise Extracellular HSP expression has been demonstrated during exercise. The first investigation was in humans and treadmill running (60%VO2max) under hot conditions, where increases of eHSP 72 were found (Walsh RC, et al 2001. Cell Stress Chaperones, 6, 4,386-93). Further investigations (Periard JD et al 2012. Cell Stress Chaperones, 17, 3, 375–383), using cycling and heat at 60% and 75% intensity (HR 97% of max at termination) demonstrated core temperature reaching 39.7°C in the 60% trial (58.9 min) and 39.0°C in the 75% trial (27.2 min) (P < 0.001). The rate of rise in core temperature was 2.1°C at the 27.2 min mark and was greater in the 75% trial than in the 60% trial (P < 0.001). A significant increase and correlation were observed between eHsp72 and eHsp27 concentrations at exhaustion (P < 0.005). eHsp72 was highly correlated with the core temperature (heat storage) attained (60% trial) and the rate of increase in core temperature (75% trial; P < 0.05). Therefore, in response to an acute physiological challenge under heat stress, intensity and duration can result in similar changes to core temperature. Interestingly, if these high core temperatures presented clinically, the person would be considered febrile. Fever is used as a diagnostic criterion in clinical settings, with temperature elevations as low as 39 °C being a potent inducer of HSP 70 in the human brain (Morrison-Bogorad M.et al, 1995 J. Neurochem. 64, 235–246. doi: 10.1046/j.1471-4159.1995.64010235.x). For example. a fever is a consistent sequel to measles virus (MeV) infection (Hutchins SS et al, 2004. J. Infect. Dis.189:S153–S159. doi: 10.1086/379652) where heat and/or virus-induced inflammatory cytokines may represent a means of indirect HSP70 induction. The latter is supported by findings in canine distemper virus infected dog brains, where HSP70 induction was observed in viral antigen negative as well as viral antigen positive astrocytes, these being restricted to areas of active viral replication and inflammation (Oglesbee M & Krakowka S 1993 Lab. Invest.68, 109–117).  . These are strange lines of best fit (correlation HSP 72 vs HSP 27), especially from baseline (60% vs 75% VO2 max), through to recovery 24 hours, after exhaustive exercise. Let's keep this in mind when discussing 'outliers' in chaos later in this dissertation. It should be noted that these extracellular HSP's are thought not to be from contracting muscle (Febbraio et al. 2002a), but rather as a result of the brain and hepatosplanchnic tissues which are capable of releasing HSP 72 in the systemic circulation (Febbraio et al. 2002b; Lancaster et al. 2004). Importantly. its extracellular expression (eHSP 72), measured in plasma and serum, has been suggested as a potential signal, triggering innate immunity and stimulating the release of proinflammatory cytokines (Pockley et al. 1998; Asea et al. 2000; Njemini et al. 2003; Pockley et al. 2003; Njemini et al. 2004; Asea 2005; Noble et al. 2008). In humans, they believe that the contracting muscles are not the source of eHSP 72. In  : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312965/#CR44 . However, contrary to this belief on extracellular HSP, it will later be argued, that contracting muscles release localised HSP, during concentric (cycling) and eccentric (running and plyometrics) exercise, where the laws of thermodynamics and concepts of myofilament micro-trauma (respectively) are applied......and that although these intracellular HSP have a different function to eHSP, their relationship is 'continuous' In the 75% trial, the rate of increase in rectal temperature was a significant predictor variable of eHSP 72 expression. For the expression of eHSP 27, blood glucose was a significant predictor variable in the 60% trial. No predictor variables were found for eHSP 27 concentration in the 75% trial. Malondialdehyde (MDA) concentrations showed a significant reduction 24 hours after the completion of exhaustive exercise. MDA is one of the final products of polyunsaturated fatty acids peroxidation in the cells. An increase in free radicals (REDOX) is thought to cause overproduction of MDA, which wasn't seen in this investigation. MDA level is commonly known as a marker of oxidative stress and the antioxidant status in cancerous patients. Importantly, the correlation of glucose and FFA to eHSP 27 and MDA, may be an important aspect to bear in mind, when we later discuss the energy consuming species of the gut biome, REDOX and the immune system. Aging, HSP and cytokines (IL's and TNF-alpha) As we age, we lose our tolerance to heat and cold, suggesting a gradual loss of HSP over time. In community-dwelling elderly, serum HSP 70 and IL-10 concentrations were significantly lower and IL-6 was significantly higher when compared to healthy young control subjects. Elderly patients presenting inflammation (CRP serum levels ≥5 mg/L) showed significantly higher Hsp70 values; and Hsp70 correlated positively with IL-6 and CRP, but not with TNF-alpha or IL-10. A significant association was also noted between Hsp70 levels and the degree of dependency and cognitive decline in geriatric patients. This data provides evidence that serum concentration of Hsp70 decreases with age in a normal population. This study also showed that higher levels of Hsp70 are associated with inflammation and frailty in elderly patients (Rose et al (2011), BMC Immunology, 12, 24, 28 March)  https://link.springer.com/article/10.1186/1471-2172-12-24. Therefore, too much IL-6 appears to be a bad thing, however, later we will discuss how increases in IL-6 in response to an acute stress induces the release of anti-inflammatory cytokine such as Il-10. Moreover, chronically elevated anti-inflammatory substances can lead to desensitisation. Therefore, it will be argued that it's the 'randomised regular intermittent impulse', whilst exercising, which tunes the system, through the laws of thermodynamics and entropy (chaos)!  Age, Heat Shock Proteins, COVID-19 and thrombocytes (clots) COVID-19 seems to disproportionately affect older people. Young people, who have a more robust 'innate' and 'younger' immune system seem to be, with some exceptions (Kawasaki Disease), immune to the disease. Some people with COVID-19, aged 20-40 years old, are presenting with neurological complications from prolific clot formation. Clots are formed from thrombocytes. Thrombocytes are formed from platelets. Investigations suggest that HSP70 and HSP90 can serve as signalling scaffolds, helping regulate function, including platelet adhesion and spreading via modulation of protein phosphatase activity. HSP27, on the other hand, may be more involved in controlling actin polymerization during the platelet shape change and subsequent aggregation (Polanowska-Grabowska R & Gear AR 2000 Platelets. Feb 11, 1, 6-22). Several roles may exist for HSPs in the immune system including intracellular roles (e.g., antigen presentation and expression of innate receptors) as well as extracellular roles (e.g., tumour immunosurveillance and auto-immunity). It has been observed that exogenously administered HSP induced various immune responses in immunotherapy of cancer, infectious diseases, and auto-immunity. Moreover, virus interaction with HSP as molecular chaperones showed important roles in regulating viral infections including cell entry and nuclear import, viral replication and gene expression, folding/assembly of viral protein, apoptosis (cell death) regulation, and host immunity (Azam B & Elnaz A Clinica Chimica Acta 2019, 498, 90-100). As already stated, viruses could regulate host HSPs at different levels such as transcription, translation, post-translational modification and cellular localization. Notably, COVID-19 seems to have unprecedented auto-immune response in those critically ill patients. Platelets Platelets are anucleate cell fragments known for their central role in coagulation and vascular integrity. However, it is becoming increasingly clear that platelets contribute to diverse immunological processes extending beyond the traditional view of platelets as fragmentary mediators of haemostasis and thrombosis (clot formation). There is recent evidence that platelets participate in: enhancement of adaptive immune responses recruitment and promotion of innate effector cell functions intervention against microbial threats modulating antigen presentation. In this way, platelets should be viewed as the under-appreciated orchestrator of the immune system (Ramadan et al 2015, Curr Trends Immunol. 16: 65–78). Heat Shock Proteins, Exercise and Upper Respiratory Tract Bacterial Count (Int. J. Med. Sci. 2020, Vol. 17) Exercise modifies airway immune responses and susceptibility to infection in healthy individuals. Investigators (Min et al 2020 Int J Med Sc, 17, 5, 640-646) examined the effects of exercise on HSP 27 and HSP 72 expression levels in nasal mucosa of both professional competitive athletes (volleyball) and non-athletes. Nasal lavage (NAL) fluids were collected from 12 male professional volleyball players and 6 healthy males pre-submaximal exercise (running for 30 min at 70-80% of maximal heart rate) and post-submaximal exercise. Expression levels of HSP27, HSP70, Interleukin (IL)-8, and Tumour necrosis factor (TNF)-α in NAL fluids were quantified and antibacterial assay using Staphylococcus aureus was performed to assess the immunological role of HSPs in NAL fluids. In non-athlete controls, HSP27, HSP70, and IL-8 were unchanged after exercise. In the professional athletes, HSP70 expression declined significantly (p<0.05), but HSP27 was not significantly changed. nor were IL-8 and TNF-α. Further, it was found that the number of active bacterial populations were influenced by the presence or absence of HSP27 and HSP70 in NAL fluids. Upon removal of HSP27 and HSP70, the initially observed augmentation of anti-bacterial activity in post-exercise NAL fluids was abolished. This is a super-interesting result, where reduced HSP concentrations were correlated with improved bacterial counts, suggesting that HSP can reduce 'good' or functional bacteria in the mucosa. Moreover, there seemed to be difference in the innate immune response, to exercise, in trained vs untrained. The influence of bacteria and the gut biome will be discussed later in relation to the immune system. Additionally, of even more interest is the effect of training on pre exercise HSP levels. Needless to say, a balance of HSP is required for a balanced mucosal bacteria and that the resting HSP levels in athletes is lower than in non-athletes. However, it needs to be said that the non-athlete group was only 6 compared to 12 athletes. Regardless, the trained athletes appear to have lower basal levels of HSP. Importantly, this could be the result of 'over-training' and/or it makes sense that training creates the optimised system which conserves these vital proteins for essential use. Notably, as we age, the number of HSP reduce, so ideally, our immune biological age is younger than it's chronological age.  A systematic literature review (Moreira A et al (2009) British Med Bul, 90, 1, 111–131, https://doi.org/10.1093/bmb/ldp010) (of 30 studies, comprising 4 descriptive, 18 observational and 8 randomized or controlled reports, that included a total of 8595 athletes, including 5471 runners and 2803 swimmers and 1798 non-athletes) found athletes were more susceptible to upper respiratory tract infections (URT) than non-athletes after prolonged and intense exercise. They postulated that the significant immune suppression (down regulation) was a protective response to limit inflammation. Furthermore, they hypothesised that as the fitness of the athlete increased, the incidence of URT should decrease, contrary to their findings. However, they also described data in marathon runners taking Vitamin C (anti-oxidant), where it was found to reduce the incidence in URT. In one study which they reviewed, the gut biome was considered to be important, where Lactobacillus fermentum appeared to have a slight anti-inflammatory effect, reflected by a decrease in IL-6 production, which is the main inducer of C-reactive protein and a decrease in the number of monocytes, which are one of the major producers of IL-6. Consumption of carbohydrate-rich beverages during exercise appears to attenuate some of the immunosuppressive effects of prolonged exercise, but confirmation of any clinical significance in this awaits further research. Exercise and Respiratory Tract Infections A narrative review (Pederson & Toft, 2000, https://bjsm.bmj.com/content/34/4/246) highlights evidence that exercise across a lifespan seems to increase resistance to upper respiratory tract infections, whereas repeated strenuous exercise suppresses immune function. There was no assessment of the reliability of data in the included studies. In an overview, researchers  (Rocco et al., 2018) analysed data from four systematic reviews (including an older version of the Cochrane review; 14 primary studies) to examine clinical effectiveness of exercise to prevent upper respiratory tract infections. The authors were able to meta-analyse five randomized trials involving only 311 participants. They observed a reduction in incidence of infection (RR 0.84, 95% CI 0.65 to 1.10; 72 infections less [157 less to 45 more] per 1000 people) in people randomised for moderate intensity exercise for 8 weeks to 12 months. The evidence was judged “very low” quality based on GRADE, meaning the findings are highly uncertain. Martin et al (2009, Ex Sp Sc Rev, 37, 4, 157-164 doi: 10.1097/JES.0b013e3181b7b57b) suggest outcomes following respiratory viral infections are improved after moderate exercise based on epidemiological evidence and animal models. They propose stress hormones stimulated during exercise reduce excessive local inflammation and skew the immune response away from a TH1 and toward a TH2 phenotype. Human studies and experimental modelling of mechanisms are lacking. Heat Shock Proteins and the 'viral' diseased state Heat shock proteins (HSPs) are recognized for their support of protein metabolism. Interaction with viral proteins also functions to enhance the development of innate and adaptive immune responses against the infecting agent. At the level of the infected cell, HSP are uniquely expressed on the cell surface, where they represent targets of lymphokine activated killer cells. Necrosis of the infected cell releases complexes of HSP and viral protein, which, in turn, binds antigen-presenting cells (APCs). One effect of binding is to stimulate APC maturation and the release of proinflammatory cytokines, an adjuvant effect, that prepares the way for adaptive immune responses. A second effect of binding is to direct the antigenic cargo of the HSP into endogenous MHC presentation pathways for priming of naive cytotoxic T cells (CTL) or activation of antigen-specific CTLs. For example, this alternate pathway of antigen presentation is essential to CTL priming following primary brain infection such as in measles (Oglesbee et al 2002, Viral Immunology, 15, 3, 399-416) Both HSP72 and HSP27 has been implicated in different disease states playing both protective and counter-protective roles. In multiple disease contexts, HSP-27, plays a role in renal injury and fibrosis, cancer, neuro-degenerative and cardiovascular disease (Vidyasgar et el 2012, Fibrogenesis and Tissue Repair, 5, 7, (https://link.springer.com/article/10.1186/1755-1536-5-7). Interestingly, HSP27 has been characterized with the ability to regulate actin cytoskeletal dynamics during heat shock and other stress conditions, functioning both to promote actin polymerization and as an actin capping protein (Guay J et al (1997) J Cell Sci, 110: 357-368; Huot et al (1996) Cancer Res., 56: 273-279). This capping function is important in respect to DNA splitting where telomeres are the caps at the end of each strand of DNA that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damaged and our cells can't do their job. HSP 70 has been associated with CNS responses to viral load from measles. Importantly, this model suggests a self-perpetuating (positive feedback) HSP expression with virus gene expression, which in turn stimulates innate immune responses in macrophages of the brain microglia (Kim & Oglesbee 2012). The extracellular HSP70 is a ligand for TLR2 and TLR4, activating signal transduction pathways that drive type 1 IFN expression (IFN-β in brain) and expression of antigen presenting complexes (MHC). IFN-β expression by brain macrophages is key to immunity against virus infected neurons (in a mice measle model). However, studies that directly examine the contribution of HSP70 to antiviral immunity and the impact upon viral virulence are lacking.   When looking at the HSP70 family as a whole, their fundamental role in protein metabolism and the abundance within cells reinforces their potential support of viral replication at multiple levels. For every step,  in viral replication (i.e., attachment/penetration, uncoating, transcription and genome replication, and virion morphogenesis), one can cite an example of a viral system that draws upon an HSP70 family member for support. Heat Shock Protein 90 (HSP-90), Geldanamycin and COVID-19 : 19 May 2020 An interesting article on drug repositioning (defined as the use of approved drugs for new indications), offering an unmatched opportunity to offer novel therapeutics to treat SARS family of coronaviruses (SARS-FCoVs); Researchers analysed, a dataset of patients who presented with SARS during the 2003 outbreak whereby they established a gene signature that defines differential gene expression in patients who were sick with SARS vs. healthy controls and convalescent patients. They used a robust platform to conduct drug repositioning based on clustered gene expression and pathway enrichment to identify best matching drugs. They identified 55 agents of potential benefit. In most of these drugs they were able to establish a link to previous related research, use as antiviral, or at least a hypothetical role in treating SARS-FCoVs. Most notably, the heat shock protein 90 (HSP 90) emerged as a major component that enables viruses to hijack infected cells through the process of autophagy (self devouring). Almost half of the drugs identified could be linked to HSP 90. As such, they propose using HSP 90 inhibitors, mainly geldanamycin and its derivatives, to treat COVID-19. (https://www.researchsquare.com/article/rs-18714/v1) Based on their findings, they suggest adding more drugs to the experimental arsenal deployed against SARS-FCoVs. These included the use of nontoxic drugs that are readily available for wide scale prophylaxis or for the treatment of mild cases of COVID–19. These drugs would include omeprazole, nonsteroidal anti-inflammatory drugs, colchicine, sulfoanamide antibiotics, antimalarial drugs and clozapine/chlorpromazine. For patients with serious COVID–19 illnesses, the above drugs can be combined with immune modulators like sirolimus, and direct HSP 90 inhibitors under well-designed clinical trials. Given the high pathogenicity of the current ongoing epidemic, they suggested that it seems prudent to attempt to use multiple drugs in combination if low risk toxicity and drug-drug interaction is established. Choosing a combination of drugs identified in this study or other drug-repositioning studies and careful reporting of the efficacy of these experiences can result in rapid accumulation of knowledge.(Iyad Sultan, Scott Howard, Abdelghani Tbakhi (2020, DOI : 10.21203/rs.3.rs-18714/v1). Therefore, albeit evidence from another class of HSP, it is plausible that fine tuning (down regulation from regular exercise) of HSP function is equally important to it's subsequent role as a fine tuner of cytokine - immune responses. This is an interesting finding, as one of the functions of another class of HSP (HSP 70) is the inhibition of apoptosis (cell death) which could be considered to enhance viral replication by preserving the viral factory. Inhibition of HSP 70 expression in human breast tumour cells result in massive cell death. Conversely, adenovirus infection causes a dramatic suppression of HSP 70 mRNA levels during the late phases of the viral replication cycle when the viral particles are already assembled, enhancing apoptosis in order to promote viral particle release (in Mi Young Kim and Michael Oglesbee 2012 Cells 1, 3, 646–666.doi: 10.3390/cells1030646). This suggests that HSP importance and function varies depending on the stage of the disease. A cycling dynamic of HSP outliers from the pathogen and host itself. Mechano-transduction: how does a mechanical force transduce to a thermodynamic energy system? We all know the feeling after unaccustomed exercise. Delayed Onset Muscle Soreness (DOMS); that feeling of heaviness and stiffness which worsens over a 2 day period. After the first run, on soft sand, in many years, resulting in the inability to walk down any stairs except backwards! Scientists describe it as 'broadening and streaming of the z-bands'. These are the micro-filaments between actin-myosin sliding filaments (introduced by Huxley 1957) which allow our muscles to lengthen and shorten. Additionally, an elastic element has been incorporated which is considered to be made up of passive collagen tissue (such as myofascia and tendon - which isn't quite true, as these tissues fibroblasts have motility and can change the structural integrity/density ), as well as myofilaments such as Titin. Furthermore, the cycling of ATP-ADP energy reserves give muscle another (sinusoidal) elastic element when doing exercise such as running or plyometric jumping-counter jumping. Did you know muscles require energy, in the form of ATP, to relax? Hence, the contracted rigid muscle (e.g. rigor mortice or cramp) can be considered a lower energy state than a relaxed one! Paradox? However, the eccentric (lengthened) contracted muscle, which requires less EMG activity (than concentric contractions) enhances the potential recoil for concentric (muscle shortening) contractions. In biomechanics, the Hill model of muscle thermodynamics was developed in the 1930's and redefined in 1974. Still today, it's considered as fundamental in any conservation on muscle dynamics, where an inverse relationship exists between muscle velocity and force production. This has direct bearing on the development of power (P=Fv or P=F. δ s/t). Considering energy, where Work = Power x time, it becomes apparent that the displacement of sliding filaments resulting in muscle lengthening and shortening defines the use of derivations from the laws of thermodynamics. The following is taken directly out of the seminal paper of 1974. Homsher E, Mommerts WFHM, Richhiuti NV (January 1974) The Journal of General Physiology Apart from calorific energy values, this model has practical implications, where an optimal velocity (change in displacement over time) and muscle length dependent force, develops optimal power i.e. the rate at which work is done (which, like your energy bill, is measured in Watts)  Plyometrics such as the one depicted above, can induce severe muscle soreness (DOMS) in the uninitiated. However, in the trained, this form of training has been known to improve the ability to run and jump. Actin-myosin cross bridge model (Huxley 1957) Force-velocity temperature dependent model (Ranatunga KW 1984 J Physiol. 351, 517-29) Cross filament model and four kinetic phases of half-sarcomere (hs) shortening following steps to the loads indicated (Ranatunga KW 1984 J Physiol. 351, 517-29) Later, Piazzesi G et al (2007 Cell 16, 131, 4, 784-95) demonstrated that it was the number of myosin motors rather than motor force or stroke size which determined force production at varying velocities, thereby providing a molecular basis for the parabolic relationship described earlier. However, later we will describe a large micro-filament called 'Titin' which has been considered the 'spring' in the system Discrepancies exist at low and high loading when using variations and additions to Hills equation. These have been attributed to the internal kinematics of actin-myosin, as well ADP-ATP energy cycling through the sarcoplasmic reticulum. However, non-linear mechanics (deterministic chaos theory) would expect such rules to break down at the extremes...and new predictive rules should take their place. That is, the 'outliers' define what 'norm' it isn't. This sliding filament system (https://www.back-in-business-physiotherapy.com/images/videos/muscle_contraction.mp4) has been modelled into a modification of Hooke's Law, Young's modulus of elasticity (using microfilament Titin as the spring) and the oscillating mass-spring. This was extrapolated, at a later date, into Bernstein's perspective of 'degrees of freedom' and motor control (adding a cognitive perspective). As the muscle shortens and lengthen it generates heat, based on tension and displacement and the load applied. The concepts of concentric (muscle shortening) vs eccentric (muscle lengthening) muscle contractions, as related to energy and the immune system will be discussed later. Subsequently, inverse dynamics was extrapolated to describe the transfer of energy across accelerating body parts (inertia) through 'muscle energy straps'. Put simply, muscles which cross just one joint, tend to be deeper muscles and act as stabilisers across the joint, whereas the bulkier, more superficial, two joint muscles, are the energy straps. This is linear dynamics which we generally learn of at school. The following will describe this in more detail. Later I will examine non-linear dynamics and deterministic chaos elsewhere in the treatise. Therefore, the development of Τorque through the movement of body parts (inertia), conservation of momentum (energy), the production of potential/elastic energy describes a 'perfectly stable' sinusoidal system. However, it is becoming more apparent, that the imperfections in the system, are what drives a healthy and optimised process of power (P = Force x velocity) production and work (W=Power x time) output. Obtaining, transforming, and using energy to do work may seem simple. However, the second law of thermodynamics explains why these tasks are harder than they appear. None of the energy transfers we’ve discussed, along with all energy transfers and transformations in the universe, are completely efficient. In every energy transfer, some amount of energy is lost in a form that is unusable (as work). In most cases, this form is heat energy. Thermodynamically, heat energy is defined as the energy transferred from one system to another that is not doing work. However, what if that heat is activating HSP or other immune-metabolic procesess? Entropy Some energy is lost as heat energy during mechanical and cellular metabolic reactions. This is good for warm-blooded creatures like us, because heat energy helps to maintain our body temperature as well as regulate HSP. As stated, strictly speaking, no energy transfer is completely efficient, because some energy is lost in a 'so called' 'unusable form'. This is called entropy but ignores concepts from deterministic chaos. The traditional definition of entropy is1. a thermodynamic quantity representing the unavailability of a system's thermal energy for conversion into mechanical work. Often interpreted as the degree of disorder or randomness in the system."the second law of thermodynamics says that entropy always increases with time"2. "lack of order or predictability"; "gradual decline into disorder".  However, the latter definition 'of the gradual decline into disorder' is not what is seen when examining high performance cycling demands or when looking at muscle paralysis. In fact, it will be shown that the supposed 'decline' into disorder of the EMG readings result in predicting a more optimised function.  Entropy and Low Back Pain In Musculoskeletal Physiotherapy there has been an emphasis on 'normal'. What is normal function and what are the constraints of a functional movement pattern. Reductionist approaches are taken to ascertain the directions of movement of 'preference' versus those of 'avoidance'. Avoidance in the acute stage of an injury frequently involves 'unloading' the injured area, whereas people with chronically painful movement frequently 'overload' the area of dysfunction. Ironically enough, their movement becomes 'predictable' and less varied. Furthermore, the reduced variability leads to either 'increased control' and less adaptability, or 'reduced control' and increased loading of 'fatiguable structures' (Thiry et al Entropy2022, 24(4), 437; https://doi.org/10.3390/e24040437). Hence, the danger for the physiotherapist is to 'drill' down to the 'offending' structure or movement, but not progress rehabilitation far enough, to include the variety entailed in the full spectrum of complex movement and loading, which is required for motor control in 'predictable' and 'unpredictable' environments. Similar, to the 'Butterfly Effect' in non-linear mathematics, optimisation ultimately requires a chaotic system of control, manifested by 'outliers' which determine the 'damping' or 'amplification' of an oscillating system. Similar, to the 'Butterfly Effect' in non-linear mathematics. Cycling, concentric contractions and optimisation of cadence frequency using entropy considerations One of the key determinants of muscle co-ordination and movement efficiency during cycling is pedalling cadence consistency. Such cadence needs to occur across multiple joints and limb segments. Whereas, inverse dynamics requires changes in velocity to achieve accelerating body parts. So, in the absence of changes in cadence, how can changes in acceleration be incorporated into the model of cycling efficiency? In-order-to achieve minimal neuromuscular fatigue, optimal pedal cadence for long distance cyclists tends to be between 85 and 95 revolutions. In contrast, maximum power (as in track cyclists) is achieved with pedal cadences between 110-135 rpm. Higher pedal rates lead to shorter duration pedal cycles, coupled with longer duty cycles, recruitment of fast twitch muscle fibres and de-recruitment of slow twitch muscle fibres leading to significant inefficiencies and loss of power at higher cadence. Furthermore, people with long limbs aren't able to develop the same moments of inertia compared to shorter limbed people. To conceptualise the latter, think of the case of the ice figure skater spinning with arms close to midline vs stretched out from midline. Chaos theory would suggest that the randomization of movement pattern, requiring perturbations of periodicity, may make the scaling of muscle action/inaction important, when considering minor fluctuations in cadence and moments of inertia. Similar to the mass-spring model described previously, a system with three orthogonal axis and a fixed point of perturbation, which has a moving point of seemingly random perturbations and everything else, can be envisage. These random perturbations are the 'outliers' which traditionally have been statistically removed from linear dynamic models. However, they should be included, as only in this way can a cadence of constant velocity be used to describe efficiency. Perturbations from the manifold, new temporary fixed points of oscillation, magnify and fine tune the system As such the intrinsic firing pattern (motor unit potential shape, firing rate variability , coherence between motor units) of muscles need to be established. Additionally, their co-ordinated firing pattern across the same muscle, other muscle synergies on the same body segment and muscles of different body segments executing the same motor task, should ascertain 'extrinsic' firing patterns. That is, one wishes to determine the influence of oscillations within muscles and the influence of oscillations from not only nearby motor units but also from nearby muscles as well. The deterministic chaos of nearby oscillations influencing the prime parameter.  (Krause M and Preston R 2002) A term entrotropic half life (EnHL) using EMG was coined and developed to examine what limits mechanical power output at higher cadences above 120rpm. Hodson-Tole et al (2020, Med Sc Sp Ex, 52, 1, 214-224) found that, in trained male cyclists (~ 10000km/yr, average 33yrs), changes in the individual muscle excitations can occur even when changes in co-ordination were more limited. Importantly, they demonstrated that features of the EMG change in a non-linear fashion with increasing cadence and that both 80 and 120 rpm represent inflection points, hinge points or potential manifolds critical in EnHL relations. In other words, cadences less than 80rpm and higher than 120rpm may have fewer fluctuations in muscle recruitment or firing characteristics leading to reduced application of force at the pedal. This variability is particular true for the bi-articular muscles, such as the gastrocs (medial and lateral), biceps femoris, rectus femoris, whereas the vastus medialis and vastus lateralis (one joint muscles) reached a minimum at 80rpm and did not change across the faster cadences studied. In this day and age of gears and the optimisation of mechanical ratios for optimal cadence, we lose light of the fact that cyclists once rode without gears and until only a few decades ago (1980's) elite cyclists used very high gears (12-20 teeth rear cluster) on dirt roads and mountain passes. My personal experience, of this time, is that I felt I had a number of gears within my muscle synergy, which I could call upon to change (in this case increase) my overall velocity. This internal gearing system was at the random mercy of the variable terrain which we encountered. Deterministic chaotic input generating an internalised randomised gearing ratio, preventing fatigue? In orienteering, people talk of internal calm, whilst running and thinking at maximum endurance power. Later in this dissertation we'll take a look at an 'uncontrolled manifold hypothesis' in orienteering which is employed as an experiential learning strategy to teach predictive reasoning (through map reading), i.e. the random from the non-random, in novel terrain. This is done through a process of filtering, contrasting the 'value' of the information and subsequent minimisation of certain information and magnification of predictive 'outliers'. That data used is that which doesn't 'cloud' the 'fidelity' within the cognitive domain. Later, we will also examine the effects of 30Hz electrical input into exercising muscles for the magnification of that muscles representation in the brain. Similarly, the lack of gears in track cycling has been exploited to produce endurance road world champion cyclists, potentially by forcing an internalisation of 'fidelity' to draw out the maximum (myosin motor unit) efficiency in the system. Arguably, this recruitment of motor units, is similar to a team sport, where individual players are strategically 'engaged', so as to maximise 'players', and minimise 'passengers' in the game. Game theory will be discussed later. Eccentric muscle contractions, loading, damage and adaptation : how a mechanical force transduces to a cytokine reaction We've examined potential and kinetic energy and thermodynamics in the muscle models of power production. Using concentric (muscle shortening) contractions it could be shown that the energy state change, and heat is dissipated. This heat might be what drives the heat shock proteins (HSP's) which we discussed earlier. What those models don't take into consideration are eccentric (muscle lengthening) contractions and their influence on muscle elasticity (stiffer -> less elastic = more damping) as well as the potential myofilament damaging aspects of this sort of exercise.  What is also of particular interest is how eccentric contractions can exert more force for less EMG input (compared with concentric contraction) and how the concentric contraction is better if immediately preceded by an eccentric one. The latter being the principle behind plyometrics training such as jump downs and counter-jumps. Touron et al (2019) examined the impact of eccentric vs concentric training on body composition and energy expenditure. Typical eccentric exercises are plyometrics and downhill running.  Eccentric training is well known for inducing greater micro tears and severe post exercise muscle soreness (DOMS). It is associated with distinctive inflammation patterns and repair processes that are particularly effective in promoting adaptations, such as skeletal muscle hypertrophy (Roig et al 2009, Br J Sports Med, 42, 8, 556-568) and mitochondrial H2O2 production ((Isner et al 2014, Muscle Nerve, 50, 5, 803-811). Eccentric exercises are, considered to be, particularly useful in cardio-respiratory compromised people, as localised muscle contractions can be made without large cardiac demands. Moreover, Touron et al (2019) found beneficial effects of exercise on body composition (lean body mass), particularly with eccentric exercise (vs concentric) at high muscular, but low cardiorespiratory, loads. The mechanical 'spring' of the muscle may be considered as that of one of muscles largest proteins 'Titin', which spans an entire half-sarcomere from Z-disc to M-line. Titin functions as serially linked springs that develop tension when stretched. There are multiple titin isoforms that vary in size and stiffness, which explains the elastic-stiffness diversity across vertebrate muscle (mouse ->elephant). Because of titin’s structural properties, its most significant role may be as the muscle spring (https://www.jospt.org/doi/pdf/10.2519/jospt.2003.33.10.557). Evidence suggests that small heat shock proteins that protect the cytoskeleton structures (e.g. titin) increase dramatically after repeated eccentric bouts (Koh TJ. 2002 Ex Sport Sci Rev. 30, 117-121). If titin is functioning as a locomotor spring, then it should be tuned to the frequency of muscle use and adapt in response to changes in physiological demand due to exercise or disease. This notion has been reinforced as titin isoform expression has been reported as an adaptable property of striated muscle (Bell SP et al 2000 Circ Res. 87, 235-240). see video : https://www.back-in-business-physiotherapy.com/images/videos/muscle_contraction.mp4 Apart from mechanical considerations, metabolic aspects of loading, energy transduction and fatigue should also be examined. We found specific fatigue characteristics with eccentric/concentric contraction regimes (Krause M & Preston R 2002).  