Always believe in continuous professional development, because it is essential to keep the profession to improve and move forward, in order to provide better service to the public.

Time passed by so fast, and we closed the calendar of 2012, yet I managed to attend 2 interesting workshop which were so interesting and will like to summarised what I had learn in these 2 workshop.

Shoulder instability and impingement

Presented by : Mr Wayne Rodger

Date: 30-31 May 2012

Venue: Singapore

Shoulder pain syndrome are very common in racket games such as badminton, squash, and overhead throwing movement e.g, baseball, basketball, handball etc. I always think that shoulder joint is the most complicated joint, and treatment take very long time. That why I intended to attend the shoulder joint cause, to sharpen my knowledge on this condition.

Mr Rodger presented a very detail and clear explanation on shoulder problem especially shoulder impingement syndrome.

 

First of all, to understand in detail what is the structure that provide stability to a shoulder joint, he divided it into 4 types
Global muscles – the muscle surrounding the shoulder joint, which provide the shoulder’s contour ( humeral torque) and it is for power production.

Dynamic stabilisers – this is another group of muscle which is to provide the shoulder’s dynamic stability and the major group of the muscles are the shoulder’s rotator cuff. Also must not forget the scapular ( shoulder blade) stability muscle which is equally important as a ‘foundation’ of the shoulder joint.

Passive controls – these are a group of soft tissue which attach the glenoid and humeral head ( the socket and the ball of the shoulder), which are the capsule and ligament surrounding the shoulder joint.

Osteological features or bony structure of the shoulder joint. – the shoulder joint is consist of a ball (humeral head) and a socket (glenoid fossa). The concave surface of the glenoid fossa provided a vacuum kind of suction, to suck the humeral head in position, and subsequently, the passive support from the shoulder ligament, capsule, labrum further increase the attachment and the stability of the shoulder joint.
  Shoulder impingement syndrome, simple to say is the condition whereby there are some soft tissue ( commonly rotator cuff tendon or subacromial bursa) being pinched by the bony structure of the glenoid fossa and humeral head, and when there is up to certain extent that there will be a rotator cuff tear after prolong pinching of the tendon.

Most of the time, we are too concentrate on the injury part, and as usual as a physiotherapist, we will try to speed up the healing of the torn tendon by providing the patient some electro therapy e.g ultrasound, TENS, but forget to look for the reason behind the injury, and resulting in ineffective treatment.

Mr Wayne Rodger emphasis a lot on the stability on the shoulder joint, as well as the scapular (shoulder blade) stability.
We cannot change the passive support or the bony structure of the shoulder joint, but we can do something over the dynamic support of the shoulder joint and scapular.

Picture above showing the relationship of the scapular towards the head of shoulder joint. At the end of one of the scapular angle ( the triangle bone ) which will become the concave surface of the shoulder joint or glenoid fossa that will later attach with the head of the humeral bone ( upper arm bone) and formed shoulder joint.

The arrow above showing the muscles surrounding the scapular and imagine that, if one of the muscle either tight, or weak, it will amend the position of the scapular bone, as well as the position of the glenoid fossa on the humeral head position, and the dynamic function of the shoulder joint will change, causing some shoulder structure under stress, and resulting in " overuse" injury. 

 

The above 2 pictures indicate the normal shoulder level with good alignment of both side of scapular, and the picture on the R showing the different height of shoulder level, with higher possibility of the muscle imbalance among scapular stability muscle( of course there will be some other reason that causing the indifference of shoulder level such as scoliosis of the thorax spine, which is beyond our discussion.)

So, to improve the muscle imbalance, we need to strengthen the weak or lengthen muscle, stretch or relax the tight muscle. When the dynamic support are improved, so will be the quality of the shoulder joint movement.

During the workshop, we were taught on the specific exercises on strengthening the weak muscle and the way to relax the tight muscle, even with self massage with massage ball.

I did learn a lot from the 2 days workshop, and now, I improved my skill in analysing of the shoulder joint assessment, which helps in my clinical decision on the treatment for patients who suffer from shoulder problem.

I will praise the workshop as five stars, cause I found that my knowledge and my management on shoulder pain is improved after since the meet up with Mr Roger.

