Iliotibial Pain (ITB) Syndrome

Iliotibial Pain Syndrome (ITBS) is the most common cause of pain on the outside of the knee which is not due to problems within the knee itself (intra-articular). Effusion (swelling) around the front of the knee, clicking, a history of twisting injuries and postive stress tests may locate intrinsic problems. Furthermore there are a few less common problems which can arise within other structures of the knee itself.  However stresses within the ITB, the band of connective tissue which arises in the pelvis and extends down to below the knee presents an interesting problem.

The forces which arise in the hip and lateral knee are considerable. Walking alone produces stresses in and down the outside of the thigh which can be three times body weight so it's easy to see how jogging and running (particularly when introduced too rapidly) may contribute to compression problems.  In addition a history of lower back and pelvic pain or stiffness can compound the situation. Why?  The gluteal muscles alone (indeed any local group of muscles) are not strong enough to stop the hip collapsing on itself when we walk (let alone run). It is the co-ordinated action of muscles bound together by the inelastic connective tissues of the ITB which produce significant strength and stability and if they do not work in unison the region is left vulnerable to injury.

What of the lower limb?  Do poor foot mechanics cause alot of ITBS?  While this is possible the literature suggests that most problems arise in the pelvic region however the foot and ankle must be considered as possibilities in each individual case.


Douglas Scown

Which is the best neurology textbook?

http://www.amazon.com/Principles-Neural-Science-Edition-Kandel/dp/0071390111

Dr Kandell and collegues are known for research into human cognition but as they point out all behavior is an expression of or an output of the central nervous system. The human nervous system is based on trillions of reflexes joined by ever more complex interrelationships which although genetically determined change in response to it's own activity and the environment which it interprets.  The opening offers an intriguing insight into the scholarly history of the brain and it's most popular theories from the Egyptians to phrenology.  What's clear is that the last 50 years have seen gigantic advances in neuroscience, our understanding of behaviour and the irreducible marriage of the mind and body.  There is a brain and a body but the two fuse when we experience the world.

Doug Scown

What does an adjustment do?

Adjustment is the conglomerate term Chiropractors use to describe a set of modalities (treatment tools).  They vary enormously from so called 'low-force' techniques to the traditional HVLA adjustment (High Velocity Low Amplitude (short distance)).  In the hands of a clinician who is trained and experienced at knowing not just what but when and how to apply it these approaches can be very effective for various neuromusculoskeletal disorders.

Sometimes people will ask "what does it do".

Here's a list of some effects which have been observed during neuroscience research (courtesy of Matthew Long CDI)

• Engages mechanoreceptors to open mechanically gated ion channels and initiate a current flow into the largest and fastest primary afferent neurons.
• Uses a rapid lengthening of muscle to activate the dynamic components of the muscle spindle receptor to fire 1A afferents at a high frequency in order to modulate central neurology (greater than 200 Hz).  
• Alters the gain on the muscle spindle system to change muscle tone via the action of gamma motor neurons that innervate the intrafusal muscle fibres.
• Produces a ‘novel’ blend of sensory input that alters the state of the dorsal horn and shapes the responsiveness of spinal cord neurons to future inputs.
• Induces plastic changes in neural circuits via long-term potentiation and depression, depending upon the type of circuit i.e. manipulation can produce long-term depression of the projection neurons of the pain pathways.
• Alters the genetic responses in spinal cord neurons and those in the higher centres.
• Produces a propagated response in neurons in the ipsilateral cerebellum.
• Alters the frequency of firing of lower motor neurons to produce a change in muscle tone, joint stability, position and motion.

Doug Scown

PAIN is reliable in an unreliable way

The guys at The University of South Australia have put a great deal of work into the study of chronic pain.

Acute pain (as we might experience when we step on a nail or twist an ankle) is straight forward.  Do this - get that.  But what about pain which persists?  And what about pain which comes and goes or changes it's nature and location?  Confused?  Welcome to the world of chronic pain and the way it colours injury and dysfunction.

Health professionals still overwhelmingly deal with pain as if it were acute and something was damaged or broken.  Patients who present with continuing pain are told that their nerves are still healing or perhaps they have re injured the injury.  Is this accurate?