What is known, is that this muscle damaging and fatiguing process, has a very powerful and potent training effect, if repeated in a dose specific manner, using temporal and intensity considerations. What is unknown is whether randomisation (chaos) in this form of training attains better results once a person has become accustomed to it. Logic would suggest yes.  It can be argued that it's this microtrauma and subsequent dyskinesia, which induces an inflammatory-immune response. However, the other hypothesis are - heat production and subsequent entropy (already discussed) - that it's the asynchronicity or 'outliers' of control (chaos) which generates an immune response as well as arguing - that it's a metabolic-immune compromise which generates the cytokine response.  Furthermore, - one should consider the effect of muscle tremor whilst doing such exercise and whether this is what is needed to readjust the system to a new stable state or even reverse a gradual decay from a previously stable state? Muscle damage during eccentric exercise and immune markers Bruunsgaard H, Galbo H, Pedersen BK, et al. (J Physiol (Lond) 1997, 499, 833–41) compared concentric and eccentric ergometer bicycle exercise and found an association between increased IL-6 level and muscle damage (seen by the increase in creatine kinase). Importantly, the level of IL-6 increased more during the eccentric exercise, and a significant association was found between peak IL-6 and peak creatine kinase on the subsequent days (r = 0.722; p = 0.028). The eccentric bicycle model results in delayed muscle damage, with peak creatine kinase levels on day four or five after exercise. Researchers (Ostrowski K, Rohde T, Pedersen BK, et al. 1998 J Physiol (Lond) 508,949–53) were able to detect IL-6 mRNA in skeletal muscle biopsy specimens obtained from runners after a marathon. These data indicate that IL-6 is locally produced in response to strenuous exercise or exercise induced muscle damage. IL-1ra mRNA was not present in the skeletal muscle, but was expressed by blood mononuclear cells obtained after, but not before, the marathon, suggesting that locally produced IL-6 induces a systemic anti-inflammatory response. Sarcopenia - loss of muscle cells and hence bulk If we don't exercise regularly, our muscles atrophy, i.e. they become smaller. However, with exercise, we can reverse this process of atrophy. After a certain age, in addition to disuse atrophy, the muscles cells can be destroyed forever (apoptosis), with inactivity. This process is called sarcopenia and commences in the fourth decade of life, in sedentary individuals. As examined previously, a deterministic chaos was suggested as the TNF alpha oscillatory mediator of nuclear factor-κB (NF-κB) activation and subsequent transcription, is that which influences mitochondrial dysfunction. Investigators have found that MuRF-1, a muscle specific E3 ubiquitin ligase is an important regulator of ubiquitin-mediated protein degradation in skeletal muscle (Bodine et al., 2001 Science. 294, 5547, 1704-8). Transcriptional factors, NF-κB and FoxO3a translocate into nucleus and subsequently upregulate transcriptional activities of MuRF-1 under certain pathological conditions (Cai et al., 2004, 119, 2, 285-98.; Gumucio and Mendias, 2013 Endocrine, 43, 1, 12-21. Perry et al., 2016, Ex Immunol Rev, 22, 94-109) such as sub-clinical inflammation associated with obesity and diabetes. This suggests that inhibition of NF-κB and/or FoxO3a pathways is a promising target for preventing muscle atrophy. An exercising mouse diabetic model (Liu & Chang 2018, Front Physiol. 9, 636) has demonstrated significant muscle changes in, an eight weeks moderate-intensity exercise (5.2 m/min, 1 h/day, and 5 days/week for a total of 8 weeks) program, where mice ran on a motorized treadmill (30 min with 0° slope) and exercise duration was gradually increased from 30 min to the target of 1h (0° slope). These included improved tibialis anterior muscle mass, suppression of NF-κB signalling, as well reduced pro-inflammatory markers IL-6 and TNF-alpha.    mm = control mice, db/dh = diabetic mice, Ex = exercise https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987703/ So, ideally, we are exercisers for life. However, don't despair if you haven't been into fitness, it's never too late. You still have the ability, to slow down sarcopenia, as well as hypertrophy the remaining muscle. Remember, it's not just about the amount of protein, but also the thermodynamics of metabolism and repair which dictate our inflammatory-immune responses. This dynamic allows for the deployment of the immune system during a time of crisis. Muscle Glutamine It has been established that glutamine is an important fuel for lymphocytes and macrophages. Several lines of evidence suggest that glutamine is used, at a very high rate by these cells, even when they are quiescent. It has been proposed that the glutamine pathway in lymphocytes may be under external regulation, partly because of the supply of glutamine itself. Glutamine stimulates in vitro lymphocyte proliferation, lymphokine activated killer cell activity, and cytokine production.(Ardawi MS & Newsholme EA 1984, Biochem J, 217, 289–96; Rohde T, Ullum H, Pedersen BK, et al. 1995 J Appl Physiol, 79, 146–50; Rohde T, MacLean DA, Pedersen BK. 1996 Scand J Immunol, 44, 648–5036) Skeletal muscle is the major tissue involved in glutamine production and it is known to release glutamine into the bloodstream at a high rate. It has been suggested that the skeletal muscle plays a vital role in maintenance of the key process of glutamine utilisation in the immune cells. Consequently, the activity of the skeletal muscle may directly influence the immune system. The glutamine hypothesis suggests, that during intense physical exercise, or in association with surgery, trauma, burn, and sepsis, the demands on muscle and other organs for glutamine is such that the lymphoid system may be forced into a glutamine debt, which temporarily affects its function. Muscle-immune conversion "The human immune system is a highly intricate network of cells and molecules designed to keep the host free from infection and disease. Exercise is known to have a profound impact on the normal functioning of the immune system. Having higher age and sex-adjusted scores for cardiorespiratory fitness and performing regular exercise of moderate- to vigorous-intensity exercise that fall within ACSM guidelines has been shown to improve immune responses to vaccination, lower chronic low-grade inflammation, and improve various immune markers in several disease states including cancer, HIV, cardiovascular disease, diabetes, cognitive impairment and obesity. The ongoing COVID-19 pandemic has raised a lot of questions regarding how exercise can protect us from infection by boosting immunity. This is becoming more pertinent as many of us have restricted access to the gyms and parks where we would normally undertake exercise and physical activity regimens. Compounding this problem are the known negative effects of social isolation and confinement on immunity. Glucocorticoids such as cortisol are elevated during periods of isolation and confinement and can inhibit many critical functions of our immune system. When we are stressed, the ability of our T-cells to multiply in response to infectious agents is markedly reduced, as is the ability of certain effector lymphocytes (e.g., NK-cells and CD8+ T-cells) to recognize and kill cells in our body that have become cancerous or have been infected with viruses. It is also vitally important that our immune cells maintain their ability to redeploy so that they may ‘patrol’ vulnerable areas in or body (e.g., the upper respiratory tract and the lungs) to prevent viruses and other pathogens from gaining a foothold. This process is also important to minimize the impact of the virus and to expedite viral resolution should we become infected." (Richard J. Simpson, Ph.D., FACSM Mar 30, 2020) Note, a relationship exists during exercise with adrenaline, noradrenaline, neutrophils and natural killer cells with cortisol levels post exercise. Cortisol having an inhibiting/controlling influence on the immune pro-inflammatory response. Interesting to note that cytokine levels continue to rise during and after exercise. Hence, the duration of the period of the perturbations, of the immune regulating mechanism, could be assumed to have variable damping mechanisms, with higher or lower frequency, depending on the frequency, intensity and duration of exercise, as well as the period of recovery between sessions of exercise.  Pedersen & Toft (2000) https://bjsm.bmj.com/content/34/4/246#block-system-main "Each bout of exercise, particularly whole-body dynamic cardiorespiratory exercise, instantaneously mobilizes literally billions of immune cells, especially those cell types that are capable of carrying out effector functions such as the recognition and killing of virus-infected cells. The mobilized cells firstly enter the blood compartment from marginated vascular pools, the spleen and the bone marrow before trafficking to secondary lymphoid organs and tissues, particular to the lungs and the gut where increased immune defence may be required. The immune cells that are mobilized with exercise are primed and ‘looking for a fight.’ Their frequent recirculation between the blood and tissues functions to increase host immune surveillance, which, in theory, makes us more resistant to infection and better equipped to deal with any infectious agent that has gained a foothold. Exercise also releases various proteins that can help maintain immunity, particularly muscle-derived cytokines such as IL-6, IL-7 and IL-15. The cytokine IL-6 has been shown to ‘direct’ immune cell trafficking toward areas of infection, while IL-7 can promote the production of new T-cells from the thymus and IL-15 helps to maintain the peripheral T-cell and NK-cell compartments, all of which work in concert to increase our resistance to infection. Exercise is especially beneficial for older adults who are more susceptible to infection in general and have also been identified as a particularly vulnerable population during this COVID-19 outbreak" (Richard J. Simpson, Ph.D., FACSM  Mar 30, 2020) Over-training - variation between sympathetic and para-sympathetic tone Chaos Theory - non linear dynamics The key to exercise is not to over-train. But, to induce a response, you need to stress the system i.e create a perturbation. This fact is important in the whole spectrum of people, from the severely de-conditioned to the highly trained. Classic signs of over-training are waking tired in the morning, 'non-restorative sleep', and irritability, 'three bastards in a day or ask your partner or significant other'. The three bastards pertained to a time prior to lock-down, where it was said if you met a person who you really didn't like, then that was unfortunate, if you met a second one, in the same day, that was doubly unfortunate and if met a third, then it wasn't them, but you. Exercise requires an 'allostatic' (restorative) response by the body to mental or physical stress (see below). It's almost akin to chaos theory. Simple perturbations of the system oscillate back to the midline (linear dynamics), with the occasional outlier (non-linear dynamics). The more extreme the perturbations, the more extreme the damping mechanisms need to be, for the non-random predictive oscillations, such as mechanically intense and/or repetitive (ie metabolic, irrespective of intensity) unaccustomed exercise. But even in accustomed exercise, in a healthy body, there will be a random 'outlier'. The random outlier, in chaos theory, is not so random, but subject to three orthogonal variables, one of which is a 'locus of control'; or a 'damping manifold'. One system has influences on nearby systems. Simply stated, it is proposed that progressive exercise, building up of endurance and resistance improves our 'damping manifold' on a ratio by ratio basis. The more finely tuned, the more amplified the ratio. Such damping, or control systems, are potentially also employed in non-accustomed exercise, metabolically compromised situations, cognitively confronting and/or during immune challenges such as COVID-19. Deterministic chaos and cytokine modulation of cytokines In a seminal paper,  ' A Systems Model for Immune Cell Interactions Unravels the Mechanism of Inflammation in Human Skin' the authors (Valeyev NV, Hundhausen C, Umezawa Y, Kotov NV, Williams G, Clop A, et al. 2010), used of deterministic chaos to explain cytokine oscillations for the modulation of one other (PLoS Comput Biol 6, 12, e1001024. https://doi.org/10.1371/journal.pcbi.1001024). Their model provides a quantitative description of multiple immune reactions based on cytokine profiles, including a model of 'immune system switching', similar to 'modal switching' between various immune states described earlier for the tuning of the NF-κB system by TNF. Specifically, the inter-dependency of the immune system is highlighted using two cytokine oscillations which can maintain a 'stable' homeostatic state as well as 'switched' to an activated stable homeostatic state, of higher cytokine concentration levels, in a dose dependent manner. The model used is the autoimmune inflammatory skin condition, Psoriasis. Skin inflammation associated with Psoriasis : whilst healthy skin contains inflammatory cytokines and macrophages, the inflamed skin contains a multiple higher concentration of those substances. This is a super interesting schematic, especially when examining IL-10 (anti inflammatory) and IL-22 (involved with cell survival and synthesis of anti-microbials for wound healing).  These could be, speculated as, potential controlling 'outliers'. It also suggests that examining one cytokine response against it's baseline is relatively simplistic and potentially erroneous if it isn't examined with baseline changes of other coexisting cytokines.  Dose Dependent Cytokine Production: Homeostasis occurs when the concentrations of cytokine production of two inter-dependent cell populations meet. Importantly this is circular, cytokine A stimulates cytokine B and vice versa. Immune - Subsystem Response : Green lines are trajectories and convergence of cytokine A and B. Purple spot and dotted line are the stable 'homeostatic' point. Arrow heads indicate the direction of non-equilibrium cytokine concentration towards the stable point and equilibrium. Situation B, where a small perturbation of one cytokine leads to a 'divergence' of the trajectories and in this case a three fold perturbation of the other (numbered 3). In C and D we can see a response two fold larger than the applied spike, meaning that a small impulse can lead to a large reaction both in healthy (and inflammatory) states. Presumably, the perturbating stimulus can arise during exercise, as cytokine release from muscle damage, such as eccentric exercises, and/or metabolic factors from oxidative processes (REDOX). Additionally, as the second law of thermodynamics still applies, the influence of heat shock proteins should also be considered. Cytokine Trigger Dynamics: Two points of homeostasis (H1 and H3 'stable') after one cytokine concentration moves out of phase (H2 'unstable') with the other. Trajectories 1 and 2 are from a lower to a higher and a higher to lower stable state (resp) with the latter occurring due to the application of cytokine B (depicted in E and F). The initial onset of signalling of cytokine A is depicted in trajectory 1, C and D. Presumably, multiple points of homeostasis could exist when confronted with varying degrees (concentrations) of inflammation and repair. Oscillatory Cytokine Concentration Dynamics : one of the 'unstable' solutions forms a limit cycle of cytokine oscillations, either around a stable point of convergence or a point of homeostasis; or any other point of 'unstable' cytokine concentrations. What is amazing, is how these nullcline diagrams look like synoptic charts. (remember Edward Lorenz and the Butterfly effect eluded to much earlier)  Small amplitude perturbation results in oscillations whereas a larger amplitude results in a single spike. Noteworthy is that small perturbations result in a many fold greater response. Small perturbation results in a return to homeostasis. Resolution : one stable point at a lower cytokine concentration. Mathematics of 'deterministic chaos' and cytokine immune inter-dependence (Valeyev et al 2010) The rate of cytokine uptake Mol/sm2 by a cell population is proportional to the numberof receptors bound to the cytokine, multiplied by the total number of receptors on the cumulative cell surface: Full immune model equation is thus given by the formula  The complete dynamic mathematical equations of interactivity between inter-dependent cytokine populations (A Systems Model for Immune Cell Interactions Unravels the Mechanism of Inflammation in Human Skin' (Valeyev NV, Hundhausen C, Umezawa Y, Kotov NV, Williams G, Clop A, et al. 2010), and their use of a 'deterministic chaos' mathematical model to explain cytokine concentration inter-dependency (PLoS Comput Biol 6, 12, e1001024. https://doi.org/10.1371/journal.pcbi.1001024).  Orienteering and the 'uncontrolled manifold hypothesis' of motor control and learning (cortical resource optimisation) Orienteering is a sport requiring the efficient movement through the forest, at high speed, along an optimal route, using a calm cognitive state during a high physiological state. Another paradox? Importantly, expertise in orienteering requires decades of experiential learning.in a potentially chaotic environment. This chaos being physical, as in uneven terrain, varying vegetation and varying geological formations. Additionally, it's potentially cognitively overloading, in the sense of navigating in potentially unique and new terrain, requiring totally different central nervous system (CNS) strategies to what they are used to. To learn, is to delve into the unknown........and the cognitively superior strategy may win over the physically stronger individual (game theory).   These cognitive - mechanical concepts are entertaining when considering chaos theory and infinitesimal controlling mechanisms. Furthermore, simultaneously induced mental and physical stress, as well as exposure to environmental pathogens, adds another variable of considerable inadvertent influences on immune responses, which vary depending on the 'selective qualitative experiences' of the individual from their years of competition, conditioning, mental health and training.  Game theory and variability of the 'outlier' for adaptability It is interesting to speculate that both the novice and elite orienteer are more susceptible to infection because they both have more rigid motor patterns, are less inclined to take risk and therefore are less likely to be confronted with error generating patterns of correctability? The assumption underlying game theory is that there is a resource over which there is a conflict.  A factor which the orienteering paradigm partially defines, and identifies, is the freedom of thought and movement. That fact that many investigations are looking at exercise and the immune system, using captive animals, might be problematic in itself. These animals are in a predictable environment, which for this purpose is ethical, reductionist and conforms with rigorous scientific research protocols, which is practical, as it reduces the number of 'dependent' and 'independent' variables. However, from an evolutionary point of view, and from the perspective of the example used here, where in orienteering, more may be learnt and fine-tuned, in an unpredictable variable environment, whereby the use of caged animals may be limiting the validity of the paradigm (deterministic chaos) which is under investigation. Moreover, in terms of cognition, confinement is a stressor. Moreover, the calmness and clarity of thought needed in the freedom of orienteering (running and navigating) through the landscape can be considered the antithesis of the caged animal.  Our ancestors were striving for energy security through appeasement, subjugation or dominance over other life forms, both internally and externally. In this sense, the 'freedom to navigate and move' paradigm, suggests that our evolutionary forefathers, used their muscles, to propel themselves out of Africa, for 'greener gut biome pastures'. Therefore, maintaining good health in new and potentially 'dangerous environments', involved an unpredictable deterministic variable. As it pertains to cognition, it is an intriguing idea that a motor-sensory curiosity, drove a mechanism, which simultaneously caused muscle hypertrophy, and endowed the muscles with enhanced glutamine and cytokine concentrations, which were needed, if an immune response to pathogens was encountered. Additionally, it is conceivable, that the gut biome was driven by the laws of thermodynamics, in the search for energy. Subsequently, the gut-environment interface provided the interaction needed, to both provide energy for movement, allowed the immune system the encounters needed to flourish, and achieved the abundance of gut species required, in a variety of situations, from feast to famine. Therefore, the gut - muscle - brain cognitive pathway, was driven at a conscious and subconscious level to meet the demands of thermogenesis and immune competency, resulting in collective gain amongst all cells which required energy. Akin to Zen Buddhist philosophy, suggestions are, that the constant sensation of mild hunger, drives the clarity of thought needed, to strive for all encompassing meaning and ultimate enlightenment. Yoga, using animal poses, to stretch muscles and enhance breathing, whilst calming the cognitive state, may be based on the same primeval paradigm, of what is good for muscles is also good for the gut and brain.  The 'dove and hawk' paradigm in game theory is interesting. If a hawk and dove compete over the same resource, direct open conflict of the dove with the hawk would be suicidal. Hence, one would think it's better to be a hawk. However, what if two hawks meet, there will be only one winner and potentially both could be injured for the same net gain. Whereas, if two doves meet, they may postulate and gesticulate and eventually one may retreat or they may even share the resource, with the less risk of injury. Hence, the stakes for the Hawk are much higher. Humans have always been in conflict for resources. Does this mean that the immune system is tuned by adaptation to 'individual' resource dominance? Or, as people developed and evolved as tribes, into communities did our immune systems come to share pathogens, which may have entailed 'herd immunity' but at the same time, gave humans a lack of species variability, making them more vulnerable to 'novel' pathogens? Even more intriguing, is the notion that within a group of similar, the weakest may be driven out, seeking new resources, which in this case means new environments and new pathogens, invoking an 'immune enriching' response?   Continuing with the 'hawk dove' analogy, if we have too many hawks in a population, the consequences are constant conflict. If too many doves, constant compromise. In fact, a single dove in a hawk environment might be totally ignored, as might a single hawk in a dove environment. Thus, the apparent weaker species could be at an advantage when it's the outlier? To carry this further, we could postulate that the hawk is more prone to injury. Does this mean that in humans, the more dominant 'aggressive' individuals have an immune system which is more in demand for potential or actual injury? Whereas, the postulating dove, activates it's immune system minimally when it's performing some form of escape or deception? Interestingly, most animal conflict encounters, go out of their way to avoid injuries to themselves. Regardless, it's likely, that in both 'stressful' situations, the immune and musculoskeletal systems are activated, in a proportionately preparatory manner. Thus, the stronger the variability in the individual, the more proportional, and therefore robust their immune response. Needless-to-say, a balance between hawks and doves needs to be established for mutual gain to take effect. In terms of the human genome, it's very underwhelming, yet it has evolved to a complex multi-cellular life form, still totally dependent upon trillions of unicellular life forms within the individual gut biome. This flies in the face of Darwinian evolution and the survival of the fittest, in that simple life forms keep complex life forms alive. Even, within the gut biome, there appears to be a symbiotic relationship with parasites and a healthy immune system (i.e. parasitic exposure appears to reduce auto-immune disease such as allergies). A 'simple' multitude (gut biome) balanced with a 'complex' minority (human DNA). Humans eat to feed their gut, their gut breaks down energy from food, which in turns propels the human, with the energy gained, to find more food. A net win win situation using the gut-brain-muscle axis.  In terms of muscles, a simplistic view, (using this analogy) would be that the glycolytic (fast twitch) muscles are the 'hawks', whereas the oxidative (slow twitch) muscles are the 'doves'. The glycolytic muscle fibres tend to be ballistic two joint (mechanical) energy straps which propel the body, whereas the oxidative endurance (metabolic energy) muscles are one joint deep muscles tending to stabilise joints and prevent injury. Therefore, the 'hawks' make the large perturbations whereas the 'doves' dampen them. Luckily, there is a muscle glycolytic fibre type which can become more oxidative (endurance power). Hence, 'hawks' which can be tempered towards a 'dove' like mentality....a balance between metabolic and mechanical energy systems, where the mechanical perturbations stimulate the metabolic-immune response. In terms of neurophysiology, this analogy could potentially be taken further, where the sympathetic nervous system is the 'hawk' and the para sympathetic nervous system are the 'doves'. Fortunately, within the sympathetic nervous system there are self modulating ('dove' like) perturbating mechanisms. But it could be envisaged that putting a 'hawk' amongst the 'doves' wakes them up from a state of complacency. Similarly, 'staleness' is an 'existential threat' to any training regime and to any 'immune system'.  Cortical 'resource' representation, mapping, in knee muscles, after injury In the context of physiotherapy, a simple model of game theory might be applied to the problem of anterior knee pain. Commonly, this problem is associated with pain at the front of the knee when it is in flexion (a bent position), such as stair climbing, cycling, squats, etc. The conventional wisdom is that the patella (knee cap) is mal-aligned due to a lack of medial (VMO) muscle activity pulling the patella inwards and too much activity of the lateral thigh muscle (VL) pulling it outwards. Game theory could be applied here as the muscles compete for finite cognitive territory to represent their individual (rather than mutual) function, where ultimately neither muscle gains, both loose out to pain generating cortical representations, reducing fidelity and increasing noise in the system. However, if the muscles were to readjust for a functional outcome, they would do so through gaining a synergy of proportionally shared resources (power sharing), hereby a dominance over pain and dysfunction is gained. Physiotherapists, use functional electrical muscle stimulation (FEMS) to give added 'resources' to the VMO, which then can be used during functional exercise training. As the system adjusts, the pain improves and the gain experienced by all the muscles convinces the VL to fire with the VMO, hamstrings and gluteals in a functional synergy for stairs, cycling (see previous), squats, etc. Hereby, game theory would suggest all have won and injury has been avoided. Investigations in Australia, by the Brazilian, Abrahao Baptista (2014), looking at 40-50 year old women with chronic knee pain, demonstrated the significant reduction in the volume of muscle representation in the cerebral cortices, as well as changes in the location of these muscle representations (see below). Moreover, in the context of neurons who 'fire together, wire together' it would be of utmost importance to find exercises that act as functional synergies and relate in a real or a 'virtual' manner to the environmental context in which they need to fire. This also becomes particularly important in psychological behavioural issues of 'fear avoidance' and disuse atrophy. Ideally rehabilitation stimulates 'wiring and firing together' of goal-oriented regions of the brain rather than those which are directed at fearing and avoiding movement. Therapist must instil confidence through their choices of treatment whereby they outline and hence monitor the expectations of outcome. In this picture, it is clear that, the volume of the quadriceps muscle representation in the cortex of people with anterior knee pain (PFP = patello femoral pain) is dramatically reduced. Not seen here, but demonstrated in other research, is the phenomenon of pain processing altering cortical activity in various brain areas (see below).  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036). Physiotherapists use FEMS (30HZ functional electromuscular stimulation) to enhance muscle cortical representation in the brain, which improves function and in turn improves pain. FEMS stimulation readjusted cortical mapping to that seen in asymptomatic individuals.  Alternatively, therapists use trans-cortical stimulation of the pre-frontal cortex to improve 'executive function' and pain.  Brain activation related to spatial discrimination of noxious stimuli is distinct from that related to perceived pain. These images are located at x = 0 mm, x = 30 mm, z = 5 mm, and y = –30 mm in standard stereotaxic space. IPL/SPL, Inferior parietal lobule/superior parietal lobule; GP/PT, globus pallidus/putamen; M1, primary motor cortex; DISCRIM., discrimination. (Oshiro et al 2007 J Neuroscience, 27, 13, 3388-3394) Abrahao Baptista (2020) and his colleagues are conducting research into trans-cortical stimulation and vagal (para-sympathetic) nerve stimulation in the treatment of patients with COVID-19. They are basing their assumptions and working hypothesis on some positive results a rheumatologist has had with this methodology for the treatment of auto-immune inflammatory disease. COVID-19 has many of the hallmarks of an auto-immune disease, including the cytokine storm. This treatise has argued that sympathetic, rather than para-sympathetic, stimulation is necessary to add a deterministic chaotic input which perturbs the immune system into action. It would be intriguing to speculate a large perturbation between sympathetic and para-sympathetic can also activate the immune response. In this case, the illness has already set the sympathetic nervous into a heightened chaotic state, which needs additional buffering (redundancy) from the vagal nerve stimulation. Exercise induced disease "The road to hell is paved in good intentions" (Henry G. Bohn's A Hand-book of Proverbs in 1855) The chaos of infections and the assault on the immune system has been seen amongst endurance athletes, such as cyclists, endurance road runners and orienteers. Saturation of inflammatory immune markers by uncontrolled mechanical irritation or infectious diseases from ticks found in the forests of Scandinavia, have been espoused as a theory behind extremely fit people having catastrophic immune consequences. After intense long duration exercise, the functions of (CD 16 natural killer) NK and (CD 19) B cells are suppressed. Thus, the NK cell activity (the ability of NK cells to lyse a certain number of tumour target cells) is inhibited. Furthermore, antibody production in the circulation is inhibited, and local production of secretory IgA in the mucosa is inhibited (Pedersen BK & Nieman DC. 1998 Immunol Today, 19, 204–6) Too much of a good thing can become a bad thing. Where does the balance lie? In the chaotic state? Anti - carcinogenic effects of exercise Alternatively, it has been shown, albeit in mice, that aerobic training activates Interleukin 10, which is considered to have colon anti-carcinogenic effects (Frajacomo et al 2016, Med Sc Sp Ex, 47, 9, 1806-1813). This supports reports on the association of aerobic exercise and marked reduction of colon cancer risk in humans (Boyle et al 2011, Cancer Causes Control, 22, 12, 1647-1658; Cerin et al 2005, Cancer Epidemiology Biomarkers Rev, 14, 4, 1000-1002). A mechanism for the effect of exercise is the production of Interleukin 6 (IL-6) as a result of muscle damage during exercise, which has been demonstrated to stimulate anti-inflammatory cytokines such as IL-10 (Benatti et al 2015, Nat Rev Rheumatol, 11, 86-97). Importantly, as discussed previously, chronic increases in IL-6 are related to frailty in the aged population. However, in the acute scenario, significantly, the release of pro-inflammatory substances, stimulate the release of anti-inflammatory substances elsewhere, as well as the stimulation of the controlling mechanisms, in the location, where the pro-inflammatory substances are released.  So, what are the controllers? When is too little recovery, too much exercise? Where and what are the balancing mechanisms of the cytokines? What behavioural methods can we use to improve our immune response? Allostasis Neural componentry and chaos Several investigations, examining surface EMG (electromyographic activity of muscles) using chaos and entropy theory, exist. Investigators, examining facial paralysis (Xiong et al 2014, Robot Intelligence Technology and Applications 2 pp 805-819), used chaotic analysis to extract new features of EMG, including correlation dimension, Lyapunov exponent, approximate entropy and so on. They discovered that the maximum Lyapunov exponents are all greater than 0, indicating that sEMG is a chaotic signal. Interestingly, correlation dimensions of sEMG on healthy sides are all smaller than that of diseased sides; and inversely, the approximate entropies of healthy sides are all greater than that of diseased sides. Consequently, they concluded that chaotic analysis can provide a new insight into the complexity of the EMG and may be a vital indicator of diagnosis and recovery in the assessment of facial paralysis  Application of chaos theory to a model biological system was used to examine evidence of self-organization in the intrinsic cardiac (heart) nervous system (Skinner et al 1996, Integr Physiol Behav Sci. 31,2,122-46). Using a rabbit model and ischaemic events, on electrical activity in and around the heart, they found that it's the neutral organization that determines the specific beat-to-beat pattern of cardiac behaviour. This was demonstrated in the independent regulation of the RR intervals (chronotropy) and the corresponding QT subintervals (inotropy), as the former defines the rate of contraction and the latter has a linear negative correlation with the peak pressure inside the contracting ventricular muscles. During accumulating ischemia/anoxia, dimensional fluctuations of the two sub-interval series as correlates of adaptation-dependent self-organization and reorganization in the underlying intrinsic cardiac nervous system, was seen. COVID-19 and Allostasis As we know, organs exposed to the outside world, such as the digestive and respiratory tracts and skin have a high functional immune component, which acts as an interface and barrier to external pathogens. At the outset of this pandemic, COVID-19 was considered a lung condition. However, as time went on, hypoxia and diffusion issues began to be noted, including oxygen blood saturation levels of 50%, skin changes in the periphery (esp toes) resembling lesions seen in chilblains and chicken pox, notably in young people (20-40 years of age). Additionally, vascular clotting began to be seen in this younger population leading in some cases to stroke. Furthermore, longer gastric emptying was seen which may or may not be an immune response. It has also been noted that it's highly contagious, human to human, animal to human and human to animal, as well as being highly unpredictable, in who survives and who does not. Since it is a 'novel corona virus' we do know that we need our 'innate immune response' to fight it. That's potentially why it generally doesn't affect children (however there have been exceptions) and it's mortality rate is much higher amongst the elderly and those who are already metabolically or immune compromised.  Furthermore, psychological stress from confinement has also been seen. Further mental health issues, from potentially the extreme viral exposure amongst essential services, and/or extreme exhaustion amongst health care workers has also been acknowledged. Psychology and mental stress, such as that from Post Traumatic Stress Disorder (PTSD) is thought to reduce the number of naive T cells, meaning a reduced ability to launch an immune response to a novel pathogen and is also thought to contribute to increased susceptibility to auto-immune disorders (Dr. Annette Sommershof).  