Jun
22

CoreBalance Therapy welcomes Tiana Tallant, MA, PT, DPT

By: admin Published: June 22, 2017

CoreBalance Therapy is delighted to announce the addition of Tiana Tallant, MA, PT, DPT to our staff!

We’ve known Tiana for years, as she was an employee prior to completing her doctorate in physical therapy, and we could not be happier that she has decided to come back and work with us now that she holds her physical therapy license. She brings a wealth of knowledge and skills as well as a delightful and empowering personality to our clinic.

Tiana holds a Master’s degree in Health Psychology, which helps her to better understand how people’s behavior interacts with their health conditions. That background fits perfectly into her interest in the management of persistent pain conditions, where treatments such as behavioral modification, meditation and cognitive therapies offer great potential for improved management and function. Tiana also has been a registered yoga therapist (RYT) for years, teaching in the community, and brings that expertise to exercise programming and design of home exercise programs for her patients. Finally, Tiana is an accomplished athlete, competing in CrossFit competitions and distance running events at a statewide level.

We asked Tiana to write something about herself, so you can all see why we’re so excited about having her:

“We are not a singular thing-we are built to change.” -unknown

This is one of the fundamental principles that I operate from in my everyday life and in how I treat patients. My name is Tiana Tallant and I am the newest physical therapist at CoreBalance. I graduated from the NAU DPT program earlier this year and am incredibly grateful for the opportunity to begin my career at CoreBalance. Before entering PT school, I completed my MA in Clinical Health Psychology which allowed me to dedicate time and effort into understanding the human relationship with change- what drives us to change, what barriers we have to overcome, and how we use our environment and/ or relationships to create those changes. In my perspective, coming into the clinic for Physical Therapy is another scenario that asks us to change. It takes us out of our normal routine and for the short term or the long term asks us to do some things differently. Whether you are seeking therapy for an acute or chronic condition, I will ask you for a commitment to try something different- maybe completing exercises at home, being more active, or trying to engage in a certain movement pattern differently. Whatever it is, you will have the opportunity to create meaningful change through your experience with Physical Therapy. I so look forward to being by your side throughout the process!!

Tiana is seeing patients at our University location. Her areas of particular clinical interest are musculoskeletal injuries of all types, patients with persistent ongoing pain conditions, and patients who are experiencing difficulty developing an exercise routine for the management of chronic health conditions such as diabetes, high blood pressure, or long-term weight management.  You can learn more about Tiana and the rest of our provider team by clicking here, or call us at 928-556-9935 to make an appointment to see any of us.

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May
6

Graston Technique

By: admin Published: May 6, 2014

by Holly Nester, PT, MPT

What is Graston Technique?

Graston is a respected form of instrument-assisted soft tissue mobilization used to effectively treat pain and restricted mobility.   Therapists specially trained in the Graston techniques utilize uniquely designed stainless steel instruments to break down fascial restrictions and scar tissue that impair normal movement.

Graston

 

What are the benefits? 

  • Assists with faster recovery by addressing the restricted tissues that are causing dysfunction
  • May reduce need for anti-inflammatory medications
  • Is effective for both acute and chronic conditions
  • Increases tissue mobility resulting in less pain and stiffness

What types of patients are treated with Graston?

Graston is appropriate for those who would benefit from manual therapy and lengthening of restricted tissue.  While I continue to have great results with direct hands-on treatment, Graston techniques offer an alternative approach that is especially beneficial for deeper or long standing restricted areas where fibrotic tissue is contributing to injury and/or pain.  Diagnoses that I have successfully treated with Graston include:

  • Neck/back pain
  • Carpal tunnel syndrome
  • Tendinitis/epicondylitis
  • Hip/knee disorders
  • Plantar fasciitis
  • Scar tissue

What to expect?

The internet has pictures of people horribly bruised following Graston techniques, but this is not the norm.  While Graston is used for professional and Olympic athletes who may tolerate that type of extremely deep work, most people treated in our physical therapy clinic can anticipate a much less severe response.  Typically we warm up the tissues so that they are less tender and more responsive to lengthening.  Hands on techniques may be used in conjunction with Graston instruments to lengthen the injured tissue and allow for more normal movement patterns and reduced pain.  There may be reddening of the skin, tenderness, and some light bruising depending on the individual and depth of pressure used.  It is always done to the patients’ tolerance and with their consent.  Exercise and ice are often included as part of treatment following Graston techniques.