 

Did you see any difference in between the 2 shoulder blade when this young man performed the activity by pulling apart the elastic band?

R shoulder level higher than L side, with the shoulder blade shift more laterally( away from midline, body twisted to Right side more than L side, what is the muscles that is not working well to maintain the shoulder blade(scapular) in centre?

Dry Needling

Presented by  : Mr Lau

Date:

Venue : Island Hospital, Penang




Dry needling using IMS (intramuscular stimulation) concept. IMS is a type of "dry needling" method using western medicine's understanding of neurophysiology of pain and it is founded by Dr Chan Gunn. He introduced an assessment techniques of identifying underlying muscles which have nerve irritation to treat chronic pain issues.

It is different from the Traditional Chinese acupuncture which focuses on the pre-mapped out points on the body (or so call acupuncture points) and meridians of energy running through the body.

IMS is widely used in western world and most of the person who practice these technique will professional such as physiotherapists and doctors, who have proper training in the human anatomy, recognise the muscles of the human body. Most of the time, the practitioner will look for abnormal ‘feeling’ over the body muscle, e.g a taut band over the muscle. When the needle is applied or insert into a taut band of the muscle ( a trigger point which having hyperactivity of the muscle fiber), sometimes, patient will feel a twitch over the muscle, and the needling point can be very sore.

Commonly patient complained of tired or sleepy, and the muscle will be sore as those as they just finished doing a session of vigorous exercise.

 

 

During the course, we were introduced on variable muscles which can be effective in applying needles. The workshop was a practical workshop, and of course, during the workshop, you will not miss the voice of 'ouch' 'ah'.... but, majority of the apprentice, enjoyed being needle.

Some muscle which I’ve never learn to needle were introduced by Mr Lau and will be much helpful in improving by dry needling skill.

 

 

 

 

Dry Needling

As a routine, a new member join us need to experience what is the feeling  of dry needle, so that she can appreciate what is the feeling of a patient who is having dry needling treatment.

From the expression of Shuhada, the needle causing some ‘ lenguh’ sensation to the area needled, and the feeling last a while even the needle was removed, but the sensation is acceptable for her.

The point that the needle inserted on the hand was LI 4 or Large Intestine 4, in Chinese ‘he gu’(合谷 ). It is a usual point used for pain relieving. It is believed that if you have headache or stomach ache, this point can be press by finger to help relieve pain.

How long are the needles used in dry needling technique?

The commonly use acupuncture needles range from 2.5cm(1 cun or 1 inch), 5cm(2 cun or 2inches) to the longest 7.5cm( 3cun or 3 inches). Which types of needles need to use are depend on the body part. If it is over the forearm, bottom of the leg, than 1 inch needle are being used. For deeper or thicker area, example, thigh, low back, the 4cm and 5cm needles are commonly used, and the longest needle (7.5) are used over buttock region, which the fat and muscles are so thick and massive, it can never be reach if we are using the short 1 inch needle.

What exactly the needles can do to a person and how it helps them?

Simple to say, when a needle inserted into the body, it traumatised the area and the human body will percept it as an injury, which it will started to bring more blood to the region for repair. When there are more blood circulation over the region, it relax the muscle which is originally tighten up(spasm or cramp feeling) due to injury.

 At the same time, the message of this injury will be convey by our sensory nerve to the spinal cord. The message or the signal of the needle fill the spinal cord sensory area(posterior horn) and causing others signal being blocked to enter into the spinal cord (pain gate mechanism), and it help to reduce the original pain of the patient. When the needle message being further carry up to the brain, it stimulate over an area in the brain, Pituitary to release ‘happy hormone’ such as endorphin and encephalin to increase the pain threshold of a person.

 

PHYSIOTHERAPY INSTRUMENT MOBILISATION (PIM)

6th November 2011, a public holiday which the Muslim in Malaysia were celebrating Hari Raya Qurban, but me and some of my colleugues will have to control our lazy mood, to attend a workshop on  Physiotherapy Instrument Mobilisation (PIM).
A drizzling rain in the morning, and I was 10 minutes late to the venue, and the class were already started with some theory about the tecnique, which I manage to catch up later.