Therefore, the essential question, is it purely metabolic and cognitive exhaustion, and/or exhaustion of the immune system from exposure to COVID-19? Would people (orienteers) used to mental stress, whilst exercising, better be able to launch a balanced immune defence? Adaptation has a damping mechanism whereas lack of adaptation does not. Additionally, it is important to launch a stimulus or perturbation strong enough to activate an appropriate balanced response. Recovery and sleep routine It is critical to maintain a healthy sleep pattern if we wish to maintain a healthy immune system. Routines of the day can become good anchor points for the body. These include eating regularly and sleep. Psychology of the immune state Psychologically, we also need to be prepared for what lies ahead. Currently, we're fighting an unknown assailant. A virus which our adaptive immune system has never seen before. This means that we must rely on our innate immune system, the one we're born with, to adapt it's RNA to a DNA antigen which can fight the disease. However, remember psychological stress of 'perceived dangers' such as job and income insecurity, fear of the disease, isolation and loneliness can affect where and when we deploy our cytokines. Importantly, when or if we are exposed to COVID-19, ideally your immune system is able to react and isn't already exhausted. Part of your exercise regime may need to include meditation and Yoga. Diet Another, important way of avoiding an 'exhausted immune system' is diet. Generally, a well balanced diet is important. Moreover, during exercise our immune system is enhance, whereas post exercise it can be depressed. One of the best ways to ameliorate this, is through amelioration of metabolic demands with pre-exercise, during long exercise and/or immediate, post exercise calorific intake, thereby avoiding metabolic imbalance and potential catabolic (break down) reactions, whilst promoting anabolic (building) ones. Besides nitrogen balance, contracting skeletal muscles, in sports such as running, are a major source of increases in the circulating concentration of the cytokine, Interleukin-6 (IL-6), seen during exercise. It's appearance decreases with the ingestion of glucose and with endurance training. Low pre-exercise glucose levels, results in greater transcriptional activity of IL-6 gene in muscle and higher IL-6 concentrations during subsequent exercise, which in turn stimulates hepatic glucose production and fatty acid mobilisation and oxidation. Thus, IL-6 may be a carbohydrate sensor, mobilizing substrates and/or augmenting substrate delivery to working muscles. Interestingly, IL-6 concentrations increased with increasing intensity of exercise, whereas tumour necrosing factor alpha (TNFα) did not (Scott et al 2011, Med & Sc Sp & Ex, 43,12, 2297-2306), suggesting a specific and therefore potentially finely tuned immune response. The gut-muscle-immune axis: a ratio of innate and adaptive immune substances? It could be simply argued that all systems are oscillatory, finely tuned through damping mechanisms and that the reference points of the tuning are not only defined by extent of the oscillation (linear dynamics) but also by the randomness of non-cycling oscillations. Mechanically, this may be analogous to a mass-spring system defined by Hooke's Law, but immunologically it's potentially defined by the balance between up-regulatory and down-regulatory immune pathways of the adaptive and innate systems? https://phys.org/news/2016-03-gut-microbiome-remarkably-stable.html Using a yeast and bacteria (E.coli Hsp60 homologue known as GroEL) model, a tenuous relationship has been proposed between HSP60 and HSP70 chaperone proteins, as they are both vital for mitochondrial proteostasis, being involved in the import and/or the folding of almost 50% of the mitochondrial proteins. Moreover, both proteins were found to carry out various functions via interaction with a large number of extra-mitochondrial complexes. In the case of HSP 70, its mitochondrial functions are performed by the classical mechanism known for all HSP 70, utilising a protein and a nucleotide exchange factor. With regard to mitochondrial HSP 60 and HSP 10, it is notable that this pair developed a unique reaction cycle in the gut (Jebara F et al 2017 DOI: 10.1002/9780470015902.a0027152), a bit like the relationship of HSP27 with HSP72. The amount of human DNA is totally under-whelming compared to that of the intestinal mircobiome. The intestine is composed of a complex ecosystem of more than trillions of bacteria, viruses, fungi, Protozoa and Archea that live in a symbiosis with the host in the gut lumen. The healthy microbiome include a limited number of highly represented taxa, such as Bacteroides and Prevotella  and a large number (>2000 to date)  of minor players with low representation but high metabolic activity. These latter 'players' with high metabolic activity are likely to be the ones which interact with the musculoskeletal system. In older age, species richness and diversity of the microbiome decline, inter-individual variability increases, and resilience to perturbations are reduced. Apart from aging, the presence of acute and chronic diseases affects the microbiome. In the aging and/or unhealthy microbiome a 'dysbiosis' can occur, where a disruption of the gut balance 'symbiosis' results in intestinal permeability, allowing bacteria, or bacterial toxins and metabolites to enter the host circulation thereby promoting sub-clinical inflammation. Clinically, sub-clinical inflammation has been referred to as 'inflammaging' and 'immunosenescence'.  All components of the innate immune system exhibit profound changes during aging. Monocytes are classified into three subtypes: classical, non-classical, and intermediate. During aging the number of nonclassical CD14+CD16+ monocytes increases, indicating a shift to senescence, proinflammatory phenotype with short telomeres. Similarly, a shift in macrophages from immunoregulatory M2 macrophages to proinflammatory M1 macrophages. Furthermore, Natural Killer (NK) cells are innate lymphoid cells, where 2 subtypes are present. CD56bright cells are immature cells providing an immune regulatory function, and CD56dimCD16+NK cells which produce high levels of IFN-gamma, associated with a potential dysregulated cytokine production, as CD56bright cells decrease with aging. Moreover, exercise appears to have the opposite effect to aging, where a reduction the number of nonclassical CD14+/CD16+ monocytes, was found, in a 12 week combined strength and endurance training program. The adaptive immune system changes with aging. Although the total number of T-cells remains constant throughout life, the two main cellular subtypes CD8+ cells increase, whereas CD4+ decrease. This phenomenon is part of the immune risk profile (IRP) and indicates immunosuppression in certain diseases. Reduction of naive CD4+ cells is driven by thymic involution from chronic antigenic stimulation and inflammation. Inflammaging chronically increases IL-6 and TNF-alpha. Improved T cell function has been reported in elderly runners who trained for an average of 17 years, and thus improvements in the adaptive immune response.  In 102 male participants between 18 and 61 years of age, with above-average VO2 had fewer senescent CD28-CD57+, CD4+, and CD8+ cells and increased number of naive CD8+ T cells. Acute bouts of exercise induces cell death in apoptosis-resistant senescent T-cells. Additionally, regular endurance training in the elderly, improves CD4+/CD8+ ratio. Although exercise seems to improve the immune system, endurance exercise seems better than strength training alone. Exercise also influences inflammation induced from visceral adipose tissue (fat). Toll-like receptors (TLRs), mainly in the innate immune system, are upregulated with physical inactivity, systemic inflammation and the development of age-related diseases. They are particularly reactive to heat shock proteins (HSP). HSP's are found in muscle and released with exercise. Conversely, a reduced expression of TLR2 and TLR4 has been found in both acute and regular exercise. Importantly, skeletal muscle itself acts as an endocrine organ, whereby muscle contractions and energy metabolism induce the production of various cytokines-termed myokines-or peptides with anti-inflammatory potential. As highlighted earlier IL-6 is one of the most effective myokine. IL-6 increases during and after exercise, proportional to intensity and duration, stimulating immune-regulatory mediators such as IL-10 and the IL-1 receptor antagonists and downregulation of TNF-alpha by monocytes and macrophages. Results form middle-aged master athletes demonstrated that IL-1ra, IL-1beta, IL-4 and IL-8 levels were elevated compared to inactive, younger-middle-aged controls. Exercise-induced IL-6 has been shown to inhibit endotoxic-induced TNF-alpha. Besides IL-6, myokines such as meteorin-like has been shown to induce brown fat metabolism, increase IL-4 levels and promote polarization of M2 macrophages. IL-7 and IL-15 are myokines that might stimulate lymphocyte proliferation and it has been suggested that IL-7 exerts protective effects on the thymus.. IL-15 seems to have further effects on immune homeostasis which induces a better survival rate of naive T-cells. At a metabolic level, IL-15 reduces the accumulation of visceral and white adipose tissue by reducing the accumulation of fat. Exercise is generally considered a positive modulator of the gut biome. Regardless of age, exercise has a positive effect on taxa involved in energy, carbohydrate and protein metabolism and short chain fatty acid (SCFA) production. Maintenance of exercise is needed to induce long-lasting modifications of intestinal microbial ecosystem. Such changes have been shown to improve the inflammatory mediators of the gut. Importantly, dosage of exercise is important, as over-exercise can induce ischaemic events in the gut mucosa, associated with acute gastrointestinal symptoms including abdominal pain, nausea, and diarrhoea. Supplementations, of probiotics and prebiotics can attenuate some of these unfavourable changes of the gut.  Probiotics have been shown to modify the gut microflora population, increase natural killer (NK) cell cytotoxicity, increase secretary immunoglobulin A (IgA) levels, and enhance resistance to infections, potentially through the kynurenine/tryptophan ratio, activated T-suppressor (CD8+CD25+) and natural killer cells (CD56+CD16+)  in high doses, whilst low doses increased activated T-helper lymphocytes (CD4+CD25+), B-lymphocytes (CD19+) and antigen-presenting cells (HLA-DR+). There is a gut-muscle axis hypothesis in age-related sarcopenia. A dysbiotic intestinal microbiota can effectively result in reduced bio-availability of dietary proteins, in particular tryptophan, which is a powerful mediator of inflammation, as well as a promotor of muscle protein synthesis. Additionally, the gut bacteria are also involved in the synthesis of many vitamins, including folate, vitamin B12 and riboflavin, which exert pro-anabolic effects on muscles.  Tryptophan is a pre-curser of serotonin and plays a pivotal role in immune system regulation. Enhanced breakdown of the tryptophan kynurenine pathway occurs in aging and in conditions with an increased pro-inflammatory response. Tryptophan and particular serotonin have been known to be associated with mood and cognition. The kynurenine pathway not only plays a role in the innate immune system via IDO (an enzyme which degrades tryptophane) and it's influence on IFN-gamma, but also in the adaptive T-cells immune response, through selective apoptosis of Th1, and not Th2, cells. Accumulating evidence implicates gut microbiota in the regulation of kynurenine pathway metabolism, and thus the gut-brain axis. Chronic exercise interventions may lead to reductions in IDO activity as a result of anti-inflammation.  Assuming that chronic inflammation induces sarcopenia and vice versa, good muscle mass reduces chronic inflammation, a vicious cycle needs to be broken by any means possible, through a combination of dose specific exercise and diet. As already stated anti-oxidants and sufficient carbohydrates and protein are important in our diets. Additionally, n-3 polyunsaturated fatty acids (PUFAs), has been shown to have anti-inflammatory properties through their effect on leukocyte action, eicosanoid production, and T-cell proliferation. PUFAs in combination with strength and endurance training have been shown to have favourable muscle building effects, where 6 months of Progressive Resistance Training (PRE) (2 x week, 3 sets per x's. 50-85% 1RM) combined with n-3-PUFA-rich diet, improved gene expression, whereby pro-inflammatory IL-1beta was down-regulated and regulator of cellular growth mechanistic Target of Rapamycin (mTOR) was up-regulated in skeletal muscle in older women. Exercise training has been shown to reduce intestinal inflammation and modulate gut microbiota profiles in insulin-resistant people (Motiani et al 2020, Med Sc Sp Ex, 52, 1, 94-104), using both moderate-intensity continuous training (MICT) and sprint interval training (SIT). High fat diets reduces the Bifidobacterium, Eubactterium rectale-Blautina coccoides, and Bacteroides genus  which leads to an increase in the Gram-negative : Gram positive ratio, meaning a subsequent increase in LBP was found by Cani et al (2008 Diabetes, 57, 6, 1470-1481). Moliani et al (2020), on the other hand, found the opposite with both forms of exercise training. There was a reduction in Firmicutes/Bactroidetes ratio, mainly due to an increase in the relative abundance of Bacteroidetes and a decrease in abundance of  Blautia spp.  and Clostridium spp at genus level. This may induce regulatory T-cells to produce IL-10 (anit-inflammatory cytokine) inside the gut (Mazmaniian et al 2008 Nature, 453, 7195, 620-625). Furthermore, it was found that Bacteroidetes  at the species level correlated negatively with plasma inflammation (LBP, TNF alpha, and CRP levels) (Moliani et al (2020). Exercise training also reduced the relative abundance of Clostridium  and tended to reduce the Blautia genus. The former thought to play a role in whole body inflammatory response and the latter found in abundance in pre-diabetic people. Moliani et al (2020) also found a reduction in TNF alpha after 2 weeks of training, which also plays a critical role in inflammation. The Firmicutes/Bacteroidetes ratio is elevated in obese people, whereas it is reduced in this study as well as in some investigations examining dietary intervention.(Ley ey al 2006 Nature, 444, 7122, 1022-3)..It is thought this ratio is important in that Firmicutes may contribute to obesity because they can harvest more energy from food (Turnbaugh et al 2008, Cell Host Microbe, 3, 4 213-223). Increases in faecal Bacteroidetes were also found, which is significant as it plays an essential role in the metabolic conversions of complex sugar polymers and degradation of proteins (Rajilic-Stojanovic & Voss 2014, FEMS Micorbiol Rev, 38, 5, 996-1047). Although, these are very positive findings for exercise intervention, chaos theory would suggest that the SIT group should have shown more changes than the MICT group. Interestingly, by choosing a cycling program, any effect of muscle micro-tears and an immune response is mitigated, as would be seen with eccentric exercises, such as a running regime. Hence, this is a purely metabolic (vs mechanical load) load, where the SIT is high intensity but of a much shorter duration (30secs x 4-6 bouts)  vs MICT of 40 - 60 minute duration. One would surely elicit an anaerobic, lactic acid, response whilst the latter would elicit a Glut-4 muscle energy metabolising response. It's difficult to reconcile this on a purely metabolic basis and perhaps it's the neural activation of exercise which is the prime signalling pathway? The Paper of the Year for Exercise and Sports Science (2020) was recognised for several findings, including exercise alters the microbiome of the gut independently of diet exercise exerts strain level selection for microbes within the host more robustly than genotype reduced exercise tolerance in situations of reduced microbiome (eg anti-biotic use and gene knock out mice)  mechanism is likely via butyrate-producing microbes gut-immune interactions via gut-associated-lymphoid tissue bile acid circulation metabolic flux Specifically, Fecalibacterium prausnitzii, has been shown, not only to be enhanced with exercise training, it is thought to improve type II diabetes outcomes, as well as improve symptoms of depression and anxiety. (Mailing et al 2019, Ex Sp Sc Rev, 47, 75-85. Weyh C et al (2020), Nutrients, 12, 622: doi:10.3390/nu12030622 Ticinesi A et al (2019) EIR 25, 84-95 Ticinesi A et al (2019) Nutrients, 11, 1633; doi:10.3390/nu11071633 Codella et al (2017), Digestive and Liver Disease, doi:10.1016/j.dld.2017.11.016 Dietert R & Dietert J (2012), Entropy, 14, 2036-2065: doi:10.3390/e14112036   Bursitis, tendinopathy and the immune system Clinically, I began to notice a relationship between bursitis, tendinopathy and gut immune compromise back in the early 1990's when I was working with Swiss elite national teams in various sporting endeavours. It seemed like a common occurrence for young healthy athletes to suddenly develop bursa and tendon symptoms after a gut infection, severe cold, etc. Since that time, many investigations have demonstrated a relationship between metabolic-immune compromise and fatty-immune substance infiltration into bursa and tendon resulting in pain. Interested readers should see shoulder tendinopathy elsewhere on this website for further details. Dosage of exercise to fine tune the immune system Hence, dosage and type of exercise becomes important as well as the way you progress your loading. The benefit of resistance training, is that you can do this indoors, using weights around the house, as well as body weight. Additionally, it is easy and important to establish a base line. That is, how many repetitions for a certain number of sets. Each set of repetitions should feel the same in each set. The last repetition is the 'point of failure' ie you cannot do another repetition. You will also need to establish the time of recovery between sets. Write these down.  Once a base line or a protective foundation of exercise has been laid down, using a deterministic chaotic variable (usually 4-12 weeks), then the introduction of random - chaotic - novel exercise, fine motor exercise, high repetition exercise, high load low repetition needs to be employed, to improve cognitive, metabolic, emotional, mechanical and ultimately immunological demand on the system. Those fortunate enough to be able to leave their home for exercise, walking and cycling are great activities. Even here, you can challenge yourself with distance, time and hills. If walking, you may wish to use a weighted backpack. If cycling, use higher gears from time to time, so as to add some resistance training into what is essentially an endurance activity. However, these activities do not replace a structured home exercise or gym based regime. Oscillations in another part of the body can be used to establish harmonic frequency elsewhere. For example, arm movements activating the opposite erector spinae activity, pelvic oscillations for scapular control, arm lifts for contra-lateral gluteal activity. Alternate kneading of the hands into something soft activates the abdominal muscles, spinal rotatores and scapula muscles. Oscillations of the pelvis around the hip activates eccentric scapula control. Alternate lifting of the arm off the wall activates the opposite buttock muscle. Alternating arm flexion/extension around the 90 degree angle activates the opposite erector spinae muscles of the low thorax and upper lumbar spine. Moving through the horizontal with a consistent oscillation also has varying effects on those muscles. Importantly, if loading is required to activate a muscle building response, then repetitions need to include tremor. Either fine motor tremor or exhaustion tremor, if we want to include a 'deterministic chaotic variable', which it is hypothesised to create an immune training variable. "In this regard, it is vitally important that we try to maintain our activity levels within recommended guidelines. Not only can exercise have a positive direct effect on the cells and molecules of the immune system, but it is also known to counter the negative effects of isolation and confinement stress on various aspects of immunity. Although no scientific data currently exists regarding the effects of exercise on coronaviruses, there is evidence that exercise can protect the host from many other viral infections including influenza, rhinovirus (another cause of the common cold) and herpesviruses such as Epstein-Barr (EBV), varicella-zoster (VZV) and herpes-simplex-virus-1 (HSV-1). Work from Jeff Woods’ lab at the University of Illinois showed that moderate-intensity exercise training during an active influenza infection protected mice from death. It also promoted a favourable immune cell composition and cytokine shift in the lungs that was associated with prolonged survival. A major focus of our research is to understand how exercise can mitigate the negative effects of stress to maintain immune function, particularly during prolonged periods of isolation and confinement such as space travel. We showed recently that astronauts who had higher pre-flight cardiorespiratory fitness and skeletal muscle endurance before a six-month mission to the International Space Station were less likely to reactivate EBV and VZV during the mission. Copies of EBV viral DNA were also lower in the fitter astronauts, indicating that their ability to infect others is also reduced. Moreover, those astronauts who had lower pre-flight fitness levels and returned to Earth with the greatest levels of cardiorespiratory deconditioning were more likely to have reactivated a virus during the mission. Viral reactivation is a global indicator that our immune system has been weakened, which, in this context, we believe to be largely due to the stressors associated with isolation and confinement. This research indicates that exercise, in addition to the aforementioned direct effects it can have on cells and molecules of the immune system, may be an effective stress-induced countermeasure to help maintain immune function and lower infection risk." (Richard J. Simpson, Ph.D., FACSM | Mar 30, 2020) "Floppies vs Stiffies" consideration when prescribing exercise There are essentially two types of people - the 'floppies' vs 'stiffies'. The forming are hyper-mobile whereas the latter are hypo-mobile. The floppies like to do fast and quick type of exercise such as gymnastics, dance, track and field, etc. The stiffies tend to do slow type of exercise such as marathon running. Hence, not only do these people have different connective tissue type, but also different muscle fibre type. The 'fast' twitch muscles are the ballistic muscles, whereas the stiffies tend to have 'slow' twitch endurance muscles with a joint and posture stabilising function. Stiffies tend to be found in the Pilates class, whilst the floppies are found in the Yoga class. In terms of clinical reasoning and injury management this should probably be the other way around. Another, interesting clinical anecdotal observation, floppies tend to do better in pulling type of exercise ie where energy is brought back into the body, whereas stiffies tend to do better with pushing type of exercise where energy is produced outward away from the body.   Motivators to exercise and to eat Interestingly, research which I undertook in 1992-93, examined the influence of the hypothalamus and the peripheral sympathetic nervous system on fibromyalgia, chronically over-exercised and repeatedly injured female elite athletes. What was exceedingly interesting were the interactions with luteinising and follicle stimulating hormone and immune system. Clinically, these athletes (orienteers, x-country skiers and distance runners) suffered from eating disorders, osteoporosis, dysmenorrhea, late menarche, and were frequently ill with skin infections and upper respiratory infections. Paucity of research on the hypothalamus, at the time and even contemporarily in humans, due to the technical nature of research in this region, means that the majority of investigations are still done in rodents. More recently, leptin, glucose and glut-2 astrocyte and neuron (related to glut-4 muscle) receptors, and neuropeptide Y (NPY) were found to be involved in a complex interaction around the arcuate nucleus (ARC), related to transcriptional regulation of motivated exercise (Good et al 2020, Ex Sp Sc Rev, 48, 2, 74-82). These areas happen to be also related to taste and smell (olfaction), which coincidentally the loss of, is one of the symptoms related to COVID-19. The olfactory system has been used as a conduit for drug and homeopathic administration, directly into the central nervous system (CNS), as there is no blood brain barrier or blood nerve barrier here. New genetically engineered biotechnology products, such as recombinant human nerve growth factor, human VEGF, and interferons, are now possible to be delivered into the brain from the non-invasive intranasal route. For gene therapy, intranasal route is also a promising alternative method to deliver plasmid DNA to the brain. Additionally, anti-biotics are also being trialled via nasal delivery in COVID-19 patients.  Insulin nasal delivery has also been approved by the FDA using a methodology originally developed by (my uncle-in-law) Eric Bechgaard of Denmark (https://www.sciencedirect.com/science/article/pii/0378517395043152), Interested readers of this modality should see https://www.ncbi.nlm.nih.gov/pubmed/21712015 for a review.. It would appear that the same area of the brain relating to eating is also related to initiation or continuation of exercise, at least in rodents. Leptin levels are reduced 1-3 hours after exercise such as running (Zheng et al 1996, Biochem biophys Res Commun, 225, 3, 747-750). In rodents, injecting an expression vector for Leptin receptors increased home cage activity . A wild type mouse had significant reduction in weight using a similar methodology (Coppari et al 2005, Cell Metabol, 1,1, 63-72). Furthermore, it's not just a simple glucose or leptin-sensing mechanism by hypothalamic neurones, but a series of inter-connecting neurones, astrocytes, integrated receptors, adenosine triphospahate (ATP) synthesis and sodium sensing within the brain. Importantly, however, these incredibly complex, areas may also exert an influence, directly or indirectly, on the immune-inflammatory axis, through it's action on muscles, which affects overall health and susceptibility to disease. Importantly, a (un)healthy relationship exists between weight and susceptibility to disease. The review by Good et al (2020) stipulates that it's the flux of leptin, rather than the absolute levels of leptin, which is sensed by the LepR POMC neurones, whereby an increase in leptin levels may signal the need to exercise, so as to remove excess available energy. Specifically, transcriptional gene regulation downstream of the neuronal basic helix-loop-helix transcription factor nascent helix-loop-helix transcription factor nascent-loop-helix 2 (NHLH2/humans, Nhlh2/mouse) in POMC neurones, drives motivation to exercise by increasing melanocortinergic and dopaminergic tone in the hypothalamus and extrahypothalamic brain regions.  Leptin, diabetes and exercise Researchers, using a diabetic mouse model, have demonstrated that decreased leptin, MCP-1, and resistin levels were observed in diabetic mice after moderate exercise training compared with the non-exercised group. Leptin, MCP-1, and resistin levels in diabetic mice+Ex mice were 8.6, 75, and 39% lower, respectively, compared with diabetic mice without exercise training (Liu & Chang 2018, Front Physiol. 9, 636). Monocyte chemoattractant protein-1 (MCP-1/CCL2) is one of the key chemokines that regulate migration and infiltration of monocytes/macrophages. Both CCL2 and its receptor CCR2 have been demonstrated to be induced and involved in various diseases, including fibrosis, arthrosclerosis and systemic inflammation such as psoriasis. Migration of monocytes from the blood stream across the vascular endothelium is required for routine immunological surveillance of tissues, as well as in response to inflammation. Moreover, a metabolic role involves adipocytes secreting various adipokines that may be involved in the negative cross-talk between adipose tissue and skeletal muscle. CCL2 impairs insulin signalling in skeletal muscle cells via ERK1/2 activation at doses similar to its physiological plasma concentrations (200 pg/mL), but interestingly, does not involve activation of the NF-κB pathway. CCL2 significantly reduced insulin-stimulated glucose uptake in myocytes. CCL2 may represent a molecular link in the negative cross-talk between adipose tissue and skeletal muscle assigning a completely novel important role to CCL2 besides inflammation (Sell H et al 2006 Endocrinology. 147, 5, 2458–67Endocrinology. 147, 5, 2458–67). Leptin and diet The first time I heard about leptin was in the mid 90's and it was described as a hormone produced by fat cells. Certain foods stimulate leptin sensitivity (vs leptin resistance and weight gain). These include Apples. Research has shown pectin—as found in apples—may be effective in fighting back leptin resistance. Oatmeal. Rich in fibre and known for decreasing insulin levels, oatmeal can help prevent that “starving” feeling.  Lean proteins. The protein you get in turkey, chicken, and other lean meats can help to raise your metabolism and reduce leptin resistance. The same with fish, a top choice for battling leptin resistance. Green tea. A European study involving mice showed that green tea is effective in decreasing leptin resistance. Almonds. Besides the essential “healthy” fats, fibre, and protein you get from almonds, you also get essential fatty acids that boost metabolism and leptin sensitivity. Broccoli. Also thought to decrease your leptin resistance is broccoli, a vegetable that’s generous in calcium and vitamin C. Eggs. Known for their vitamin B12 and protein contributions, eggs can lift your metabolism and help keep you from becoming leptin-resistant. Generally speaking, keep fruits and vegetables front and centre at your meals. Top choices: grapefruit, watermelon, pears, and blueberries along with purple sweet potatoes, peppers, lettuce, carrots, and zucchini. Exposure "Currently, the greatest risk of COVID-19 infection is exposure. It is paramount that we find creative ways to exercise while maintaining social distancing and proper hygienic countermeasures. While exercise may not prevent us from becoming infected if exposed, it is likely that keeping active will boost our immune system to help minimize the deleterious effects of the virus, ameliorate our symptoms, expedite our recovery times and lower the likelihood that we can infect others with whom we come into contact. This is merely my intuition, but I do expect a large body of exercise immunology research to follow after this pandemic so that we can provide more specific exercise recommendations as they pertain to infection risk and control in both healthy and clinical populations." (Richard J. Simpson, Ph.D., FACSM  Mar 30, 2020) Low Back Pain, lumbo-pelvic movements and sample entropy An interesting article was published in 2022. For many years, it has been observed that people with chronic low back pain (LBP) have less perturbations of movement. There was the famous investigation in the 1980's, where people standing still with a WW1 German spiked helmet on their head, seemed to sway less when suffering chronic LBP. Clinically, it has been observed that chronic LBP is frequently associated with loss of ranges of motion (degrees of freedom). Thiry P et al (2022, Entropy, 24, 437, https://doi.org/10.3390/e24040437) demonstrated lack of randomness (entropy), of lumbo-pelvic movements, in a 70 seconds 'touch the stool' test, in people with LBP. Moreover, this lack of variability can persist, even after the cessation of LBP. It is thought that this smaller amplitude and less variability of the instantaneous centre of rotation results in a potential overloading of certain structures and underloading of others, creating disuse atrophy or overuse trauma. So, in the presence of CLBP, the aims of therapy would be to ascertain movement restrictions, ameliorate those, introduce oscillatory mobilisations and exercise techniques with increasing amplitude, displacement and ultimately variability.  Musculoskeletal Physiotherapy in the recovery from injury Previously, we discussed game theory in terms of adding resources to the VMO through FES (functional electrical stimulation) to moderate anterior knee pain and regain quadriceps cortical representation and function. We also described the need to stress the system to induce the change needed to improve immune health. Those stressors may, if they cross the threshold from functional to dysfunctional at times, need to be managed,. The latter inducing pain, which if it persists, results in clinical or sub-clinical inflammation, thereby creating an immune compromised states. Obvious everyday signs of this are frailty and obesity. Clinically, traditional Manipulative Physiotherapy (now called Musculoskeletal Physiotherapy) used a multitude of questions from the cognitive domain to ascertain a persons dysfunction. Parameters included the stage (temporal), stability (current or past history of ease of recurrence), irritability (time to worsen vs time to ease) and severity (how disabling). Intrinsic to questioning, was establishing a persons normal baseline of activity w.r.t. their age and wellness level, and calibrating that degree pf loading to questions on the triggers of their pain and dysfunction. Multidimensional reasoning on ascertaining perturbations or 'outliers' to an expectation of this persons and the average persons functional capacity, health and physical as well as mental well being. Once, these 'outliers' are correlated into a clinical picture, a reductionist approach to treatment, exercise prescription and goal setting can be achieved within the construct of the persons expectations, values and beliefs. The 'outliers' of the subjective examination are correlated with the 'outliers' of the physical examination. For clinicians, the 'noise' is the average, the 'fidelity' are the answers we receive from the inductive and deductive reasoning. Knowledge is strength. Physiotherapists, Exercise and Sports Scientists, Team managers and Trainers should have the confidence in their construct validity by incorporating their knowledge of the immune system, 'outliers', game theory and deterministic chaos into their treatment, rehabilitation, training regimes and sporting strategies, using a multi-modal reasoning approach. Conclusion Does exercise create a chaotic environment which stimulates and tunes the immune system? I have argued that it does, based on the muscle itself being an endocrine organ, in which multiple immune reactions occur and from which there is an interaction with multiple organs, including the brain, gut, thymus and liver. Additionally, intrinsic to exercise is the use of the lungs, which in essence is an immune interface with pathogens from the outside world. Where does chaos fit in? Chaos could be considered the non-harmonic perturbations of an oscillatory or regulatory system. A system of ratios, higher 'fidelity' as the magnification of the ratios, where perturbations of cytokines creates oscillations and new states of homeostasis through modal jumps. These oscillatory systems also include those of the second law of thermodynamics, motor and metabolic control. Paradoxes exist which allow the seemingly random fluctuation of a homeostatic system. Exercise can be deemed to be an easy tool for us to use in order to push the boundaries of these fluctuations, in order to set the reference points for a dynamic damping mechanism. The greater the fluctuation, the greater the damping needed. Importantly, in any damping system, over-shooting and over-oscillating need greater damping, which could include sound professional advice from physiotherapists and trainers. This may include advice on types of training (eccentric vs concentric, metabolic ), rest, avoidance of over-training, good and varied diet as well as mental strategies for a calm cognitive - psychological state are of paramount importance in the application and dampening of stressors. Moreover, hands on therapy may be required if injury were to occur. Most importantly, exercise can be seen to stimulate muscle, one of the largest organs of the immune system. In such a sense, prophylactic exercising of muscles, makes this strategy an inoculation against immune challenges both now and in the future. In this age of COVID-19, a great opportunity has arisen where people working from home may more easily exercise. Moreover, whilst in shut down it is even more important to exercise, and if the possibility arises walk, run or ride to work, thereby incorporating exercise and deterministic chaos into your daily routine, whilst avoiding confined spaces such as public transport. However, bear in mind that the trip to work shouldn't be exhaustive, as that can lead to immune compromise, for several hours after the cessation of exercise. Justification This article was adapted from a key note guest presentation I made at a conference in Rome in 2005, as well as Post Graduate research on neuro-immune-inflammation in Low Back Pain from 1995, an under-graduate research topic on Bernsteins perspective of motor control and linear oscillatory systems to control degrees of freedom from 1986, inverse dynamics and the Hill model of the mass-spring spring cycle and thermodynamics in calf-achilles problems from 2008, and research into Orienteering on a motor-immune-cognitive control hypothesis from 1998, as well as reading on non-linear dynamics and chaos since 1992. I wrote it, in response to the pandemic, but also as a conceptual framework on which I wish people build deterministic chaos theory into their reasons for motivation to train the mental and physical well being. Hopefully, physiotherapeutic interventions incorporate game theory of 'doves & hawks' into their thinking whilst, bearing in mind that muscle is an endocrine organ of the immune system, with a gut, lung and brain axis. Stay well, stay safe, support yourself, your family and your community Martin Krause April - May 2020 References References can be found within this text and in the original papers published in 1986, 1995, 1998, 2003, 2005 and 2008 and found here elsewhere on this site : - Sarcopenia and the immune system : https://www.back-in-business-physiotherapy.com/we-treat/exercise-muscle-mass.html - Pain and inflammation : https://www.back-in-business-physiotherapy.com/pain-and-inflammation.html - Inverse Dynamics and Hill model of mass spring system : https://www.back-in-business-physiotherapy.com/we-treat/achilles-tendonosis.html - Degrees of freedom and Bernsteins concept of motor control using a linear oscillatory system : https://www.back-in-business-physiotherapy.com/shoulder.html - Orienteering, motor control and the immune system (uncontrolled manifold hypothesis) : https://www.back-in-business-physiotherapy.com/sports-performance/orienteering.html - Endurance Training : https://www.back-in-business-physiotherapy.com/endurance-training.html Uploaded : 3 April 2020 Updated :26 November 2023 Read More

