Vitamin D metabolites are known to be involved in hundreds, possibly thousands of gene transcriptions in the genes themselves. This makes it not really a true vitamin. The website www.vitamindcouncil.org has regular updates comparing the relationship of vitamin D levels to many pathophysiologies, but seldom mentions them in relation to musculoskeletal pain. We do know from a 2003 study by Plotnikoff and Quigley that D hypovitaminosis is common with non-specific musculoskeletal pain.

I have lifted the following article written by Dr John Cannell MD from the website in its entirety because of the description of an astounding drop in the bodies vitamin D levels after elective surgery as reported below.

Reid D, Toole BJ, Knox S, Talwar D, Harten J, O’Reilly DS, Blackwell S, Kinsella J, McMillan DC, Wallace AM. The relation between acute changes in the systemic inflammatory response and plasma 25-hydroxyvitamin D concentrations after elective knee arthroplasty. Am J Clin Nutr. 2011 May;93(5):1006-11. Epub 2011 Mar 16.

“Dr. Reid and colleagues of the University of Glasgow found 25(OH)D fell dramatically after a knee replacement. “

“They measured 25(OH)D before and after a knee replacement on 33 subjects and found 25(OH)D reduced by 40% from before to 2 days after the surgery. Even at three months, 25(OH)D was still 20% lower than preoperative levels indicating, perhaps, the healing knee was “using up” or metabolically clearing the vitamin D. Again, since we don’t know what the 25(OH)D levels were before the MIs in Dr. Barth’s paper, we don’t know if acute MI’s metabolically clear any vitamin D. I suspect they do, although nothing like a knee replacement, which involves major damage to a large joint.”

“While we only definitively know about the effects of knee replacement surgery on 25(OH)D, I think in the meantime it’s important to be sufficient in vitamin D for lots of reasons when going to the hospital. The take home message is that if you are going into the hospital for any reason, especially surgery, make sure you have plenty of vitamin D reserves by having your 25(OH)D at around 50 ng/ml before admission.”

The three best ways to get your vitamin D dosage optimized are in order; get out in the sun for at least part of the day, go to a tanning bed if the sun don’t shine, and thirdly take a vitamin D supplement. I can’t tell you how much to take because I’m not a doctor. Dr Cannell can, and does, on his website.

Let the sun shine in…

Stew

A whole session of FRC3 was devoted to scar and adhesion. Gathering scar tissue can be elective or not, adhesion is definitely non-elective.

Adhesions are described as attachments of tissues at non-anatomic sites. They can be filmy or dense, vascular or non-vascular. They can be related to surgery (90% post-colonectomy, 55-100% post-op incidence in gynecology), are equally male and female and can be age related.

It seems that adhesion build ups are very common; they can contribute to pain, interfere with ADLs, cause post-op complications and lead to hospital re-admittance. Various factors influence adhesion build-up and may include an adhesion phenotype, hypoxia and high fibrinogen levels.

Dr Michael Diamond opened with dynamic, if not a little gruesome, video clips of hypodermic needling the whole length of the scar, injecting a substance that made the scar hubble and bubble. The aim was to lift the scar from the underlying tissue and allow fascial continuity to flow both sides of the scar.

Hal Brown, DC explained that even the smallest scars can have 3 dimensional effects. Sometimes one wants to cause damage, as in prolotherpay. But, says Brown, prolotherapy is not about making scar, it’s about making the original tissue.

There was much discussion on the relationship of scar and the sympathetic nervous system; fight or flight impulses coming out of scar. Some said you need to switch this off with local anaesthetic in order to reboot both the ANS and the action potential.

Susan Chapelle RMT (nice to see a Canadian RMT giving a presentation) described her massaging rats tummys after they’ve been opened up and had their organs abraded with a tooth brush. Well, it seems that early intervention (8 treatments in the first 12 hours) using manual rolling of the small intestine can prevent or reduce the build up of adhesions in rats. Abdominal massage may well reduce adhesions and ileus (reduced intestinal propulsion) following abdominal surgeries.

A very interesting poster presentation by Rena Margulis showed a relationship between a C Section scar in a woman and an inguinal hernia scar in a man and severe chronic palmar hand pain! This scar restricted abdominal and thoracic flow, leading to trigger points in pectoralis minor. Pectoralis minor has a classic referred pain zone (RPZ) to the palmar surfer of the hand. The problem was permanently solved it by acupressure on the scar itself.

All this has led me to make extra room for information gathering about scar tissue on our Medical History Intake forms. Old scars may play an important role in current pain and dysfunction.