                                                       

PIM, a mechanical assisted joint mobilisation utilise a technological instrument and the treatment principal are according to physiotherapy principles, including the concept of physiotherapy model of joint mobilisation and manipulation, Mulligan's concepts of mobilisation with movement and positional faults. According to the speaker, these technique has being accredited by the Australian Physiotherapy Association as complying with their high standards of continuing professional(physiotherapist) development.

Manual therapy is a hard work - PIM technique using the mobilising device substitutes  high velocity and lower forces generated tools, ensuring effective joint mobilisation. One question raised, what would you prefer, an effective dose controlled repeatable reliable 2 second instrument application or 4 sets of  grade IV Passive Accessory mobilisations with clinician's thumbs? 

These is very true, because I started practicing since 1996, and in some busy days, my thumb already given me some sign of retirement ( oh no, I am too young to talk about retirement ...), this tools, seems to be a good option for me to rest my thumb's MCP( metacarpal phalangial joint), especially for small joint such as TMJ, cervical, acromio-clavicular, carpal and tarsal joint, very excellent result.

Furthermore, this instrument mobilisation enable the clinician to give fast and effective manual therapy, saving not only the clinician's thumb, but the energy and time for treating more patients in a day with less fatigue. 

From patient's feedback, PIM is less painful, compared to my fingers (are you sure?), and most of the time, patient no need to expose, with light clothing is desirable, and it showed quite an exciting clinical outcomes, which is what the clinician want.

Well, overall the workshop was so enjoyable, all the participants kept 'gun' here, 'gun' there, and I gun on my Right wrist's carpal joint, which already given me some problem due to joint mobilisation, and the result was satisfactory, my wrist extension improved after my self treatment.

Look at our lovely, sweet face and the powerful firing 'gun'....

squatting, 2nd from left - me....

A number of studies have investigated instrument mobilisation for its effectiveness and found it to be equivalent to manual mobilising techniques in reducing pain and improving function in patients. Ongoing research in to the basic science of instrument mobilisation and clinical trials have quantified intervertebral motions, electromyographic and neurophysiological responses to instrument mobilisation. 

Last and not least, allow me to express my appreciation to Mr Tim Mann and his lovely wife, Pam, who came all the way from Australia to conduct the workshop. Hope to see them soon for --- PIM 2nd part.

Penang Bridge International Marathon 2011

THE WORKSHOP OF 'DRY NEEDLING FOR MYOFASCIAL PAIN'

The workshop of " myofascial pain and dry needling - head/neck/shoulder girdle" at The royal London hospital for integrated medicine hospital.

It was not the first time, but it was a pleasure to meet Dr Robert Gerwin again for his myofascial pain workshop. Dr Robert Gerwin, a Board- Certified neurologist form Washington State, Medical Director of Pain and Rehabilitation Medicine in Bethesda, an associate professor in the Department of Neurology at John Hopkins University School of Medicine. He had the opportunity of training in the diagnosis and management of myofascial pain syndromes under the renowned Dr Janet Travell, and now runs a multidisciplinary pain clinic specialising in this field.  


Dr Gerwin is the author of over 30 peer reviewed articles, reviews, book chapters and consensus statements. he reviews articles for over a dozen medical journals. He is on the editorial board of the Journal of Musculoskeletal Pain, co-editor of the book Clinical Mastery in the Treatment of Myofascial Pain, along with Lucy Whyte Ferguson. 

Dr Gerwin demontrasted on a participant during the course.

The topic of these workshop was regarding myogenic headache ( headache origin from muscular pain.) and facial pain.

Decades ago, it was believed that, headaches are causes by intercranial pressure pain ( the increase of pressure in the brain), but nowadays, a lot of the medical professional that working on muscles or myofascial, having a revolution thinking that majority of headaches causes by the muscle surrounding the neck and the head.

Headache caused by a trigger point in the sternocleidomastoid muscle( a pair of muscles that located in front of neck) was described by Dr Travell 1955. Dr Janet Travell explained further that headache caused by trigger points in the trapezius muscle, the sternocleidoastoid muscle(both are neck muscle), and the muscles of mastication(muscle surrounding the jaw), and noted the contribution of mechanical stress,including a variety of postural stresses, on the development of trigger points that could lead to headache (Travell J : Mechanical headache. Headache 7:23-29 , 1967).