Managing stress as a multitasking mother in the time of COVID-19 Are you a working mum? Or perhaps a full-time mum trying to manage kids, a house and everything that comes with it? Or maybe the events of the world right now are forcing you to wear both these hats – all at once! Being a parent can be very stressful. Between waking up and going to bed each night, there is a list as long as your arm of daily chores and jobs to do. Many of us have been there and totally sympathise with just how hard it is to juggle all of these elements of life. Here at Back in Business Physiotherapy, it is not uncommon for us to see mums in pain, stressed out and struggling to balance family, work and life. Of course, there are dads out there juggling all these elements as well, so if you’re a dad reading this, take note! There isn’t an easy solution to this problem, but there are many things you can try to do to begin making this process more manageable. Have a read through these five tips to see if they might work for you: 1. Set a consistent routine: This is a very handy thing to have in place. Busy schedules can be hectic and difficult to stay on top of. There are certain daily events that we can keep to a strict schedule, which can help to limit stress by managing each task. Try and keep wake-up and bed-times, bath times, mealtimes and story times to the same time every day. This gives you less to think about and frees up some brain space for concentrating on the day ahead, which may include an important work presentation that needs focus. Most children respond well to routine, so getting one established can mean more settled children and a more chilled mother. 2. Exercise regularly: We know that exercise is beneficial for staying fit, healthy and strong. There is also countless evidence for the effect of exercise on the mind and helping to reduce stress levels. Exercising regularly can help to reduce fatigue by improving sleep, concentration, mood levels and overall brain function. When we exercise, our bodies produce increased levels of the happy hormone (a.k.a endorphins) which help us to both tackle and stave off the effects of life’s stressors (bored screaming child). If you can’t get out for a walk or run, try some at-home exercises, a YouTube clip, or better yet, turn up the volume, and have a dance party with the kids. It lets them burn some steam, while you get some activity in. And it builds connection – win, win! 3. Consume a healthy diet: Stress hormone release is controlled by our adrenal glands. High stress situations over time can lead to increased levels of stress hormones coursing through our bodies. What we eat can help control the effects of stress. Controlling blood sugar levels is pivotal in maintaining good control of adrenal gland function. We recommend a balanced diet containing high amounts of natural, whole foods and keeping intake of sugary, nutrient-poor foods to a minimum. Foods rich in vitamins C and B are particularly important for supporting adrenal function. Try to include red bell peppers, nuts, seeds and leafy green vegetables to ensure you are getting a good supply of essential nutrients. 4. Stay hydrated: This is a simple and easy method to implement. It takes nothing to pour yourself a glass of water from the tap. Water is life-giving to humans. Without it we die quickly. All of our bodily processes and tissues rely on it to function efficiently. This includes proper function of the brain and all of the organs in our body. When we become dehydrated, the levels of cortisol (a stress hormone) increase. Stay ahead of the game and keep a bottle of water with you through-out the day. Sip regularly and your body will stay well-hydrated and ready to deal with any of those stressful scenarios that might pop up during the day. 5. Take time for yourself: We think this is the most important one of all. With being a parent comes enormous responsibility, but if you do not look after yourself above all, there is no possibility of looking after one or a whole troop of other family members. Set aside time when you can to read a book, do some exercise, meditate or do whatever makes you happy. Take a trip to the zoo or a museum on your own every now and then. If you organise these things in advance to ensure the kids are looked after by a friend or family member, then these things are easily achievable and help to keep you sane and grounded. 6: Home gym: if you have the space and a place to roll gym equipment out onto a balcony or verandah, you can keep up your fitness levels whilst in 'lock-down'. Multiple equipment will allow everyone to exercise at once. Elliptical Trainer, Plyometrics Box, Stationary Bikes, Treadmill, Rower, Punching Bag, Heavy Rope, Chin up bar, Swiss Ball, etc, etc. In these uncertain times, a pandemic which keeps on giving, potential worlwide economic collapse, home schooling, working from home, restrictions of liberty will all test our humanity. Emotional and physical stress will make parenting more difficult than ever before. We don’t think for one minute it is as easy as ABC to get all of this going alongside all this madness. Planning now, especially if there is a complete shut-down. It also looks like we are in for the long haul, potentially up to several months. But try to implement things slowly and steadily to make sure it fits well into your new daily routine. There is no handbook in such an unprecedented scenario for stress-free parenting, but we hope we’ve given you some food for thought! Isolate and keep up a routine. Uploaded : 1 April 2020 Read More