Click here for a printable information sheet on Graston technique.

What research is available?

If you are interested in reading available research articles, please visit www.grastontechnique.com for more information.

What Do Patients Say?

“Before receiving Graston, I had repeated injuries of various sorts (e.g. pulled hamstring and chronic tension).  With Graston, Holly was able to get to areas connected to the “tight spots” that ultimately got to the root of the issues.  I am so grateful for her wisdom and the Graston technique!  Now I know that what was once chronic pain does not have to be normal for me any longer.”

 

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Apr
18

NeuroScience of Chronic Pain Part III

By: admin Published: April 18, 2013

by Jay McCallum, PT, DPT, OCS

How Does Chronic Pain Change the Sensory System?

In my last post I tried to outline the super-complex process that the brain goes through to generate the experience of pain, and what I want to try to do today is talk about what changes when the nervous system is bombarded by pain impulses over a long period of time.  This can be a challenging idea to transmit to people who have had pain for may years – they have nearly all heard some refrain on the idea that ‘your pain is in your head,’ with the subtext being ‘your pain is not real’ or, worse yet, ‘you’re faking it.’  I have had patients become angry and leave care, or become tearful or defensive when I try to bring this topic up, which is why I wanted to spend the time writing in my last post about how the experience of pain is generated by the brain.  What we are talking about here is not ‘the subconscious’ or anything like that – it’s about structural changes in the parts of the brain responsible for processing various inputs and generating the output or experience of pain.

There are several ways that the nervous system adapts over time to pain, and unfortunately the idea that we get tougher or desensitized is not at all accurate.  Remember that our nervous system is “plastic”, that it, it changes its structure in response to stimulus.  Generally, the more of a stimulus you give the nervous system, the more ‘resources’  it devotes to that stimulus.  Think of practicing a skill like hitting a golf ball – to break down the details of that, we improve our skill at that because with practice we devote more neurons to the motor program.  Or think of a sommelier who can identify many nuances of a wine — again, more neurons devoted to that process.  With pain, what we see is that the spinal cord itself ‘turns up the gain’ on its pain pathways, devoting more neurons to nociception (pain stimulation) than ‘normal.’  It looks a bit like this diagram, if you think of the vertical axis as being basically loading to a tissue, with the peak being the point at which injury would occur:

Normal Protective Pain

Normal Protective Pain

This is how pain is supposed to work – the person feels pain just a little before the point at which tissue damage occurs.  But when the spinal cord is turning up the gain, it looks more like this:

Abnormally early onset of pain in relation to tissue load

Abnormally early onset of pain in relation to tissue load

In this diagram you see that there has been a change in true tissue tolerance related to the original injury but the nervous system begins to generate pain far before any tissue damage begins to occur.  Let me emphasize here for a minute again that this is TOTALLY REAL PAIN, it just isn’t calibrated well to tissue damage anymore.  This change appears to happen primarily in the spinal cord, and as such is often referred to as “central sensitization.”

Central Facilitation

As if this isn’t enough, the brain itself has to get into the act.  As with other things I’ve described with this series of posts, the changes are complex, but there are two main themes – loss of precision and a process called facilitation.  We’ll start with the loss of precision.  As neurons in the sensory cortex of the brain are continuously bombarded with stimulation the stimulation basically starts to bleed over to neighboring neurons, to the point that brain imaging scans show overlap between areas of activation in the brain with stimulation of different parts of the painful region.  Patients experience a sense that their pain is spreading over time, sometimes even spreading to the opposite side of the body, and simultaneously becoming more difficult to describe.  Rather than pointing at the pain with a finger they wave at a whole area of their body, and they describe a sensation that the pain is ‘moving around.’  This loss of precision is easiest to ‘see’ experimentally in people who have a single extremity involved, say a very painful right arm.   We use our sensory cortex to help us identify whether we are looking a picture of a right arm or a left arm, basically sort of superimposing that picture onto our sensory cortex to see which side it ‘fits.’  Those patients with painful right arms, for example, are significantly slower to identify pictures of right arms than left arms, which tells us that their sensory cortex is not processing information quickly or accurately.