Chiropractors tend to see people with chronic or long term complaints.  Their problem often began yrs before but in the early stages their pain and dysfunction was brief and self limiting.  Furthermore it was aggravated by specific things, usually an awkward movement such as lifting and twisting.  Recently though the patient reports that their pain came from "nowhere".  "I slept wrong", "It just went out and now it's not going away".  In short their brief, self limiting problem has become chronic, 'unstable' and aggravated by trivial movements.  Additionally the pain has changed. It was sharper and "here".  Now it's sometimes sharp, often a dull ache or burning and it's spreading.  It feels like it could just "go" on me.

The patient has developed chronic pain.  The brain learns and changes through repetition and the repetition of pain can do interesting things with a plastic or moldable neurology.  Pain itself is a complex experience suffice to say it's important to pin down what originally triggered the problem (the disc, joint, bone, distortion - the diagnosis) and what may have led to it weakening (usually a combination of injury, sensation disturbance, lifestyle and of course genetics/epigenetics).

Ref   Apkarian et al. (2004) Chronic back pain

Do backs 'go out'

Can your back 'go out'?

The old model for SPINE (which is still used a great deal) was 'bone out of place'.  It made sense.  Hard bone, soft nerve, ouch.  Then someone applies a force to a joint, it may feel better and (particularly if we hear a pop) we connect the dots.

"My bone was out, it hurts, it's pinched a nerve, I heard it pop back in, now it feels better = bone out of place."  It feels like this, it sounds plausible and to cap it off even health practitioners (and specialists) still believe this to be true.  And if they don't they are not sure how else to explain it.

The trouble with this theory was this - there was never any evidence for it.  Short of fracture and dislocation there is NO evidence that we can put a displaced joint 'back in'.

So what on earth is happening? 

The model is now multifaceted and the research supports that MOST changes are due to neurophysiological changes (changes in the nervous system when physical modalities are applied (exercise, joint manipulation, etc) .  A big one is normal proprioception or 'joint position sense' which can be disrupted by injury, lack of use and pain.  Even if we ignore all of the other effects this deficit in the brains ability to properly sense and therefore control and protect the spine is reduced.

Physically based treatments aim to 'leverage' or target these deficits thus improving this innate body function.

The following research from the Physiotherapy profession illustrates the failure of the 'bone out of place' model to explain the effects we see.

http://www.pain-ed.com/wp-content/uploads/2013/08/SIJ-pelvis-In-Touch-Beales-OSullivan.pdf

Is a 'muscle spasm' just a muscle spasm?

We are all quite familiar with muscle cramps following exertion or perhaps associated with conditions of the blood vessels but what about those acute and often painful spasms of the back muscles?  What is happening here and why do they seem to affect the spinal muscles so much?  Why for example do we not feel the same thing in the arm or leg?

More importantly is 'muscle spasm' a valid diagnosis or is it a sign of something else?

Most of our brain and nervous system is built for one purpose - PROTECTION - and the structures of the spine are some of the most sensitive to errors and injury, so much so that even trivial injury can invoke significant pain and muscular guarding.  Muscle spasm is in effect a protective behaviour.  Something is triggering it.

Muscle spasm due to simple joint strain is common and self limiting however a history of repeated episodes is more complex.  Why do they keep recurring?  Why are they becoming resistant to conventional treatment?  What is going on?

 Meniscoid extrapment, Chronic facet synovitis, disc herniation, degenerative spondylolisthesis, cervical dystonia and other syndromes can all cause a tightening of the spinal muscles.

In short muscle spasm is a non specific symptom.  If it keeps coming back it requires a diagnosis.

Move it or lose it. Why stress is good.

Explanations of joint pathology, the reasons why it may have developed and what can be done about it can become complex and difficult to understand.  In particular information relating to the structure and function of biological systems is continually mounting.  Much of the time we tell patients that in the end it boils down to a lack of complex movement.  In days past 'overdoing it' led to injury and trouble but is that what happens most of the time?

The phrase 'move it or lose it' is old and I suspect it's been around in some form for thousands of years.  We observe what happens when we don't move.  We become weak and flaccid, our balance deteriorates and there is evidence that even our automatic functions (such as blood pressure) which are neurologically controlled become disordered and dysfunctional. 

Neuroscience is now mapping out the mechanisms whereby we break down due to a LACK of stress.


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