Uploaded 4 March 2020 Read More

Effects of Sleep Deprivation and Acute Muscle Recovery For many years sleep deprivation has been known to affect brain function, whereby 48-72 hours of sleep deprivation has been used as a means of torture. As in the famous novel by George Orwell, 1984, acute psychosis can be induced with sleep deprivation. Additionally, sleep deprivation can induce metabolic dysfunction including a blood spectrum similar to metabolic syndrome in otherwise young healthy individuals.   Any of us who have undergone intense unfamiliar exercise know the uncomfortable feeling of DOMS (delayed onset muscle soreness) and restless sleep. A combination of lack of sleep, over-training and inadequate recovery can result in the 'three bastards in a day". Read to the end to know who these three bastards are. Taking into account the many layered affects of sleep deprivation, it should come as no surprise that muscles may also be affected. Dattilo et al (2020, Med Sc Sp Ex,52, 2, 507-514) examined the effect of total sleep deprivation on muscle recovery after eccentric exercise induced muscle damage(EEIMD). They found that, in 10 healthy untrained males, sleep deprivation did not affect muscle recovery but modifies inflammatory and hormonal response. More precisely, sleep deprivation increases blood IL-6 levels and modifies the blood hormone balance by increasing IGF-1, cortisol, and the total cortison/testosterone ratio. Significantly, acute IL-6 elevation is known to stimulate hypertrophic signalling and myogenesis through regulation of muscle stem cells. However, chronic elevation of IL-6 can be very detrimental to skeletal muscle such as seen in cachexia. Muscle damage alone stimulates an immune-nervous system response   Normally functioning balance between pro-inflammatory and anti-inflammatory substances and neuro-immune modulation is referred to as allostasis   An interesting hypothesis is how sleep deprivation affects the cognitive evaluation of 'danger signals' in the presence of heightened arousal in a 'milieu' of an already stimulated immune-hormonal response to muscle damage Commonly, the sympathetic nervous system is viewed in terms of the 'fight-flight' response to perceived and real danger. Top down modulation or conversely bottom up modulation? A Psychologist may think top-down whereas a physiotherapist, exercise physiologist or sports trainer should think in both directions, especially since we are muscle specialists.  Commonly, over-training or over-reaching is associated with non-restorative sleep and nitrogen imbalance. This can affect catabolic processes such as those induced by cortisol and attenuate anabolic (muscle building) processes such as that induced by testosterone. Symptoms of over-training and sleep deprivation are nitrogen imbalance and the "three bastards in a day' rule. So who are these three bastards? If you meet a person who you really don't care to meet again, then that is fine. If you meet a second person like that on the same day, you might be very unlucky or in group company. If you meet a third person like this, and they aren't part of group, it's not them but you!!! Commonly, when people have asked me 'how do I know when I am in over-training?' I say, just ask your partner or spouse or have you met three bastards in a day lately??!!! Uploaded : 22 February 2020 Slides used are from a presentation I made at a conference in Rome in 2005.  Read More

Ketogenic diets and Exercise Ketogenic diets have become popular in the decade of the teens. It involves fasting up to 16 - 18 hours between meals (Dinner at 7 and lunch the following day at 1pm) as well as maintaining a strict low carbohydrate diet. In principle, this methodology, similar to repeated acute bouts of exercise, presumably encourages the fat mobilising/oxidative pathways whilst sparing glucose. Although, investigations into liver metabolic pathways to ketogenic diet and exercise, in mice, have shown them not to be additive, they have found both enhanced liver enzymes and pancreatic enzymes used to metabolise fat (Huang et al 2020, Med Sc Sp Ex, 52,1 37-48). Anecdotal evidence suggest that this glycogen sparing diet can be beneficial even in ultra-endurance type of events.  When working at high intensities, carbohydrates provide the most efficient source of fuel for ATP per volume of oxygen, in the mitochondria. The size of carbohydrate stores are limited, however they can be acutely manipulated, expecially in prolongied sustained or high intensity exercise, maintenance of carbohydrate availability enhances performance. Carbohydrate plays direct and indirect roles in the muscles adaptation to training. An example of the latter is the commencement of a second bout of training before the restoration of carbohydrate stores results in a co-ordinated up-regulation of the transcriptional and post transcriptionsl responses to exercise. Additionally, carbohydrate restriction during exercise can alter and improve mitochondrial oxidation of lipids. Periodization of training and of carbohydrate loading and unloading are techniques used to manipulate athletes performance.  Short term restriction of carbohydrate (CHO), when using a ketogenic diet, were shown to effect iron deficiences via the modulation of interleukin-6 (IL-6) and hepcidin levels. Acutely, the iron levels of a ketogenic diet were lower than in the CHO rich group. This may be partly due to the removal of the large iron content in the western CHO rich diet, but also as a result of a positive change to functional iron use such as increased erythropoiesis, DNA synthesis, and oxidative enzyme production. After a 3 week adaption of elite walkers to a ketogenic diet, the CHO rich diet group showed a greater decrement to serum ferritin despite greater IL-6 and hepcidin responses in the ketogenic diet group (McKay et al Med Sc Sp Ex, 51, 3, 548-555). Such a paradoxical response suggests the need to periodically check ferritin levels. Patency of blood vessels may be critical to good joint health. Elevated cholesterol levels are thought to affect blood vessel patency, as the formation of plaques within the vessels results in the relationship of blood particle number (Reynolds Number) and blood flow becoming critical causing stasis and end vessel infarction. The articular joints tend to be at the end of the line for blood vessels and hence their small diameter may be critically compromised by elevated cholesterol levels. Hence, supplementation with anti-cholesterol agents such as 1000mg of EPA and DHA in Fish Oil, the use of Co-enzyme Q10 may go some way to mitigating the effects of cholesterol. Uploaded : 18 Feb 2020 Read More

How to protect muscles as we age Welcome readers! This month we are going to talk to you about an important subject we all need to think about as we get older. The health of our muscles is important as we move through life into our later years. The body is made up of a host of different systems: the nervous, vascular and musculoskeletal systems are all examples. The skeleton is made up of bones that fit together forming joints. Muscles attach to bones and provide movement at the joints, all under supervision of the vascular (i.e. the ‘blood’ system) and immune-nervous system (i.e. muscles, the brain, spinal cord and nerves). It’s a little bit more complicated than that, but you get the gist. Our bodies rely on movement for countless different internal processes to occur, and for us to maintain function and be able to get around and stay alive. Movement keeps our bones strong, our digestion and toilet habits regular, and provides the force required for fluids to move around the body, just to name a few examples. If you look at an average person’s lifespan, we grow and get bigger and stronger until the age of 30 (give or take). After this, if we don’t work towards keeping it all, we start to lose muscle mass, bone strength and joint health, which forces our body to decline as we reach the elder years. Naturally, we start to move less and our injuries, stiffness and pain increase… Joyous thoughts I know, sorry! But… It doesn’t have to be all doom and gloom. If we spend time on our bodies throughout life, exercising, feeding it the right stuff and living a stress-less approach each day, it is very possible to move into our later years with a good body that will keep us moving well. If we take control of our bodies early on and not abuse them, it gives us the best opportunity to have a problem-free life down the line. Goodbye expensive medical bills. How nice would it be to not have to rely on our private health insurance or Medicare services?! Food for thought. Let’s recap… Muscles are movers, and we need movement to be healthy and alive. So naturally, we need to look after our muscles. “What can we do?" I hear you ask. The answer is, LOTS! • Exercise regularly: In order for our muscles to stay strong, we need to use them. The saying goes ‘if you don’t use them, you lose them’. And this is very true. Look at someone who has broken their leg and are immobilised in a cast for a six-week period. Once the cast comes off, look at the size of their muscles on that leg compared to the non-injured side. Through lack of use, the muscles have got smaller and weaker (i.e. they have ‘atrophied’). Losing muscle due to aging is a slightly different process (known as ‘sarcopenia’), but the same rules apply… If you want to increase the size and strength of your muscles, you need to be doing some regular and progressive resistance training. Whether you are using your own bodyweight, resistance bands or free weights, to be progressive means to increase gradually. In this context, you can gradually increase weight or the number of repetitions or sets in order to gain strength and continue to do so. Remember that in order for muscles to get stronger, they also need rest and recuperation, so be sure to include rest days in your plan. • Look at your diet: So you’ve ticked off regular exercise and now you need to tick off a healthy diet to back up all the good work you do getting your pump on. A muscles favourite food is protein. When we eat protein, our body breaks it down into smaller pieces (called ‘amino acids’) which our body uses to build muscle tissue. It is a good idea to give your body a protein boost following your resistance exercise routine, but if you aim to take on protein with each meal in some form, then you should be giving the muscles the food they need. You have many options… We recommend getting a good mix of fish, poultry, yoghurt, milk, cheese and eggs to ensure you hit the protein goal each day. Beans, peas, nuts and seeds are also a great source of protein. • Drink lots of water: A piece of advice we will keep coming back to time after time. It is simply a must for everyone, every single day. Our bodies are predominantly water and pretty much every process carried out inside the body needs it in order to function. The muscles are no different. Muscle tissue is full of blood. It relies on the blood to feed it all the nutrients it needs to stay healthy and to continue strengthening. Blood is largely made up of water (shocking I know!), so stay hydrated for good blood. Good blood equals a good transport system for food to get to the muscles. This is our advice to you. We know it is tough trying to figure all this out on your own, but the good news is, you are not alone… Our team here at Back in Business Physiotherapy are here to answer any queries you may have about your body and how to age as gracefully as possible. Although the body is a very complex machine, it’s not rocket science when it comes to looking after it. Just be kind to it every day and let us worry about the scientific stuff. This is what we spent years studying for. For more detailed information on improving your muscle health for the future, including exercise and dietary advice, please call us on +61299226806 to make an appointment. P.s. Please remember to drink water every day (this won’t be the last time you read this!). Further Reading : Sarcopenia and aging (Rome Presentation) Exercise, physiotherapy, deterministic chaos and the immune system Uploaded :4 February 2020 Read More