Referred pain pattern from the sternocleidomastoid muscle.

There are evidences shown the involvement of myofascial in headaches. E.g;

Olesen, the first to estimate tenderness in the pericranial muscles during a migraine attack , and found that temporal , masseter( muscle over the face) and neck muscles were tender (Prevalence significance of muscletenderness during common migraine attacks. Headache 21:49-54, 1981) , (Electromyography of pericranial muscles during treatment of spontaneous common migraine attacks. Pain 14:137-147 , 1982) & (Pericranial muscle tenderness and pressure-pain threshold in the temporal region during common. Pain 35:65-70 , 1988).

He also studied pericranial muscle tenderness in chronic tension type headache and correlated lower pressure pain thresholds and increased pericranial electromyographic activity with chronic tension-type headache (Muscular factors are of importance in tension-type headache . Headache 38:10-17 , 1998).

Jensen studied 735 subjects from the general population , and found 22 with chronic tension-type headache. Muscle pressure pain thresholds were lower in person , particularly females, with chronic tension-type headaches, than the general population (Pathophysiological mechanisms of tension-type headache , in Copenhagen : Foreningen af Danske Laegestuderendes Forglag , 1998, p 68).

Discussion and thinking during practical session.

Every time after the workshop is a hard time for me, because I need time to digest all the knowledge which being delivered during the workshop, but, honestly, I really learn a lot, and have no regret to travel all the way from Malaysia to London, UK for it.

No time tO excersice ... nO excuse ......




4 minutes Computer & Desk Stretches Sitting at a computer for long periods often causes neck and shoulder stiffness and occasionally lower back pain. Do these stretches every hour or so throughout the day, or whenever you feel stiff. Also, be sure to get up and walk around the office whenever you think of it.

4 minutes Computer & Desk Stretches Sitting at a computer for long periods often causes neck and shoulder stiffness and occasionally lower back pain.
Do these stretches every hour or so throughout the day, or whenever you feel stiff. Also, be sure to get up and walk around the office whenever you think of it.

 

Flat Feet (Pes Planus)

A true flat foot is rare. Generally, a flat-footed person is only suffering from a functional flat foot caused by excess pronation. Excess Pronation causes the foot's arch to collapse & elongate giving the appearance of a flat foot. A functional flat foot is quite common and generally exhibits symptoms ranging from sore/tired feet to general leg fatigue and body aches.

VASYLI products are designed to control excess pronation (the common cause of functional flat feet and thereby restoring the foot's arch to normal)

BALL OF FOOT PAIN 1

(Metatarsalgia)

This condition commonly occurs with women, however many men suffer from pain in the ball of the foot. Sometimes a callous develops in the centre of the foot and footwear may wear out in a similar fashion.

This condition causes a burning sensation in the ball of the foot and can become very painful. Ball of Foot Pain (Metatarsalgia) commonly occurs from rotation and dropping (plantarflexion) of the metatarsal bones along with excess pronation and weakening of the soft tissue (ligament & muscle) structures.

VASYLI products align the central three (3) metatarsal shafts using a inbuilt 5mm met raise to correctly position and maintain the Metatarsal bone position. By balancing the weight distribution over the five (5) metatarsal bones, this helps remove excess weight & friction which commonly causes the callous and burning sensation.

BALL OF FOOT PAIN 2

(Morton's Neuroma)

Commonly assocciated with Metatarsalgia (see previous ccondition), this condition is generally caused by entrapment of the interdigital nerve lying between the third and fourth metatarsal bones. Ball of Foot Pain (Morton's Neuroma) exhibits similar symptoms to Metatarsalgia, but may also cause numbness, tingling and discoloration of the third and fourth (lesser) toes.

VASYLI products may greatly assist in the early stages of Morton's Neuroma when damage to the nerve sheath is minimal. VASYLI products re-aligns the metatarsal shafts and prevents interdigital nerve jamming. Severe fibrosis of the interdigital nerve may require surgery. However, VASYLI products may prevent further problems post-operatively.