Facilitation basically means ‘priming’, and to understand this remember that the brain is absorbing information about many different things as it creates the experience of pain, and over time it no longer needs the entire set of stimuli to create the experience.  In our course, the analogy was to ask a group of attendees to stand up, then sit, then stand, then sit, etc.  Each time the speaker gestured along with giving a verbal command, until the last time when all he did was gesture.  And everyone stood.  A partial stimulus – had he just walked up to them and gestured initially they would have just stared at him – leading to the output of standing.  With pain, it might be the stimulus of an environment or activity that has historically provoked pain.  A case study of a bicyclist who had chronic pain with hill climbing was presented – she was placed in a setting where screens to either side of her could be tilted to make it look and feel like she was climbing a hill, and her pain could be brought on (and relieved) simply by tilting those screens, with no change in the actual intensity of her riding.  A partial stimulus of hill climbing leading to the experience of pain.  (You can read more about her here).

So…to recap:  Nociception (remember, that’s the name we use for nerves in the body that carry a painful stimulus to the brain) gets amplified by the spinal cord over time.  The sensory cortex of the brain that is responsible for generating the sensation of pain and sending it to our consciousness becomes somewhat sloppy (very like what happens with the motor cortex as I described in my first post on this subject).  And the pain system begins to leap to conclusions based on incomplete data.  Finally, just because I can’t say it enough times, the pain is REAL.  It’s just no longer accurately representing tissue damage like it is supposed to.

I have one more post in the pipeline, which will deal with what we can do in physical therapy to address this process, but the short version is that it is very much a thing that physical therapy can impact because it’s about retraining the brain, and PTs work with changing brain function every day.  Lots of things can change the way the brain functions, including everything from trauma (a head injury or a stroke) to what might amount to an overuse injury to part of the brain (chronic pain), and PTs treat all those things.  So if you have a history of longstanding pain that has not always ‘made sense’ to your medical providers, then consider giving us a call at 928-556-9935 or an email at [email protected].

 

 

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Apr
2

Neuroscience of Chronic Pain Part II

By: admin Published: April 2, 2013

by Jay McCallum, PT, DPT, OCS

 

The Sensory System

In the first post of this series I focused on how the motor system changes in response to longstanding pain, basically with a shift in strategies towards more of a mass bracing pattern that over time tends to perpetuate the pain.  But that’s only half the story, at best – the way we perceive pain also changes in response to a chronic painful stimulus.  And, as you can imagine, those changes are not particularly helpful.  But, before we launch into a discussion of how the system changes, let’s start with talking about how it normally functions.  As with everything else our brains do, it’s an amazingly complicated process, so I’m just going to hit some of the highlights.

How Does the Brain Create an Experience?

We all like to think that we are directly connected with the reality of the world around us.  We use our eyes to see what’s there to see, our ears to hear what there is to hear, and we feel things based also on the stimulation of our nerves.  But the process is really not nearly that straightforward.  optical illusion

This is an example of an optical illusion, where the viewer is asked to count the number of black dots.  Problem is, they keep moving around – white when you look right at them, black when in the periphery of your vision.  In reality, they’re all white, but the brain does not accurately present that information to your consciousness because it is affected by the dominance of the black squares.  There are also examples of auditory illusions, tactile illusions, even smell illusions!  And let’s be careful about this term ‘illusion’ – the perception is quite real – I really do see little black dots in that picture.

So, the best way probably to think about how we experience the world around us is to envision a product that has been presented to our consciousness by our brains, after taking multiple inputs into account.

So What Goes Into the Experience of Pain?

Quite a few things.  The first, obvious one is stimulation of a nerve or nerves, at least in most cases.  That input to the brain is called nociception.  But we know that nociception is neither necessary nor sufficient for the experience of pain.  For example, consider a person with phantom limb pain after an amputation.  The sensory nerves and the tissues that they are responsible for no longer even exist, but the person nevertheless experiences extremely real pain.  We’ve all heard stories about people with terrible injuries who didn’t realize that they even had the injury until later, because they were busy dealing with the situation at hand.  Or, on a more daily level, that cut or scratch that didn’t start to hurt until you saw it sometime later.  Some of the other inputs the brain takes into account in generating an experience of pain are things like our sense of body position, what we’re seeing and hearing, and what our prior experiences and beliefs surrounding similar circumstances are.