HIIT workouts for all Alright people, it’s a new year which means it’s time to get a move on and start ticking off those resolutions. We know for a lot of us this will include exercising more, getting healthy, or losing weight. And we also know for most of us, once normality resumes, it will be the same old story of not having enough time in the day to do it. Well we may have a solution for you! HIIT stands for? High-intensity interval training. And if you are one of those time poor people we described above, this type of training could be just what you are looking for. It’s a form of exercise that has become incredibly popular in recent years and is a great way for people to get their burn on, within a short space of time. So, if you can barely find time to think between kids, work, cooking, washing and sleeping (hang on… there is such thing as sleeping???), then read on to learn more. What is HIIT? HIIT is a type of workout that follows a repeated pattern of vigorous exercise over a short time period, followed by a rest or recovery period of less vigorous exercise. This repeated pattern will usually take place over a period of up to 30 minutes. Thirty minutes is all you need! And it has been shown that the effects on the body after performing this type of exercise are similar to that of double the amount of medium-intensity exercise. Starting to see why it is so popular? Let’s give you a little example of what you could do. Try running as fast as possible on an inclined treadmill for 30-40 seconds, followed by a light jog with no incline for 4-5 minutes. Repeat for 30 minutes. Sounds hard, right? Well it is, but that’s OK. You’ll feel goooood afterwards! What are the benefits of HIIT? There are several positive effects of HIIT on the body. These include: High calorie burn - you’re sure to burn loads of calories even when performed over a short period of time Increased metabolism - you’ll keep burning those calories for hours after you’ve finished exercising due to the boost your metabolism will get doing HIIT Fat loss - HIIT can help you reduce fat from your body, including fat that may have developed around your organs (i.e. ’visceral fat’) Reduced heart rate and blood pressure - this has been shown more in the overweight and obese population. HIIT can help to improve your cardiovascular health! Reduced blood sugar - this has been shown when performed consistently over a long period of time. This is particularly great news for the diabetic population Improved use of oxygen - regular HIIT workouts will help to improve your muscles ability to use oxygen, similar to the effects that you get from running or cycling over a long period Muscle and strength gains - although not the best way to gain muscle and strength, depending on the type of exercise you perform, you may also notice some gains in this region too Sound good? We think it does, so why not give it a try? If time is always an issue, then this is worth a shot. Please always consider your health and level of fitness before trying new forms of exercise. We recommend talking to one of us at Back in Business Physiotherapy if you are thinking of starting up a HIIT program of your own. We can assess you and advise you on a safe workout that isn’t going to send you straight right back to us with a new injury. It’s time to burn! Who’s ready? References 1. Kong, Z. et al. 2016. Comparison of High-Intensity Interval Training and Moderate-to-Vigorous Continuous Training for Cardiometabolic Health and Exercise Enjoyment in Obese Young Women: A Randomized Controlled Trial. PLoS One. 11 (7). e0158589. Available from: https://www.ncbi.nlm.nih.gov/pubmed/273680572. Skutnik, BC. et al. 2016. The Effect of Low Volume Interval Training on Resting Blood Pressure in Pre-hypertensive Subjects: A Preliminary Study. Phys Sportsmed. 44 (2). 177-183. Available from: https://www.ncbi.nlm.nih.gov/pubmed/269188463. Healthline. 2017. 7 Benefits of High-Intensity Interval Training (HIIT). [Online]. Available from: https://www.healthline.com/nutrition/benefits-of-hiit. [Accessed 13 Dec 2019]4. Batacan, RB. et al. 2017. Effects of high-intensity interval training on cardiometabolic health: a systematic review and meta-analysis of intervention studies. Br J Sports Med. 51. 494-503. Available from: https://bjsm.bmj.com/content/51/6/494.short Uploaded : 19 December 2019 Read More

Sports Physiotherapy Clinical Reasoning : An unusual case - femoral artery compromise A 23 year old female cyclist presented with a 2 week worsening history of severe anterior and posterior hip pain when sitting, intermittent 'giving way' and 'loss of power' in the knee, especially worse going up stairs and going from sitting to standing. She reported a minor fall onto her right side a few weeks previously whilst mountain biking. Otherwise, no previous history of any specific injury to that area, however a few major falls off bikes over the years, but nothing serious enough to require hospitalisation or on-going treatment. Examination revealed a clinically stable knee. Step ups were described as weak but no 'giving way'. Knee extension strength was reduced. Sciatic nerve mobility testing was within normal limits. Hip flexion was uncomfortable but didn't reproduce the intense pain which she was describing. Ranges of motion testing of the hip, in flexion,were otherwise unremarkable. Gaenslen's testing in hip extension revealed some limitation of the Psoas Major and Rectus Femoris.   Patrick FABER's testing was full range as were other hip and SIJ tests Prone Knee Bend testing for femoral nerve demonstrated some restriction in movement as well as some sensitivity and restricted movement in the upper lumbar spine    At this stage of the clinical reasoning process, things weren't getting any clearer. I noted previously that the foot seemed a little cold, I then asked her to return to supine, where i questioned her on any recent plane travel. An adventure racing friend of mine had a pulmonary emboli from a DVT in the abdominal region after spending time at altitude in Tibet and then flying home to Switzerland. I also quizzed her on any Leyden's Factor V or other clotting issues either diagnosed in herself or in someone in the family. I tested the femoral pulse superior to the inguinal ligament and it seemed quite strong. She was not taking anti-coagulants but was on the contraceptive pill. I decided to treat L1-L3 with joint mobilisations and the anterior hip with various techniques, including soft tissue massage, trigger points to the iliacus, quadriceps and adductors. Hip traction at 90 degrees flexion 'felt good'.The combined treatment improved the quads strength. However, I still didn't feel convinced that either the history or the physical examination and treatment had really explained the symptoms. Five days later I received a phone call from her where she said she was falling frequently and that she could not sit due to extreme pain. I suggested to go to accident and emergency since the situation sounded desperate. Several tests were conducted, including a CT to the abdominal cavity and a doppler ultrasound which revealed a mass pressing on the femoral nerve and artery. Emergency surgery was peformed where a haematoma was discovered. This was evacuated resulting in an almost full immediate recovery. Some loss of quads strength was still evident 6 weeks later but was purely clinical.   Reviewing the literature revealed this to be a rare clinical presentation in the absence of taking anti-coagulant medication. When it did present, it was most common post surgically or in young adults and adolescents. "Compression of the femoral nerve secondary to iliacus haematoma is widely reported in patients with blood coagulation disorders and those on anticoagulant treatment. Femoral nerve palsy caused by traumatic iliacus haematoma in the absence of bleeding diathesis has not been reported widely in the literature. All published reports occurred in young patients aged between 12 and 24 years and most cases were precipitated by a traumatic injury while participating in sport. Haematomas in this region present insidiously and are not heralded by an obvious lesion or ecchymosis. Patients initially complain of groin pain with the onset of neurological symptoms occurring as late as 10 days following the injury. The differential diagnosis for this syndrome is large and early recognition requires a high level of suspicion. A simple muscular strain is a common diagnosis in young athletes and can mimic iliacus haematoma in the early stages, and is regularly treated with non-steroidal anti-inflammatory drugs. These drugs have been implicated in the progression of the haematoma in a number of published cases. The most common mechanism of injury in reported cases is a fall onto the back or buttocks, although more indolent precipitating injuries are described. Direct trauma to the pelvis or hyperextension of the hip may result in muscular tears leading to iliacus haematoma. Two separate syndromes of lumboscacral plexus compression are recognised. The entire plexus can be compressed within the psoas muscle resulting in weakness of those muscles supplied by the obturator and femoral nerves. Alternatively, the femoral nerve is compressed as it passes through the closed fibrous compartment formed by the iliac fascia and the ileum." Murray et al (2010) ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027788/  Uploaded : 2 November 2019 Read More

Rolled your ankle? Have you ever rolled your ankle? Plenty of us have, especially people who partake in sports such as netball, basketball, volleyball, football and soccer, where ankle injuries are one of the most common injuries of all. These sports all involve pivoting, quick changes of direction, jumping and landing. The classic ankle injury involves rolling your ankle during landing on an uneven surface from a jump, or lunging for a ball during a tackle, where your foot rolls inwards and your leg outwards upon contact with the ground.   About ligaments Our ankles are stabilised either side by an outside and inside ligament (tissues that attach bone to bone). The inside (medial) ligament is much stronger than the outside (lateral) one, therefore injuries to these ligaments where you roll your foot outwards, are much less common. The outside ligament is made up of three parts - front, middle and back. The front part of the ligament is the weakest and is usually the most affected in ‘rolling’ injuries. With more severe injuries, it is possible to affect the other parts too. What happens when I roll my ankle? When you roll your ankle, forces placed on the outside ligaments may be too great, and the ligament will sprain. A sprain is broadly categorised into three grades:• Grade 1 - the ligament is overstretched but not torn• Grade 2 - the ligament is partially torn with some ligament fibres still intact• Grade 3 - the ligament is completely torn (also known as a ‘complete rupture’) Signs & symptoms As with most ligament injuries, it starts with a moment where too much strain or force is put through the joint/ligaments, and you feel something give. This is usually painful and may or may not be accompanied by a ‘pop’, which usually signifies that something has torn. Depending on the severity of the injury, you may start to see swelling and bruising appear quickly, or it may take time to develop. Either way, bruising is another sign something has torn and bleeding has occurred under the skin. Whether you can put weight through the joint and walk straight after injury is an important part of the process. If you can, this tends to indicate a less severe injury. If you can’t and require help to move off the field or court, this may mean something more serious has happened, like a fracture alongside a sprain. If this is suspected by your physio, you may be sent off for x-rays to confirm. Immediate treatment  It is important that the injury is managed well from the word go to ensure a speedy and hassle-free recovery. The first goal is to protect the joint from further injury. Depending on severity, this may require you to be off your feet for a short period, so crutches may be needed. Additionally, the use of an aircast may be required. After this, it is recommended to start putting weight through the joint to help reduce swelling and increase movement. Ice, compression and elevation are also recommended in these early stages. If it turns out you have a fracture too, there will be a short period of immobilisation in a moon boot to allow the fracture to heal.  Further treatment and return to play After the acute period is over and your swelling and pain are controlled, your physio will get to work on your ankle. You would have lost range of motion of the joints, so they will mobilise them and give you exercises to keep mobilising at home between treatments. You would have lost some strength as well, so you will need to strengthen the surrounding muscles, as well as work on other aspects of fitness including balance. During this period, you will get back to full weight bearing activities starting with walking and moving through to jogging, running, jumping and landing, adding agility exercises to retrain the ankles' ability to pivot and change direction without giving out on you again. You’ll need to complete some rigorous training before your physio clears you to return to the field of play to compete. The time it takes you to get back playing will depend on the severity of your injury, with a simple low-grade sprain taking anywhere from 2-4 weeks to heal, and a severe sprain and fracture taking months. The latter is particularly true if there is a tear of the syndesmosis and/or a Weber Fracture.  Weber Fracture Syndesmosis tears (picture c) can easily be missed and minor fractures of the malleolus can masquerade as acute tendonosis. Tears of the syndesmosis can lead to a chronically unstable ankle. These conditions are often treated in a moon boot, but occassionally surgical intervention is necessary. Take action If you have rolled your ankle and need some help to get back to the field or court, then look no further. Call us today on 02 9922 6806 to book your appointment, and we’ll have you hopping, skipping and jumping in no time at all! References 1. Brukner, P. and Khan, K. 2017. Clinical Sports Medicine. 5th ed. McGraw Hill Education : Australia2. Chen, ET. et al. 2019. Ankle sprains: Evaluation, rehabilitation, and prevention. Current Sports Medicine Reports. 18 (6). 217-223. https://journals.lww.com/acsm-csmr/Abstract/2019/06000/Ankle_Sprains__Evaluation,_Rehabilitation,_and.7.aspx Uploaded : 22 October 2019 Read More

Preventing falls in the elderly Hello everyone and welcome to our October blog. This month we’re going to talk about the older generation of people we are fortunate enough to share this world with. It only seemed fitting given that on the 1st of this month it’s International Day of Older Persons. It’s no secret that the elderly population is growing. People are living longer, and in many cases, having to work longer too. Being a physio is not just about treating sports injuries. We treat people from all walks of life and we certainly see our fair share of elderly patients. Most people know that as we age our bodies go through a process of gradual degeneration. Our joints are susceptible to wear and tear, our muscles weaken and other areas of the body like eye-sight also become affected. Our ability to move efficiently declines and this can lead to an in-creased risk of falls and subsequent injury. Falls are actually one of the leading causes for injury in the elderly population and it’s not unusual for us physios to be called upon to help in the after-math of a fall. Common injuries include hip and wrist fractures, as well as shoulder and head trauma. It’s our job to get these people moving again and on a speedy road to recovery. Prevention is better than cure We are always there for anyone who has been unfortunate enough to experience a fall and have a resultant injury. Whether it’s getting them moving again following hip surgery or a wrist fracture, we have the tools and knowledge to get them back to their best. However, everyone knows that prevention is better than cure. And there are lots of things that can be done to prevent falls in the elderly. Let us outline some things we can do to help: • Biomechanical assessment - we know human biomechanics. We can look at how you move and highlight any dysfunctions within your body that may be a risk factor for falling. We can then provide you with hands-on treatment, a home exercise program and sound advice on how you can nip those issues in the bud to reduce your risk of falling.• Strength and conditioning exercises - a common cause of falling is weakness, particularly in the lower limbs. We can test your strength and provide you with a gentle strengthening program to ensure you are working towards a stronger body that can support you better as you age.• Balance and coordination exercises - our balance and coordination can also be affected as we get older. And you can imagine, if your balance is poor, then the likelihood of falling can in-crease. Well fear not, we can provide you with exercises that aim to improve your balance and coordination. You’ll be feeling steady on your feet in no time!• Advice for the home setting - it’s not just issues with the body that increase the risk of falls. It’s also important your home is set up in a way to reduce your risk of falling. For some elderly people, ensuring that carpets, rugs and mats are removed from common walkways, and ensur-ing there is plenty of room to maneuver around furniture can greatly reduce the risk of falling in the home.• Help with walking aids - some elderly people require the use of walking sticks or frames. We’re here to help you get the best out of your walking aids. We can teach you how to use them so that they are a benefit to you rather than a hindrance. During a consultation, we may highlight other areas that need attention outside of our domain. You may need a medication review from your GP to ensure your medications are not a risk factor. If you have poor eyesight, you may require the help from an optician or optometrist. And if your feet require some further expert eyes, we will be able to point you in the direction of a good podia-trist. We’ll ensure you know exactly which areas require attention so that the risks of falling are as low as possible. We understand that getting older is often a challenge and that it can be very difficult to come to terms with a body that is not working as well as it once was. We are here to tell you that help is at hand and we promise it’s not all doom and gloom. You have the power people! If you eat well, drink heaps of water, exercise regularly and work at keeping your body the temple it deserves to be throughout your life, your body will thank you for it later! References: 1. United Nations. 2019. International day of older persons. [Online]. Available from: https://www.un.org/en/events/olderpersonsday/. [Accessed 06 Sept 2019].2. Waldren, N. et al. 2012. Falls prevention in older adults: Assessment and management. Aus-tralian Family Physician. 41 (12). 930-935. https://www.racgp.org.au/afp/2012/december/falls-prevention/3. Richardson, M. et al. 2019. A study to evaluate the potential contribution of medication use to falls in elderly patients presenting to an acute hospital. In Hospital Pharmacists Association of Ireland Annual Conference 2019. Uploaded : 26 September 2019 Read More

Physiotherapy… What is it exactly? Hello everyone and welcome to our September blog (it’s 4 months until Christmas - the countdown is on!). This month we are going to answer a question that we get asked A LOT by our patients. And because we get asked it so much, we thought we would dedicate a whole blog to it. The question we refer to is ‘What is Physiotherapy?’. To answer this question, we’ll give you some insight into what Physio is, how it can help you, and the sorts of things you can expect to experience during a typical consultation with a Physiotherapist. So… What is Physiotherapy? If you are looking for a simple definition of what Physiotherapy is, we think the Royal Children’s Hospital Melbourne sums the profession up very nicely. They say, “Physiotherapy is a clinical health science and profession that aims to rehabilitate and improve a person’s ability to move and function”. The lead governing body of Physiotherapy in Australia, the Australian Physiotherapy Association (APA) say that “Physiotherapists help you get the most out of life. They help you recover from injury, reduce pain and stiffness, increase mobility and prevent further injury. They listen to your needs to tailor a treatment specific to your condition”. We couldn’t have said it better ourselves! Basically, if you have hurt yourself or have a long-standing mobility issue, there is a good chance seeing a Physiotherapist is going to be beneficial to you. We use our expertise in the anatomy, physiology and biomechanics (i.e. how the body moves) of the human body to assess and provide treatment to people of all types with a wide range of health problems. And to ensure you are in the safest hands possible, each Physiotherapist has to obtain a university degree and be registered by law with the Australian Health Practitioner Registration Agency (AHPRA). So, you won’t be walking in and placing your health in the hands of any random off the street. Your Physio has been put through their paces to ensure they provide you with the best possible care. What to expect during your appointment For those who have never seen a Physio, we understand it can be quite daunting booking your first appointment. Fear of the unknown… What are they going to ask me? Will I have to get undressed? It’s perfectly natural to feel these things when you are trying something new. But ask someone who regularly uses the services of a Physio and they will be able to put your mind at rest. Physio’s are friendly and knowledgeable people. Yes, they ask you questions, and yes you might have to show your arms, legs and other body areas during the consultation, but everything is done with the patient’s well-being in mind. We know getting undressed can be embarrassing for some people, so we always advise you to wear comfortable loose clothes like shorts and a sports top, and if we require to see an area of the body like your abdomen or back, rest assured we’ll only look where we need to, and you should always, always, always keep your underwear on, and of course decline if you’re uncomfortable. Most Physio clinics will provide you with a robe or gown to wear during an assessment or treatment to ensure you feel safe and protected at all times and cover you with towels where appropriate. We promise there is nothing to be afraid of. After you have arrived for your appointment and have been greeted by your Physio or receptionist, you will likely be asked to fill out some paperwork that takes care of your personal details and all the administration stuff. Then you’ll be directed into a room or space where your Physio will sit down with you and talk to you about why you are there, and most importantly, what you want to achieve with their help. Once they have all the information they need (expect questions relating to lifestyle, occupation, social life, sleep, exercise and hobbies… They are all important), they will then carry out an assessment on you. During the assessment they will watch you stand and get you to move. They may even move some body parts for you and carry out a range of tests so they can come to an accurate diagnosis. Once they have a diagnosis, there’ll be a brief discussion to let you know exactly what is happening, what treatment is required, and a general plan laid out, so you know exactly what is going to be involved. Before your Physio carries out any treatment on you, they will always get your consent and tell you why they are wanting to perform that treatment. Physio’s use a wide variety of techniques to treat their patients. These might include soft tissue massage, joint mobilisation and manipulation, dry needling and acupuncture, hydrotherapy (i.e. the use of water in rehab), exercise and treatments that may use treatment aids such as splints, casts, braces, tapes, crutches and wheelchairs. This obviously depends on the issue you are being treated for, as each person and their rehab is completely unique. Appointments will usually last anywhere from 30-60 minutes and by the end of your initial consultation, you will have a clear explanation of what is going on with your body and a plan of attack to get you out of pain in the quickest and safest way possible. If your Physio thinks you require a scan of a body part, or the opinion of another health professional such as a GP or specialist, they will also discuss this with you. So, there you have it. We think we’ve covered just about everything. If you are wanting to book a Physio appointment, or are looking to find out more information, please do not hesitate to contact us on 02 9922 6806. We are ready to help you! Uploaded : 22 August 2019 Read More

Sports Physiotherapy Clinical Reasoning : Stress facture in an adolescent female track and field athlete A 16 year old female track and field athlete presented with a 6 month history of foot pain. However, it was never enough to stop her from competing and training. She did seek the intervention of a sports podiatrist. She was running 3-4 times per week, playing hockey and touch football. Her identical twin sister was doing a similar amount of exercise. Current History June 2018 - Combined Inter Schools X-Country race where she experienced no pain during the race which she won, but immediate intense pain once the race was over. Imaging An MRI was undertaken showing a stress fracture of the second metatarsal. A CT scan noted the callous formation either side without union Additional clinical findings were a Mortons toe and normal menarche and menstrual cycle. She was also excessively mobile and potentially has Ehlers Danlos Syndrome Mortons Toe is where the 2nd toe is longer than the first toe. Biomechanically this results in forefoot pronation and excessive loading of the 2nd ray. In Roman times this was considered a sign of beauty. Vikings generally had the opposite, a very large big toe and much smaller 2nd toe. Treatment Moon Boot for 4 months Daily bone stimulator -> Exogen Physio -> intrinsic muscles of the foot, calf and gluteal strengthening, Soft sand walking and running can become an ideal environment for this in the latter stages of rehab Eventually Alter G Treadmill program to recommence return to running Used Hoka A minimal shoes Land based return to running programme and agility exercises Fully returned to running 9 months later Uploaded : 8 August 2019 Read More