Cheerio for now,

Stew

The original work of the Latvian, Stanley Lief, in the early 20^th century was based on the collected ideas of Varma and ayurvedic medicine and combined with American chiropractry and osteopathy. After moving to Europe in 1925, Lief developed Neuromuscular Therapy (NMT), along with his cousin Boris Chaitow (1940s), over many years. They emphasised palpatory sensitivity to assess the state of the soft tissue.

Lief’s work was taken up by his son, Peter, and later by the osteopath Leon Chaitow in Europe. They developed neuromuscular techniques which were mainly used by osteopaths and occasionally by physiotherapists.

In the USA, Raymond Nimmo, a chiropractor graduating from the Palmer School in 1931, had developed a receptor-tonus theory based on hypertonicity of soft tissue. He questioned the chiropractic ‘bone out of place’ paradigm. To quote him “Didn’t they ever consider that the bones are where the muscles and ligaments put them?” He came across the trigger point theories of Janet Travell, and noted that these noxious points coincided with his own soft tissue findings. Paul St. John studied under Nimmo and published manuals and ran courses throughout the USA under the heading St John Neuromuscular Therapy. In turn, Judith DeLany trained under St John in the 1980’s, before she developed her own off-shoot called NMT American Version.

In the last decade DeLany and Leon Chaitow have combined their ideas to write the seminal two volume texts called “Clinical Application of Neuromuscular Techniques”. Both the European and American versions have a similar theoretical base. The differences lie in the treatment approach. European NMT has a set routine and treats anything it finds along the way. American NMT treats the client according to the preliminary findings found in a thorough pre-treatment assessment. Both use specific manual techniques to identify and treat tension, ischaemia, trigger points, nerve impingement and postural dysfunction.

St. John version NMT was brought to New Zealand in the mid 1990s, by the American Leon Botello, and his teacher John Barrera from Corpus Christi. Stewart Wild was the first graduate in NMT from the NZ College of Massage in Auckland. He began teaching NMT in 1998.

Modern Neuromuscular Therapy is now a hybrid of many different therapies; therapeutic massage, myofascial release (MFR), manual trigger point therapy (MTT), positional release (PRT), muscle energy technique (MET), connective tissue massage (CTM) and may even incorporate lymphatic drainage (MLD), visceral manipulation (VM), and neural mobilisations. To reinforce the treatment gains homecare activities (HCA) are  often recommended.

This whole body approach  emphasises not only the biomechanical aspects of the body (physical damage and dysfunction) but also the biochemical and psycho-social components. Thus, aspects of mental, social, emotional and environment issues are combined with nutritional, physical fitness, lifestyle advice and stress reduction for total structural and functional balance, leading to full health and well-being.

Stew

Night two at the sold out Fascia Research Congress 3 (FRC3) in Vancouver Canada was considered film night. Delegates were treated to brand new contributions from Jean-Claude Guimberteau, Robert Schleip, Andrejz Plat and Gil Hedley.

French Plastic Surgeon and filmmaker Jean-Claude Guimberteau made his film debut in the US in Boston 2007 when ‘Strolling Under the Skin’ was shown to stunned viewers one lunchtime. He filmed under the skin using high-resolution close-ups. This film showed loose connective tissue, blood vessels, tendons and nerves slipping, sliding and telescoping upon muscle contraction. It’s still considered a classic.

With each successive film exquisite slow motion shots are accompanied by great music ranging from Strauss waltzes to Tchaikovsky’s 1812. And just to keep it even more interesting for the alert listener he uses voice-overs by people who speak exquisite queen’s English, but who every now and then slip in a pronunciation of a word that makes you go ‘what?’ They have got to be French.

Five years later Guimberteau has just produced his fourth film called Muscle Attitudes. I now have a copy of that, plus film #3 called Interior Architectures, which (it says) combines new scenes inspired by film 1 & 2.

Next came a short video clip by Robert Schleip describing his new DVD that promotes ‘Fascia Fitness’. This workout video suggests a fascia-oriented approach to sports and movement therapies. I have it on order, stay tuned.

Another short film by Andrjez Pilat from Poland began artily with a slow-mo solo female dancer with exquisitely undulating arm movements. The dancer’s arms were later overlain with what looked like CGI generated muscle anatomy. Very good to watch. Unfortunately, I have no copy to show.

Despite these fascianating AV renditions the highlight of the evening was Gil Headley’s one-man performance art show outlining proposed changes to the notions of his cult classic, ‘fuzz speech’. Since posting the 5 minute ‘fuzz speech’ on You Tube 3 years ago it has been viewed over 200,000 times. That’s googleviral for a fascia film. My students and me have watched this speech dozens of times and it never fails to make me chuckle.

Gil is renowned for his 6 day dissection workshops, his www.somanautics.com website and his wonderful cadaver video collection.