The key thing to remember here is that the purpose of pain is to alert us of a threat, and that the brain is attempting to make a threat decision with what it presents to our consciousness.  The more threatening the combination of inputs is, the greater the pain is.  Lorimer told a great story that summarizes this well.  He was walking in ‘the bush’ as they call it in Australia, and felt something catch his foot momentarily.  There was no pain, just a catch, and he continued with his walk.  Then he woke up in the hospital – he had been bitten by an eastern brown snake, a terribly venomous snake with an extremely painful bite.  But his brain had not reported pain to him, because he had such a large experience of walking in the bush and scratching his leg on twigs, so the very similar input of the snakebite was not judged as dangerous.  Months later, he was again walking in the bush and felt something catch his leg, but this time it was hideously painful, with persistent pain for a week afterwards.  But, you guessed it, scratched by a twig.  But that combination of inputs – walking in the bush, stimulus to the outside of the leg, etc – was now on the ‘really dangerous’ list as far as his brain was concerned, in that last time it nearly killed him.

Say Again?

Let’s pause here to summarize all this.  Pain is an experience, not a stimulus.  It is generated as a result of many inputs, including both things happening to our bodies and around us as well as our past experiences and beliefs.  Nociception (that stimulus of a nerve fiber in a tissue in the body somewhere) is neither sufficient nor even necessary for the experience of pain to occur.  There is, rather, an extraordinarily complex orchestra of events that are oriented around risk assessment that leads to the experience of pain.  And, like anything complicated, sometimes that orchestra starts to malfunction.  In my next post I’m going to talk about how that happens, but the really short version is that the more the orchestra plays the pain tune, the better it gets at it, until it’s going on and on in a way that is partially or even completely disconnected from the input its getting from the tissues.  It looks a bit like this:Pain diagram

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Mar
10

The Neuroscience of Chronic Pain

By: admin Published: March 10, 2013

by Jay McCallum, PT, DPT, OCS

This post has been a very long time in the incubator, partly because we’re all so busy and partly because we wanted to be able to give you both some science and some clinical reality.  It started last October when Amy and Jay went to a conference in Portland on the topic of chronic pain.  It was taught by a pair of amazing researchers, Paul Hodges and Lorimer Moseley.  Paul and Lorimer are both physical therapists – ‘physiotherapists’, actually, given that they’re Australians – but they have devoted their professional lives to the study of how pain works and between them have published nearly 300 scholarly articles on the topic.

Because they covered so much ground this is going to be the first of a three part blog.  I’ll talk about Paul’s work today, and then try to cram Lorimer’s material into a second blog, and finally talk about our experiences in the clinic working to implement their findings into actually treating patients.

How Does Chronic Pain Affect How We Move?

This is really what Paul Hodges’ work is about.  He is best known in the world of physical therapy as the researcher who told us all that the transversus abdominus is important in stabilizing the spine, but that’s really not at all fair to the body of his work.  What he has focused on is how the body solves the problem of keeping a stack of bones like the spine stiff enough that it doesn’t collapse, yet mobile enough to move.  And, what he’s found is that people do it in lots of different ways (of course).  There are, however, some patterns once you step back from the detailed specifics, and, more importantly, people who have a history of back pain tend to use a different set of strategies than people who don’t have back pain.  Most of the research here is focused on back pain, but it’s quite likely that similar patterns are at work with other locations of chronic pain, like the neck.

Generally speaking, the muscles of the trunk can be divided into muscles that are closer to the spine and those that are further away, with of course some muscles situated in a bit of a gray zone in between.  And Paul’s work suggests that the ‘normal’ way that we move is that the muscles that are closer to the spine activate to create just the right amount of stiffness to support the loads we put on our spines, while those further from the spine are primarily concerned with generating movement of the spine.