Repetitive linear head trauma can cause cummulative subclinical effects on visual and vestibular (balance) function Linear repetitive impact without concussion symptoms have been shown to have some impact on visual memory and vestibular (balance) function. Interestingly, although these researchers didn't find clinical neurolgical deficits, others, using MRI imaging, have reported anomalies. Speculation remains, that cortical cognitive reserve means that these deficits are not immediately apparent, Judicious use of ball heading is recommended and potentially should be completely avoided in the young. (Caccesse et al 2019. MedScSpEx, 51, 7, 1355-1361). https://www.back-in-business-physiotherapy.com/we-treat/concussion.html Read More

Attention all bookworms! Let’s pack for your back! On your marks… Get set… GO! Let’sseehowmanybookswecanreadasquicklyaspossiblewithoutstoppingforbreathinbetween! And breathe… Yes, it’s that time of the year again for us book lovers. Book Week 2019 is being celebrated this August (17th-23rd) and it’s time to get prepared. For some of us, this might mean we’ll be reaching for an epic page turner for the first time in ages, or it might just be a great excuse to read an extra one (or two or three) books that week. For your children attending school, there will likely be several activities they will be taking part in to recognise the event, which means they’ll have one or two more books they need to carry in their school bags. As if they didn’t have enough already right?! You might be starting to think, why is my physio posting a blog on book week? Well, let us explain. Let’s face it, who doesn’t like grabbing a book, a mug of tea, a few biscuits, your favourite blanket, and snuggling down into your favourite armchair for endless hours of reading? OK, so it might not be for EVERYONE, but we love it, and for those that do too, it may mean being stuck in the same position for hours on end whilst your head is in your book and you become too engrossed in the story to realise you are straining your neck. And what about your kids? Their school bags are already heavy from packed lunches, sports kits and textbooks, and now they must take in their favourite books to read in class too. Just think what all that weight is doing to their developing little frames as they drag their backpacks around the school yard. We’re here to give you some sound advice on how you and your family can stay safe and healthy this book week. Although the advice stretches to the other 51 weeks of the year too. Sitting bookworms We’re all for snuggling up in your favourite chair or lounge to read a book. We just want to make sure that you aren’t putting yourself at risk of injury from being in the same cramped position for hours on end — and that’s not taking into consideration the possibility of falling asleep in the same spot either. If this happens, you might need to reconsider your book choice! To ensure you aren’t straining your neck and back whilst reading, try the following: Sit comfortably, but try to sit straight (this is achievable, honest) to keep your spine aligned If you do adopt a different position (i.e. lying down or curled up in a foetal position) make sure you move regularly to give your body a break from being in one position for too long Take regular breaks from reading to give your hands, shoulders and neck a rest At the end of a chapter, get up and do some stretches, squats, lunges or whatever else you enjoy doing (this includes grabbing a well-deserved cup of tea) Remember to attend to necessary life requirements like talking to family members, cooking dinner, and sleeping (hopefully not because your book is boring though) – yes, this one is tongue in cheek (although a reality in many cases)!  Backpack advice When sending your kids off to school with backpacks in tow, there are some important things to remember to keep the pressure off their backs and shoulders (remember this also applies to adults too — they are not immune to the effects of heavy baggage either). Try these: Always wear BOTH straps - a single strap might look cool and be convenient to sling over the shoulder, but it will increase strain down one side of the body leading you to a possible postural imbalance Tighten the straps so that the backpack sits above the waistline (avoid letting it hang below the waist) Tighten the straps enough to limit side-to-side swinging of the bag on your back when walking - if you have a chest strap, this will also help to reduce swinging and keep the straps in place If you have a waist strap, this can help to spread the weight of the backpack over the pelvis and hips, whilst reducing load through the shoulders. You rarely see a hiker not wearing their waist strap, so why shouldn’t you? After all, carrying around a heavy backpack for most of a school or working day, repeated five days a week, can take its toll. Follow the recommended backpack weight guidelines of no more than 5-10% of a person’s bodyweight (an average 11-year-old weighs around 36 kg, so ensure their backpack weighs no more than 3.6 kgs) If you follow the above advice, then you are taking positive steps towards keeping you and your family safe and reducing the risk of injury. If you would like further advice or have woken up with a stiff neck after a hefty night of reading, please call us to book an appointment. We will ensure you are the turning pages pain and risk free before you can finish the synopsis (you know, the bit on the back of a book that we sometimes forget). Oh… And keep your waistline healthy by only having one or two biscuits please. We know how moreish they can be! #longlivebooks References  The Children’s Book Council of Australia. 2019. CBCA Book Week [Online]. Available from: https://cbca.org.au/news/cbca-book-week-2019. [Accessed 10 July 2019]. National Safety Council. 2019. Back Pack Safety: It’s Time to Lighten The Load on Our Kids. [Online]. Available from: https://www.nsc.org/home-safety/safety-topics/child-safety/backpacks. [Accessed 10 July 2019] Uploaded : 23 July 2019 Read More

WEAK GLUTES? GET YOUR BUNS OF STEEL HERE! Nip into your nearest gym and you’ll hopefully see a bustling atmosphere of people working out, trying to reach goals and get their bodies stronger. You’ll see all kinds of movements occurring, push, pull, jump, squat, lunge, lift… The list is endless. Maybe your physio has advised you to get to the gym yourself and work on some strength training. —You’ve been getting a bit of lower back pain and they’ve highlighted that your glutes are weak and may be contributors to your pain. It’s hard to fit everything in! You have to sit all day at work, and you just don’t seem to find enough hours in the day after work, kids, cooking, washing and shopping to set aside time to concentrate on you and getting yourself stronger. So the bad news is, sitting for long periods of the day could be contributing to your back pain. When you sit for long periods, your hip flexors become shortened and tight. This prevents your hips from being able to extend properly (we need this to help propel us forward when we walk, run, jump and climb the stairs) and which muscle is responsible for hip extension? That’s right, your gluteus maximus muscle! Not being able to extend the hip well, means the gluteus maximus muscle becomes a bit lazy. It’s not being used properly, it’s not able to contract all of those muscle fibres through their full range to provide you with a powerful contraction. Therefore, weakness sets in and other areas of the body have to work harder to compensate for this. The lower back is one of the areas that works harder when your glutes slack off— and it lets you know it is working too hard by sending a signal to the brain that all is not well. You feel this as pain. Now it’s not all doom and gloom, don’t worry. There is good news! Your trusty physio here at Back in Business Physiotherapy will be able to use their magic to get your hip flexors released and the hip moving successfully into extension. But you’ll have to back up the work done on the treatment table by performing exercises at home. These exercises might include some hip flexor stretching, hip mobility, and gluteal activation, as well as strengthening exercises. To make it simpler for you, we’ve described three beneficial glute exercises that you can perform at home to ensure your glutes will be firing on all cylinders. Check them out below… 1. Hip thruster - Sit with your upper back against the edge of a bench (the seat of your couch will work just fine!)- Reach your arms out to the side along the bench for balance- Have your knees bent and feet flat to the floor approximately hip width apart- Squeeze your buttocks as you raise your hips up until your body and thighs form a horizontal line- Be careful not to over-arch your lower back- Return to the start position and repeat 2. Split squat - Stand tall and place your back foot behind you on a step or bench- Your front leg should be slightly out in front of you- Slowly bend your front knee, dropping your back knee down towards the floor- Squat with your front leg to an angle of approximately 45-90 degrees- Pause and then push up through your heel whilst you squeeze your buttocks- Return to the start position and repeat 3. Deadlift (using a resistance band) - Stand with your feet hip width apart on top of a resistance band- Squat down with a straight back and hold the ends of the band with each hand- Draw your shoulders back, chest up, and push up through your legs to a standing position against the resistance of the band- Return to the start position and repeat- A progression of this one may be to use a bar bell instead of a resistance band Suggestion: Try 3 sets of 10-15 repetitions, 3-4 times per week for each of the three exercises above. 4. Buttock Ups - Simply, in standing or sitting, tighten and hence lift your buttocks. Hold for up to 90 seconds and repeat every hour. As the buttocks contract you should feel the deep abdominal and pelvic floor muscles contracting. Test your upper arm strength. With the arm stretched at 90 degrees ask someone to push your hand down towards the floor. Your upper limb strength should be better with the gluteals contracted. Good gluteals should improve lower limb stability. Resistance exercise training has been demonstrated to improve insulin resistant diabetes and reduce the severity of sarcopenia (https://www.back-in-business-physiotherapy.com/latest-news/239-mitochondrial-health-and-sarcopenia.html)  Please remember to speak to your physio before attempting any new exercises and always give yourself rest days to allow for recovery and strengthening to take place. We have the expertise to guide you on which exercise is ideal for each stage of your rehabilitation. Be persistent, work hard, and you’ll be on a path to having fully functioning glutes and awesome buns of steel in no time!  References 1. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw-Hill Education2. Jeong, U. et al. 2015. The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients. Journal of Physical Therapy Science. 27 (12). 3813-3816. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713798/3. All exercise descriptions taken from The Rehab Lab website Uploaded : 29 June 2019 Read More

 What is incontinence? Incontinence is the term used to describe the uncontrollable loss of urine from the bladder or faeces from the bowel. It ranges in severity from losing only a very small amount of urine, to a complete void of the bladder or bowel. If you’ve never experienced this, you can only imagine how distressing this must be. There are different types of urinary incontinence, including: • STRESS INCONTINENCE, where small amounts of urine leak due to small increases in pressure on the bladder during physical activity, or from coughing, sneezing or laughing.• URGE INCONTINENCE, where you get an unexpected, strong urge to urinate with little to no warning. This is usually as a result of an overactive bladder muscle.• INCONTINENCE ASSOCIATED WITH CHRONIC RETENTION, where your bladder cannot empty fully, and you get regular leakage of small amounts of urine. There are many causes for this, including an enlarged prostate in men, or prolapsed pelvic organs in women, as well as medications and certain conditions, such as diabetes and kidney disease.• FUNCTIONAL INCONTINENCE, where you are unable to get to the toilet, possibly due to immobility, or wearing clothes that are not easy to get off in time. Faecal incontinence is when you have a lack of control of bowel movements and you may accidentally pass a bowel movement, or even pass wind without meaning to. This may be due to weak muscles surrounding the back passage (Unfortunately ladies, this is common following pregnancy and childbirth), or if you have severe diarrhoea. TAKING THE STRESS OUT OF INCONTINENCE! For all those suffering in silence, it is time to speak out. There is no need to be embarrassed, it is surprisingly common – and like we have already mentioned, help is out there! You may not need to look very far. Your local physio may be able to help. The most common type of incontinence that we see and treat is stress incontinence. Although seen across both sexes, women are three times more likely to experience it than men. It is very common in women following pregnancy and childbirth (when the pelvic floor muscles get over-stretched, and sometimes even damaged), during menopause (due to hormonal changes) and in the elderly. It commonly affects men who have had prostate surgery. The pelvic floor muscles sit at the bottom of the pelvic bowl, spanning from the pubic bone to the tailbone (front to back) and from one sitting bone to the other (side to side). Imagine a tarpaulin stretched out with a person holding each corner and you kind of get the gist. When these muscles are strong, they help to support our internal pelvic organs (i.e. the bladder, bowel and the uterus in women) and wrap around the openings of the front and back passages, allowing us to control when we decide to do a number one or two. Following pregnancy for example, they may become weak and dysfunctional, and we can lose that ability to control voiding. It only takes something as small as a cough, or an activity like jumping or running (things many of us take for granted) that may cause a person to lose a small amount of urine. WHAT CAN BE DONE TO HELP? The most important thing to point out is that not all types of incontinence will improve or resolve with just strengthening of weak pelvic floor muscles. So, it is very important to get an accurate diagnosis, because there will likely be other factors that need addressing too. For instance, losing weight, stopping smoking, and making other lifestyle changes are just as important in the management of these conditions, if relevant to the person of course. Some people may also require release of tight and over-active muscles. Once you have your diagnosis, then strengthening may well be a part of your therapy. In order to strengthen, you need to know where the muscles are, and how to activate them. Below is a little step by step guide to getting a grip on those pelvic floor muscles (we don’t mean literally!): 1. Get in a comfortable position - try sitting or lying on your back and take a few breaths to relax.2. Imagine you are trying to stop yourself from urinating mid-stream by squeezing for about a second. If this is not easy to feel, next time you are on the toilet emptying your bladder, have a go at stopping mid-stream and then relaxing again to finish emptying (don’t hold it for too long please - just enough to feel which muscles you need to use).3. Do the same as step two for the back passage - this time imagine you are trying to stop yourself from passing wind by squeezing.4. Do these quick squeezes 3 x 20 reps a day. Once you’re comfortable, you can do it sitting or standing. Make it routine… Do it when you’re brushing your teeth, eating lunch, or in the ad breaks of your favourite TV show. These two contractions together form the basis of what you need to be able to do to begin your pelvic floor muscle training. If you struggle to feel this, then ask for help from your therapist. They will be able to help you perfect the activation of the correct muscles. We hope you have found this blog interesting and helpful. Please join in celebrating World Continence Week (17-23 June), References 1. Continence Foundation of Australia. 2019. World Continence Week. [Online]. [Accessed 07 May 2019]. Available from: https://www.continence.org.au/events_calendar.php/482/world-continence-week 2. Continence Foundation of Australia. 2019. Laugh Without Leaking. [Online]. [Accessed 07 May 2019]. Available from: http://www.laughwithoutleaking.com.au3. Continence Foundation of Australia. 2019. Key Statistics. [Online]. [Accessed 08 May 2019]. Available from: https://www.continence.org.au/pages/key-statistics.html4. Milsom, I. and Gyhagen, M. 2018. The Prevalence of Urinary Incontinence. Climacteric. 22(3). 217-222. DOI: 10.1080/13697137.2018.15432635. Continence Foundation of Australia. 2019. Pelvic Floor Muscles in Women. [Online]. [Accessed 08 May 2019]. Available from: https://www.continence.org.au/pages/pelvic-floor-women.html 4 June 2019 Read More

ATTENTION ALL NEW MUMS! May!!! We agree…. How is it May already? Well, May allows us to celebrate those very special people in our lives - our Mums. Being a parent can be very challenging at the best of times. And especially if you’re a new mum. It doesn’t matter whether it’s your first, second, or fifth child, being a new mum comes with a whole host of daily challenges. Your new little human requires all your attention - feeding constantly, changing eight nappies a day, bathing… Throw in another child, other family members, work, groceries (and the list continues) into the equation and it’s easy to see how life can be taxing on you and your body. The good news is, we’ve devised a little self-help guide for new mums! Below we give you tips on how to be kind to your body and not put yourself at risk of injury, so you can give your little munchkin the attention they need. FEEDING You’re going to be doing a lot of this. Your new recruit requires constant nourishment to ensure they grow strong and stay healthy. And it doesn’t matter whether you breast or bottle feed, it’s likely you are going to be seated for long periods, looking down at your baby. This all leads to extra strain through your neck, back and shoulders. So, try some of these little gems of advice to help keep this process pain free: 1. Get a comfortable, supportive chair - pick a chair that is going to feel good to sit in, but one you can easily get up and down from. If it’s too low, allowing you to slouch right back into, you’ll struggle to move yourself and your baby around without compromising your back.2. Keep your neck moving - feeding is a great time to bond with your baby. Eye contact is important but try not to spend the whole time looking down at a funny angle. Once your baby is comfortable feeding, it’s OK to break that eye contact every now and then to move your neck. Doing some light stretches will ensure you don’t end up with sore, overworked muscles.3. Consider a feeding pillow - these are great for taking the weight of your baby, so your shoulders and arms don’t have to. And they still allow you to have that important close contact.4. If you have a partner who can help feed, allow them to help regularly to give you a break. This tip is more for the bottle feeders of course, but it can make a huge difference.  CHANGING It’s going to be nappies galore! This can mean a lot of bending over, so it’s important you look after your posture so your lower back doesn’t take all the strain. Try to avoid changing your baby on the floor in these early days. Ideally, get yourself a changing table. It means you can place your baby down on the table and change them at a height where you don’t have to bend forward and hold an awkward position. And of course, the same advice can be followed when changing your baby’s clothes. Look after that back, you’re going to need it! OTHER USEFUL TIPS The following tips are by no means any less important, so try to take these on where possible: 1. Sleep when your baby sleeps: Getting those extra hours in when your baby is taking a nap is important to conserve your energy and reduce the risk of fatigue.2. Eat and drink well: It’s easy for the focus to turn to your baby, and rightly so, they are little and dependent on you. Remember though, you can’t look after your baby if you aren’t well. Eat for the health of you and your baby - lots of water and good nutritious food such as fruit and vegetables!3. Stretch: Especially your shoulders, neck and chest. Once baby comes along, our arms are always in front of us. Whether it’s holding, feeding, changing or playing, we’re usually a little slumped in our shoulders. Build stretching into your routine (like every time after baby feeds for example). We want to reverse the ‘slump’ position, so take your arms out wide, open up your chest and hold for 30 seconds (and repeat). Aim to do this three times a day (or whenever you get the chance!). Gentle shoulder shrugs and neck stretches can also help.4. Take time to relax: When the opportunity arises, get your partner, grandparent or friend to look after your newborn while you take a bath, read a book, or close your eyes for a little while. You deserve it, and it helps keep you sane and grounded during a very busy period in your life. 5 May 2019 Read More

Caffeine augments the prothrombotic but not the fibrolynic response to exercise Development of clots pose a risk of cardiovascular and cerebrovascular accidents. Prothrombotic (clotting events) and fibrolynic (clot dissolving) can be influenced by altitude (thicker more viscous blood), inactivity (plane flights), genetics (haemochromatosis, prothrombin factor and/or Leyden's factor V), and paradoxically caffeine ingestion around exercise. Investigators studied the affect of a single dose of caffeine during a single acute high intensity. They found the fibrolynic effects of exercise were not affected by caffeine. However, caffeine did increase coagulation factor VIII, which suggests an elevated risk of clotting (Nagelkirk et al 2019, Med Sc Sp Ex, 51, 3, 421-425). 4 April 2019 Read More

Three favorite exercises 1. Walking and runningA classic! An oldie, but a goodie, walking or running is a great all over body exercise. It works lower and upper leg, your buttocks, core, and even your arms! If you’re not much of a mover, start small with 15-minute walks, and build it up over time. Once you’re happily walking 30 minutes, start doing intervals, like running for 30-seconds and walking for two minutes (or more). Over time, increase your running time, decrease your walking time and soon enough you’ll be jogging for 30-minutes flat! Runners – interval training is great to mix up your training too. Try running at 90% effort for a minute, and then jogging for a minute. Play around with your run/jog times depending on your fitness and goals. 2. Squats These are a very popular exercise, and for good reason. These strengthen your lower body and back. Start with no added weights to ensure you have good technique. Stand with feet shoulder width apart. Keeping your back straight, push your bottom outwards to mimic sitting in a chair - try to keep your weight through your big and little toes, and your heels. When your thighs are parallel with the ground, return to the start position giving your buttocks a squeeze on the way back up. Keep your knees over your toes (which should point forward) – don’t let your knees waver in or out! A good progression is to add weight when you are ready; start with 1-2kg in each hand (or use bottles of water or books in shopping bags!) and work your way up! Eventually you can add weighted arm movements during or after your squat to get that whole-body work out. You can also do squats while brushing your teeth or waiting for the kettle to boil! 3. Box Jumps or step ups This is another lower body exercise but is also a great calorie burner and really engages the whole body to perform. You need a box (we strongly advise against cardboard ones!) or a strong raised surface that will take your weight with no issues (like a step/platform). Jump up onto the box, landing with both feet and raise to a standing position. Then jump back down and repeat. Start slow and low and build up to faster and higher jumps. Of course, if you aren’t quite at jumping yet, or you have any lower body injuries or heart problems, try stepping up and down to start. Try not to let your weight shift side-to-side too much as you step up. Start by doing 3 x 30secs, building up to 3 x 1-minute sets. Or try 3 x 10 jumps, building up to more as you progress. Make sure your knees and toes point forward, and if in doubt, start small! Uploaded : 16 March 2019 Read More

WHY YOUR BODY IS LIKE A CHAIN The concept that the human body is like a chain has been around for a long time. The body is a complex network of systems that all work together to allow us to move and do the things we like to do. When referring to movement, most people straight away think of muscles, bones and joints. However, there are a whole host of structures required to function together in order to produce movement. The musculoskeletal system is primarily associated with movement. From head to toe, our bones are joined at various points called joints, which are held together by strong structures called ligaments. Muscles then attach to bones via tendons and the muscles exert forces on the bones, which basically causes a joint to move. But, without blood and electrical stimulation, the muscles themselves cannot function to exert that force on the bones - so the circulatory system (which carries the blood around the body) and neurological system (where nerve impulses travel around the body) play just as important roles. Of course, the overall picture is much more complex than this, but you can see how you need lots of different elements to work together so our bodies can do what they have evolved to do – MOVE! Us humans are what we call bipedal, which means we walk upright on two feet. Other animals that do this are birds (when they are walking and not flying of course) and apes (although not all the time). Even cockroaches and some lizards sometimes move bipedally (usually when running at full speed), and of course, our native Kangaroos hop and jump in the same fashion. Think back millions of years to Mr T. Rex, who also walked around on his two back legs – it has been around a long time! Unless we move around on our hands and knees (which we don’t tend to do much after learning to walk from a young age), our main contact points with the Earth are our feet. And once we have learned to hold that upright posture, our body acts as a chain from feet to head to allow us to function as humans - get up, go to work, drive, play sports, eat our meals, and so on… If something goes wrong somewhere in that chain of muscles, bones, joints and systems, then it can lead to the whole or parts of the chain becoming dysfunctional. And when we have dysfunction in the body, it quite often leads to pain. For example, you have flat feet or collapsed foot arches – this means your feet tend to roll in. Now because the foot bone’s connected to the leg bone, and the leg bone’s connected to the thigh bone (sing along!), the flatness of your feet directly affects what is going on above in the ankle, knee and thigh. The leg and thigh bones must compensate for the lack of foot arch, which will commonly mean the knees fall inwards and you may end up with a case of knock knees. Flat feet may not cause pain in the feet themselves, but it’s very possible that knee or hip pain (areas further along the chain of the body) could be caused by such a problem. However just remember that many people who have flat feet have no pain whatsoever, so just because you have flatter feet than your friend, it doesn’t mean you are going to get pain. It just means you may be more susceptible to certain conditions because of the extra stress on the body’s structures (e.g. muscles, ligaments, joint surfaces) due to the compensations it has had to make. The body will compensate well for you, but there is always a point where the body will start to tell you it needs some help. Pain is usually the first sign of this! Often manual therapy - soft tissue release, joint mobilisation/manipulation – and some form of strengthening exercises will get the body back on track to reconnecting the chain to its former glory. In the case of flat feet, you may need some form of orthotic in your shoe too. It’s at this point where you start to feel better and can get back to playing your sport, or even just getting in the car to drive to work without being in pain. All the elements start to function together again, the body can move without, or at least with less, compensation, and that equals a much happier you. So, if you think you have a little kink in your chain, don’t take it to the jewelers to get fixed. Book in for an assessment, treatment, and some expert advice on how to manage your problem. You’ll be back roaring like a T-Rex in no time. Roar. Uploaded 16 feb 2019 Read More