The central theme of the original ‘fuzz speech’ is that “you can see time in fuzz”, meaning that lack of movement and/or injury will build up restrictive connective tissue, or fuzz, over time between fascial layers.

The revision espoused by Gil on a rainy March evening in Vancouver was pure theater; goofy, sacrilegious, strange, smart, silly and borderline embarrassing. He would rescue the situation with wonderfully original descriptions and videos of body organization and sincerely felt reverence for the donors.

His point was to outline the problem with the old fuzz concept. Seems that in a fresh unembalmed body when you lift superficial fascia from deep fascia and deep fascia from muscle there really isn’t much fuzz, unlike the embalmed cadavers that prompted the original speech. On top of this, he now maintains ‘fuzz is meant to be there’! So, there’s no bad fuzz. And he proposes that the new term should now be ‘filmy fuzz’. You can see a hand held video on You Tube if you search using ‘fuzz speech revision’.

It all reminds me that I’ve not done his dissection workshop for 5 years now. Must get back to work in Boston and save my pennies. There’s nothing like massaging cadavers with Gil looking over your shoulder.

BTW We will shortly be advertising 360NMT’s own film nights. Lots to share.

Cheerio for now,

Stew

In a probably not so recent blog I wrote about the ability of thrilling music to reduce pain. Thrilling music is defined as ‘music that sends tingles up your spine’. I hope that you’ve all felt it. Yet another way to reduce pain is by sheer physical effort. I trust that you’ve felt this too – the runners high, the cresting of a mountain, a hard day in the garden, that euphoric feeling at the end of a hard workout. These efforts all produce endorphins and enkephalins. The topic of this blog is effort.

Just over two years ago a 60-something woman, ND. trudged into my treatment room having being sent by a local Pain Care Center. She came with her older brother, who filled in the gaps with my questioning. She had been diagnosed with fibromyalgia, chronic widespread pain etc. and along the way had many therapies and procedures performed on her. She was highly medicated and seemed like a character from an old black and white zombie movie. She described pain from head to foot. She stood the whole time, bracing first on one leg then the other. She could not sit for the pain.

I began in traditional Neuromuscular therapy fashion with postural assessment, palpation, muscle length testing and ROMs. She had a noticeable scoliosis and boggy or flaccid musculature, but not much else. I attempted to put out the various trigger point and tender point fires in the order of her pain priority. At the beginning of subsequent visits she handed me pages of hand-written notes describing her pain hour-by-hour. Her file started to fill up.

Later, her family contacted me to ask whether I thought she was as mad as they thought she was. I said no. Then they decided to put her in an assisted living facility. Despite this semi-incarceration she found a woman to regularly drive her an hour each way to my clinic. I realised that orthodox NMT wasn’t working well; I needed to think outside the box. I started to use movement retraining techniques à la Feldenkrais. These gentle, rhythmic and rather complex movements have the legs going one way, the arms the other way and the head yet another way. They seemed to help, possibly working like a neurological resetting mechanism.

Along the way I suggested that she either stop her fixated note writing, or better still only write about the pain-free moments.  The notes stopped coming. I started a regular, safe strengthening programme to address her poor muscle tone, and gently progressed its challenge.

For the last 6-12 months I have trained her using free weights and body weight. The only bodywork I do is on her neck for her forward head position. She now sits on a Swiss ball with her feet on wobbly objects without complaint as she works out. This is a far cry from the woman who shrunk back in horror from the chair I offered.

She is really putting in the effort. She sweats. She corrects me when I forget to switch to the 5lbs from the 4lb weights (I really need 6’s now). She has lost the sense of damage and danger in posture and position and she seldom mentions any pain. She’s back home living independently and volunteering at the local school. There’s a spark in her eyes and a smile on her lips and she’s being weaned off the meds.

Throughout this 2 year period ND has kept up her choir singing, even when she couldn’t sit between songs on the hard bench.  Thrilling music and physical exercise may have turned this woman’s life around. It just took a bit of finely tuned and gently graded effort.

Cheerio for now

Stew

From the opening ceremony featuring native Squamish drummers and chanters to the low-key closing three days later I have to say that this third edition of FRC is going to be hard to beat. The principle FRC organizer, Dr Tom Findlay, coined the phrase ‘ bench to beside and back’. This summed up the gathering of scientists, anatomists, and researchers on the one hand and the various clinicians from all walks of manual therapy life. At FRC I in 2007, the gap was monumental. In 2012 it has narrowed considerably.

FRC3 was sold out when the 800^th person signed up. Our hosts in Vancouver were the Massage Therapy Association of British Columbia, who along with New Zealand are the only places in the world that have three year degrees in place. The depth of questioning by RMTs (LMTs) fully proved their high standard of understanding.