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Do I need a scan? "a picture tells a thousand words" - not really! by Martin Krause A scan, in it's self, will not improve anyone's condition. The purpose of a scan is to gain more information about the pathology. Sometimes this information may be irrelevant to the management of a patient's condition. For example, if you knocked your elbow on a door frame and suffered a bruise, which was already beginning to resolve, an ultrasound scan may show some minor soft tissue damage, but that was already obvious by the fact of the bruise, and the information gained from the scan has not helped nor changed the management of the bruise. Therefore, the main reason for getting a scan would be because there is concern that the presence of certain pathologies may lead to a change in the medical management. For example, sometimes a rolled ankle can be more than sprained ligaments, and may require surgey or immobilisation in a boot. If the therapists suspects this might be the case, then they will recommend or refer for a scan (probably an X-Ray) to check the integrity of the bones (especially the fibular and talar dome), because if there is no bony damage then the patient can be managed conservatively with taping, exercises, ultrasound, massage, joint mobilisations etc. However, if there is boney damage, for example, then it might be necessary for the ankle to be immobilised in a boot for three - six weeks, for example. This dramatically different medical management depends on the results of a scan, and it is therefore worth doing. However, scans have no predictive value to the presence or severity of pain. Thirty-three articles reporting imaging findings, in the low back, for 3110 asymptomatic individuals were investigated for pathology. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. (Brinjikji, W et al Spine Published November 27, 2014 as 10.3174/ajnr.A4173). Hence, the results of imaging need to be assessed within the context of the entire clinical picture. Frequently too much emphasis is placed on the imaging not only by the clinician but also by the patient. Some people react to pathology seen on scanning as an affirmation of their problem and can either use it to gain clarity and become better or conversely become worse. Moreover, some people find imaging with inconclusive results as a 'panic moment' - "no one knows what is wrong". Similarly, ultrasound imaging of the tendond has good predictive diagnostic and aids in clinical reasoning when it comes to full tears. However, with partial tears it is a totally different 'ball game'. Ultrasound is highly user dependent, with specifically trained musculoskeletal radiologists able to produce high-quality images that may provide more clinically relevant information than those produced by clinicians with less experience in imaging. Sean Docking, a leading tendon researcher at Monash University, cited 7 authors who found pathological tendon chnages in 59% of asymptomatic individuals, whereas he found that 52% of asymptomatic elite AFL sportsmen had tendon pathology on imaging! Furthermore, symptomatic individuals who improved clinically to the point of resuming play, weren't shown to have improvements on imaging. Again, the clinical context and the clinical reasoning can in many instances prove to be the 'gold standard' not the imaging itself, when considering management options. Shoulder supraspintatus tendon pathology, in the abscence of trauma, is known, in many instances, to be a disorder of immune-metabolic compromise of the tendon and bursa. Imaging may show some changes in signal intensity but, unless it's a complete tear, it can reveal neither the intensity nor the severity of pain when taken outside of the clinical context. A thorough physical and subjective examination integrating all the clinical dimensions of the problem will have far greater value than any one single imaging modality. Yet, imaging still should be used in instances of progressive rapid deterioration and suspected serious pathology which may require surgery and/or immediate medical intervention. In summary, sometimes it is worthwhile getting a scan, because the information gained from that scan will determined the type of medical management that is employed. However, at other times, the scan may be unneccessary, because the information may be irrelevant or lead to an incorrect change in medical management, due to over-reporting of 'false positives'. You will be able to make this decision on the advice of your health care professional. On occasions it can actually be detrimental to have a scan, because some patients can become overly obsessed with the medical terms used to describe their scan results, which then can become the major focus for the clinician and the patient, rather than the more prefereable focus on their symptoms and functional abilities. For example, many people have lumbar buldging discs yet have no symptoms, yet sometimes when these patients have an MRI or CT scan, they can develop symptoms because they think they should have pain if the scan says so! Conversely, for some people the results of imaging can have a positive and reassuring affect. Therefore, it is very important to assess a clients attitude to scans before prescibing them so that the patient's expectations are managed appropriately, and not burdened by the additional, sometimes confusing, information supplied by a scan. Uploaded : 10 October 2017 Read More

Pain in the Brain and Neural Plasticity by Martin Krause There are several mechanisms that can create a sensation of pain, which has been described as 'an unpleasant sensory and emotional experience in response to perceived or potential tissue damage'. Pain can be the result of peripheral sensitisation from peripheral inflammation, vascular compromise, necrosis, swelling, etc. Importantly, higher centres of the central nervous system not only perceive such sensitization of the peripheral nerve receptors, they can also modulate and control the intensity and tolerability of the perceived sensation through descending modulation at the peripheral receptor and in the spinal cord and through transcortical mechanisms depending on the 'meaning' and 'context given to the pain. Moreover, the higher centres can create a 'state' of perceived 'threat' to the body through emotions such as fear and anxiety. Rather than the brain acting as a filter of unwanted sensation, in the higher centre induced pain state, rumination and magnification of sensations occur to create a pathological state.  Paradoxically, representation of body parts such as limbs and individual muscles can reduce in perceived size. In such instances the pain doesn't represent the sensation of pathology but rather pain has become the pathology. Hence, the brain generates pain in the brain, where the pain is perceived to be some sort of non-existent inflammatory or pathological sensation in the periphery. Evidence for this neural plasticity comes from imaging studies, where brain white matter structural properties have been shown to predict transition to chronic pain (Mansour et al 2013, Pain, 154, 10, 2160-2168). Specifically, differential structural connectivity to medial vs lateral prefrontal cortex and connectivity between medial prefrontal cortex and nucleus accumbens has been shown in people with persistent low back pain. In this case the back pain becomes the inciting event and given the persons' structural propensity, establishes specific functional connectivity strength. Some of these changes, in the neural architecture, might be explained by the fact that roughly 5000 of our 20000 genes which make up the human genome are dedicated to chronic pain   further reading Peripheral input is a powerful driver to neuroplasticity. Information gathered by touch, movement and vision, in the context of pain can lead to mal-adaptive plasticity, including the reorganisation of the somatosensory, and motor cortices, altered cortical excitability and central sensitisation. Examples of somatosensory reorganisation come from the work of Abrahao Baptista when investigating chronic anterior knee pain, who not only demonstrated reduced volume of Vastus Medialis but also is cortical translocation to another part of the cortex. Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, https://doi.org/10.1093/pm/pnx036)   AKP = anterior knee pain The same researcher (Abrahao Baptista) has shown that maximal tolerable electrical stimulation (eg TENS) of muscles can induce normalisation of the cortical changes through a process called 'smudging'. Transcortical stimulation has also been applied as a cortical 'primer' prior to the application of more traditional therapy such as motor re-training, exercise, and manipulation. The altered muscle activation around the knee may lead to altered inverse dynamics, energy dissipation and propagation, leading to increased risk of knee osteoarthritis. An increase in just 1% baseline knee adduction moment has been associated with a  six-fold increase risk of radiographic progression of knee osteoarthrits in a 6 year follow up study (Miyazaki et al 2002, Ann Rheum Dis, 61, 7, 617-22). Brain White Matter microstructure of people with Lateral Ankle Sprain Lateral ankle sprains occur in approximately 70% of the population. These can become chronic and quite disabling leading to declines in physical activity and its concomitant morbidity. Additionally, in the elderly, this can lead to an increased risk of fractures due to falls. Ruptured ligaments have the capacity to alter the somatosensory input to the cortices, thereby altering in turn, the afferent input from the cortices to the periphery, as evidenced by increased use of hip musculature (Doberty et al 2015, Clin Biomech, 30: 129-135), over-reliance of visual input (Song et al 2017, J Sci Med Sport, 20, 10, 910-914) and the frequent use of external stabilisers such as braces and ankle supporting footware. Speculation of pyramidal grey matter changes in the motor cortices have also been made (Terada et al 2016, PM R, 8, 11, 1090-1096). Such altered mechanics has been associated with changes in the central nervous system microstructure of the white matter in the superior cerebellar peduncle (Terada et al 2019, Med Sc Sp Ex, 51, 4, 640-646). Cause and effect cannot be established, however, clinically, emphasis must be placed on both peripheral tissue issues as well as higher centre processes if the chronic cycle is to be broken. Motor strategies learned during pain are sustained upon pain-free re-exposure to task. Adaptations to pain can interfere with movement planning and execution. Researchers have investigated the influence of pain on shoulder and elbow muscle activity during pain and subsequently after the resolution of experimentally induced muscle pain. They found that the same strategy of reduced muscle activation and reduced co-contraction occurred on subsequent pain-free re-exposure to the task (Solomoni et al 2019 Med Sc Sp Ex, 51, 11, 2334-2343). Furthermore, task accuracy was achieved through a concomitant reduction in antagonist muscle activity. Reduced EMG activity was attributed to reduced central neurological drive from higher cortical centres. Although a reduction in muscle activity may seem like a better 'economy' of movement, it places the joints at risk, as the normal, really important, stabilising mechanism during initial learning, of a novel motor task, is compromised. Physiotherapeutic Treatment Body illusions are another novel way to promote the normalisation of cortical function through adaptive neuroplasticity. Examples come from people with hand arthritis, whose perception of their hand size is underestimated (Gilpin et al 2015 Rheumatology, 54, 4, 678-682). Using a curved mirror, similar to that in theme parks, the visual input can be increased to perceive the body part as larger (Preston et al 2011 DOI: 10.1093/rheumatology/ker104 · Source:PubMed ) . Irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand (Whitkopf et al 2017, Exp Brain res, 23, 5, 1933-1944). These visual inputs are thought to affect the altered functional connectivity between areas of the brain thereby affecting the 'pain matrix'. Another, novel way of looking at movement and pain perception is the concept of the motor engram. This has been defined as motor skill acquisition through the modification and organisation of muscle synergies into effective movement sequences. The learning process is thought to be acquired as a child through experientially based play activity. The specific neural mechanisms involved are unknown, however they are thought to include motor map topography reflecting the capacity for skilled movement reorganisation of motor maps in a manner that reflects the kinematics of acquired skilled movement map plasticity is supported by a reorganisation of cortical micro-circuitry involving changes in synaptic efficacy motor map integrity and topography are influenced by various neurochemical signals that coordinate changes in cortical circuitry to encode motor experience (Monfils 2005 Neuroscientist, 11, 5, 471-483). Interestingly, it is an intriguing notion that accessing motor engrams from patterns acquired prior to the pain experience might lead a normalisation of brain activity. My personal experience of severe sciatica with leg pain, sleepless nights and a SLR of less than 30 degrees, happened to coincide with training my 9 year old sons soccer training. I was noticing that the nights after i trained the children, I slept much better and my range of movement improved. I commenced a daily program of soccer ball tricks which i had been showing the kids, including 'juggling', 'rainbows' and 'around the worlds'. Eventually, I even took up playing soccer again after a 30 year absence from the sport. Other than new activity related pain issues (DOMS), four years on, the sciatica hasn't returned. I can only conclude that this activity activated dormant childhood motor engram, worked on global balance, mobilised my nerve, encouraged cross cortical activity and turned my focus into functional improvement. Further explanations for my experience comes from evidence suggesting that a peripheral adaptive pain state is initiated, whereby transcortical inhibition occurs by the contralateral hemisphere to the one which controls the affected limb. Additionally, excitation cortical (M1) drive of the muscles of the contralateral limb to the one which is in pain also occurs. In such cases re-establishment of motor drive to the affected side is important. In terms of tendon rehabilitation, external auditory and visual cues using a metronome have been employed and are showing promising results (Ebonie Rio et al 2017 Personal communication). In terms of my experience with the soccer ball tricks, the external visual cues and the cross talk from using left and right feet, head, shoulders, and chest during ball juggling manoeuvres, whilst calling the rhythm to the kids may have been the crucial factor to overcome the dysfunctional brain induced pain - muscle inco-ordination cycle, which I was in. Additionally, I was cycling which allowed me to focus on motor drive into the affected limb. However, work by Lorrimer Moseley on CRPS has established that 'brain laterality' must be established before commencing trans-cortical rehabilitation techniques. Lorrimer's clinical interventions use 'mirror imaging' techniques which are only effective once the patient is able to discriminate the left and right sides of the affected body parts, presented visually, in various twists and angles.   Alternatively, the altered pain state can result in a hostage like situation, whereby the pain takes control. Similar to the 'Stockholm Syndrome' where the hostage begins to sympathise with their captors, so do some peoples brain states, where it begin to sympathise with the pain, creating an intractable bondage and dysfunctional state. One screening question which may reflect commitment to the process of rehabilitation is to question whether they were able to resist the cookie jar when they were a child? Or were they committed to any sporting endeavours as a child? This may give some indication for the presence of motor engrams which can be used to overcome dysfunctional pain induced muscle synergies (neurotags), but also indicate an ability to be self disciplined, as well as being able to reconcile and identify goal oriented objectives, in spite of the cognitive pain processes? Remember that neurons that fire together, wire together. Uploaded : 4 June 2019 Updated : 18 July 2021 Read More

Taking Ibuprofen immediately after resistance training has a deleterious effect on bone mineral content at the distal radius, whereas taking Ibuprofen or undertaking resistance training individually prevented bone mineral loss. http://journals.lww.com/acsm-msse/Fulltext/2017/04000/Effects_of_Ibuprofen_and_Resistance_Training_on.2.aspx Read More

Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) by Martin Krause B.Appl.Sci. (Physiotherapy); M.Appl.Sci (Manipulative Physiotherapy), Post Grad Dip Hlth Sc (Exercise and Sports), Post Grad Cert Hlth Sc (Education) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentation as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly coordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be useful in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementation such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragement of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasised over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strengthening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her dislocations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Yoga vs Pilates Many hyper-mobile people love yoga. They are good at it. However, they could be pushing themselves from a fine line of hyper-mobility to functional instability, pain and muscle spasms. The latter feeling of stiffness, drives them to do more yoga, ultimately perpetuating a vicious cycle which could ultimately end with chronic neurogenic pain. The reality is that hyper-flexible people should choose a more gentle form of yoga and consider a form which encourages stability. Other disciplines may be more appropriate such as Pilates or more specific stabilising physiotherapeutic exercises, involving isometric contractions, oscillations and balance. Alternatively, mind-body holistic approaches such as Feldenkreis and Alexander technique may be more appropriate. The mere elongation of the upper neck, in Alexander technique, activates the pelvic floor, deep core, diaphragm and shoulder blade stabilisers. Marathon vs Sprinting Comparing a marathon runner with a sprinter is like comparing an African Wild Dog with a Springbok. The former has the ability to run for days, whereas the latter has the fastest speed of any animal on earth.   You will very rarely find a 'floppy' lined up at the start of a marathon. They like to sprint and are frequently good at other ballistic activities such as high jump, pole volt, gymnastics. The 'stiffy' on the other hand loves the marathon as their stiffness stabilises them. Hence, 'floppies' need to stabilise. The stabilising muscles are the deepest layered ones, those which frequently only cross one joint and cannot easily be touched. Non-impact endurance exercise should therefore be encouraged. Sports such as swimming and cycling encapsulate this. However, even here, shoulder impingement needs to be avoided, whilst swimming (hydrotherapy), with good shoulder blade and core stability. Hydrotherapy conditioning can be practice out of water with a Swiss Ball and with Theraband exercises. Cyclists may develop knee, back and neck pain so they need to do a lot of gluteal and hamstring training in a closed kinetic chain e.g. reverse lunges for the knee, and should - shoulder blade - neck and back exercises for the upper body postures. Endurance exercise may also help calm the autonomic sympathetic nervous system, which is often seen as dysfunctional in people with EDS. Postural Orthostatic Tachycardia Syndrome (POTS) is frequently found amongst people with hypermobility. It is essentially an imbalance between heart rate and blood pressure which affects cardiac output (= SV x HR). The Modified Dallas POTS Exercise Program can be found here, which describes a progressive 4-6 month exercise program. Rock climbers are frequently hypermobile people. Clinically, I've found hypermobile people prefer to pull rather than push. They are pulling energy in towards themselves creating a stabilising force. However, they seem, initially, to gain a lot from yoga, where a lot of pushing stabilisation work can occur in positions such as high plank, down-facing dog, etc. However, too much of a good thing can become a bad thing. Stabilisation, without the aim of gaining range of movement, but rather, controlling range of movement should be the objective. Muscle synergies can play a very important role, where a group of muscles from the legs to the arms can be stabilising, whilst one limb is moving, the others are dynamically or statically stabilising. The classic three points of contact in rock climbing. Interested readers should look at the climbing section of this website for further information. There are links to exercises, concepts of shoulder and shoulder blade-thorax stability, as well as hip-pelvic-back stability. Agility vs Clumsiness and Deterministic Chaos Hyper-mobile people tend to be either highly coordinated or clumsy. There doesn't appear to be a middle ground. I therefore like people to use exercises which either are isometric, pull energy towards them (pull up vs a push up), and use oscillations. These oscillations or periodicities are able to encourage movement around a fixed point based on visio-spatial (eyes), cerebro-vestibular (ears), and musculoskeletal inflection points. These inflection points can be the therapeutic building block of all movements. It needs to be remembered that when the (chronically) injured person comes to you, if they once were a 'great' athlete (which is very common), they had learnt to move outside of the 'average' movement system. Their brains are still tuned to those fundamentals, but are now over-ridden by the 'static' of pain generator input! Those movement patterns of a prior pre-injured life are still somewhere to be found. Like peeling back the layers of an onion to disseminate what is what, and the rebuilding the system. However, it should be remembered, that those movement patterns were born of fast controlled->uncontrolled movement. These 'outliers' are essentially what 'deterministic chaos' encapsulates.    Ultimately, only oscillatory balancing movements, based on a solid isometric gluteal base, can achieve achieve redemption. Activation of gluteal muscles results in the activation of the core, not vice versa!!!! Activation of the gluteal muscles also improves arm strength. Exercises - draw energy into the body to stabilise People need to use their muscle synergies to support the skeletal structures, not the other way round. Muscles support bones and organs, bones don't support muscles, they act as levers for the muscles. Consider the body to be lying in 'slings of muscles', similar to when you lie in a hammock. These slings are known as the front/anterior, back/posterior (x's 2, 3, 4, 5 and 8), inside/medial and outside/lateral (x's 1 and 6), as well as spiral slings. The following exercises are designed to invoke the muscle bellies in the loading mechanism. The strain should be felt within them, not at the joints. The joints are just the axels around which movement occurs. Basically, hyperflexible people should avoid the tendency to hyperextend/flex their joints, and nullify the habit of overloading their tendon, ligament and joint surfaces. In X's 2 try to go back and diagonally back whilst keeping the knee over the ankle and dropping the stance hip down. There should be no pressure in the knee. All the pressure should be in the butt, hamstrings and quads in the upper 2/3rds of the thigh. Similarly in X's 3 lean forward enough so that you experience the butt, upper quads and hammies doing the work, with no pressure in the knee.  Back X's - posterior sling : 7, anterior - posterior sling : 6, spiral : 7, medial and lateral and anterior : 11 (add Buttock clenches and you get posterior as well) Spiral : 12, 13 and 15, Lateral and Posterior : 14, Anterior : 17 Medial : 22, Anterior : 20, Posterior : 21 Shoulder Blade stabilisers Immune system People with hypermobility may also have an auto-immune disorder. Ironically, some hyper-mobile children develop severe stiffness later in life as a result of sero-negative arthropathies such as Ankylosing Spondylitis and Psoaratic Arthritis. The latter frequently is associated with scaly inflamed skin. Additionally, irritable bowel syndrome may also occur. The gut is known to be essential to immune health, where an imbalance can lead to several dysfunctional immune-inflammatory interactions.  See : Trends in Microbiology, Moya and Ferrer: “Functional Redundancy-Induced Stability of Gut Microbiota Subjected to Disturbance” http://dx.doi.org/10.1016/j.tim.2016.02.002 Additionally, energy species of the gut interact with skeletal muscle. Skeletal muscles, not only allow us to perform movement and work, they are also an important immune endocrine organ. Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducible; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10º, genu recurvatum of both knees > 19º, and the ability to touch his thumb to his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occurred in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome respectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlanto-axial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Concussion Severity of concussion has been associated with JHS. An interesting case of EDS and it's affect on post concussion syndrome can be read elsewhere on this site. Temperomandibular Joint (TMJ) Disorders The prevalence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevalence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Conclusion EDS and JHS are complex, multi-factorial debilitating conditions, which frequently, for many years, are misdiagnosed. Therapeutic intervention will depend upon the stage, stability, irritability and severity of the disease, Issues such as misuse, abuse, overuse and disuse will also need to be entertained. Regardless, a multi-modal approach to a multidimensional problem needs to be considered. Importantly, the individual must be engaged in every stage of the treatment intervention process. Updated 28 October 2022 Read More