With successive blogs I will describe you some presenter views that are related to the material taught in our own Manual Trigger Point Therapy (MTT) seminars.

The first speaker was Mary Barbe, from Philadelphia. Her subject was Changes in Fascial Tissue With Repetitive Motion Disorders (or RSI). With performance of high repetition tasks, early inflammation was observed that was accompanied by musculoskeletal tissue adaptive remodeling.

However, with continued task performance, pathological remodeling was induced, such as fibrotic repair in tendons, muscles, nerves and their fascial sheaths. Damage included neuronal damage (moth-eaten and kinked fibers), connective tissue changes (thickening of the matrix), tendon changes (disruption of the tendon – paratenon separations), muscle (collagen type 1 build up) and bone (osteopenia). Generally these changes are accompanied by pain from release of cytokines, substance P, TNF-alpha etc.

The take home message was that early intervention is key. Tendonitis responds early to anti-inflammatories, but subsequent morphing to tendinosis doesn’t. Barbe’s team has now embarked on an exploration of interventions strategies to target the early inflammatory responses and promote non-fibrotic tissue repair.

Personally, I would like to marry the bench research showing these pathophysiological changes found in her rats to the studies of the Hoyle and Treaster (human rats) that we quote in MTT pain sciences. Here, workers were exposed to postural stress, visual stress, or both. Treaster found myofascial trigger point build up mostly in the high visual stress cases (www.ncbi.nlm.nih.gov/pubmed?term=Treaster%20postural%20visual). Hoyle found trigger point development in multiple trapezius sites after one hour of typing (www.ncbi.nlm.nih.gov/pubmed?term=Hoyle%20postural%20visual).

I thought that this was a fantastic start to the conference. Pathology from Repetitive Motion Disorders is only going to get worse (think texting). We need to convince sufferers that early intervention is the way to go. Can we get an app for that? One that measures how many keystrokes you can do before an alarm goes off telling you its time to see a manual therapist.

For more free information use pubmed, and search using ‘Barbe and Coq’

Cheers,

Stew

During the course of the 2011 Myopain Seminars teaching year, great emphasis was paid to the subject of pain science. I wish I could quote you the name of a single text that can be used as a reference. I can’t. I sampled far and wide and still do.

Readers of a previous blog will understand my frustration at western medicine’s blinkered approach to pain. I’ve been pretty much silent since that blog. (Even my favourite series of Fascia Research Congresses under-emphasize the role of pain and fascia.) Despite this, all the students of Manual Trigger Point Therapy have been introduced to a broad and comprehensive understanding of pain’s complexities. Prolonged pain is what has kept 360 NMT solvent throughout the economic downturn.

Let’s investigate pain, then give you some examples of therapeutic intervention. Trauma releases substance P (P for pain) in the tissue and signals are sent to the brain. The brain processes this unpleasant sensory information, determines the damage and danger, and usually produces an appropriate amount of pain then sends it to the appropriate location. I say usually, but the brain can get this very wrong. (More on this in a later blog.)

In response to pain, the body can produce hormones called endorphins in the periphery and neuropeptides called enkephalins in the brain, both of which inhibit substance P (P for pain). There are many ways to stimulate these analgesic biochemicals. Three of them are: one is to cause pain itself, two is by physical effort, and a third is by listening to thrilling music. What?

Thrilling music is defined by music that sends tingles up (or down) your spine. A research study was published whereby a surgical outpatient department in New Haven, CT gave each of three groups of people the ability to control their post-op pain meds as delivered by drip. One group listened to thrilling music, one to white noise and the third to general OR sounds. Seventy percent of the first group needed no analgesia. Of the other thirty percent of this same group, they used half that of the other two groups.

This revelation created great interest amongst 360 NMT staff.  As I write I’m listening to a 2 disc set of tunes compiled by our own Jennifer Parmenter from submissions of music from the 360 NMT staff that were considered thrilling (and with that the possibility of analgesia). We were asked to pick just three, a pretty much impossible task! As I listen to the discs I can’t help wonder at the variety; from pop to classic, from hard rock to jazz, from Icelandic to African. All considered thrilling.

Can we use this therapeutically? The traditional world-view of massage music is ambient music; full of waterfalls, native pipes and distant drums washing over you. Not so thrilling. But with Neuromuscular Therapy our clients don’t come to luxuriate. They come for pain relief. Should we bombard them with Radiohead, Rachmaninov, Sigur Rós or Edith Piaf? Not so great for our renowned active client/therapist communication process. More reasonably, should we ask each person to choose their own thrilling music and bang the headphones on in the comfort of their own living room? Musical homework? Sounds good.