The best known of those deep, stabilizing muscles are the multifidus and the transversus abdominus, and the ones we tend to forget about are those that make up the pelvic floor.    These muscles are relatively small, located right in there close to the spine, and are designed to stay ‘on’ for long periods of time at a relatively low intensity.  They are also supposed to ‘pre-activate’, meaning that before you go to pick up that pencil on the floor the brain tightens them to stabilize the back.

View from the side of the multifidus, pelvic floor and transversus abdominus

What goes wrong?

We get stuck in a pattern.  When a person first injures his or her back, the body’s reaction is to brace it – to tighten the bigger muscles that are further out from the spine and have longer lever arms to pull on it.  Those muscles normally exist to generate movement, but get pressed into service to hold the injured spine in place.  That pattern is supposed to quiet after a while, but if it doesn’t it can become the “new normal,” the primary strategy for keeping the spine stable.  And that’s really a problem, because those muscles are NOT designed to be on for long periods of time, and so they complain about it, and get trigger points, and make the spine feel stiff all the time.  And they use too much force, so the underlying joints have too much pressure on them.  And they just aren’t very good at this new job, so people hurt their back picking up that innocent pencil because the nervous system didn’t stabilize the spine quite right (but they DON’T hurt their back lifting heavy things, because they consciously brace.  Sound familiar?).  And so, the classic pattern goes, people have further episodes of back pain and each one intensifies this pattern.

Hey!  That’s me!  What can I do??

And…there we have the problem.  Obviously, what we’d LIKE to do is turn off those overactive superficial muscles and re-activate the deep ones.  But, it isn’t quite so simple.  These changes in muscle activation are accompanied by changes in brain structure.  Put more simply, most people have had a LOT of practice at this pattern.  We’ll talk about this more in my third post, but a couple of key points is that pain of this type is not just a ‘strengthening’ issue – it’s much more about coordination.  And you have to work at it from a lot of angles, trying to both activate the deep ones (intentional exercise, practice, feedback) and quiet the overactive ones (stretching, motion, relaxation, massage and manual therapy).  Most importantly, treatment needs to be individualized and very attentive to details, which is how we do things at CoreBalance Therapy.

If you want to learn more, give us a call at 928-556-9935 or email us at [email protected].

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Aug
30

The serratus anterior – the ‘forgotten muscle’ in shoulder and neck pain

By: admin Published: August 30, 2012

by Jay McCallum, PT, DPT, OCS

Board Certified Specialist in Orthopaedic Physical Therapy

What the heck is the serratus anterior?

Because the serratus anterior is largely hidden from view underneath the shoulder blade, it is remarkably easy for both patients and clinicians to forget about this vital muscle.  It originates from the underside of the shoulder blade near the inner edge and has a broad attachment to the ribs.  It gets its name from the way that it is serrated, like a knife blade, as it attaches into the ribs, and is anterior (forward to) the shoulder blade.  Even though the serratus anterior is not visible on most people’s bodies, it is normally a very strong and fairly large muscle.

Serratus Anterior side view

Okay…so what does it do?

And here is where the confusion REALLY sets in.  The serratus anterior has historically been though of as performing two primary functions.  The first is to hold inner edge of the shoulder blade against the ribs, preventing ‘winging’ of the shoulder blade, as shown here.

Winging of the shoulder blade due to serratus weakness or paralysis

However, winging of this type is fairly rare, occurring mostly with injuries to the nerve that supplies the serratus anterior, the long thoracic nerve.  The second commonly thought of function for the serratus anterior is ‘protraction’ of the shoulder blade, pushing it forward relative to the body  in a punching motion.

So, the reader is thinking at this point, if my serratus anterior is weak then my right hook isn’t what it used to be, and I have a funny looking shoulder blade.  Tell me again why this is important?  Turns out that the serratus anterior does two other things that are a bit more functionally useful to us.  The first is that it is the strongest, best positioned muscle to create upward rotation of the shoulder blade, basically aiming the socket up.  In order to reach higher than about shoulder level the shoulder blade must upwardly rotate.  If the serratus is weak, then the shoulder blade literally can’t get out of the way of the arm, and that leads to pinching at the top of the shoulder, frequently known as subacromial impingement syndrome or subacromial bursitis.  Over time, it can even lead to development of a rotator cuff tear.  The other really important function of the serratus is to solidly anchor the shoulder blade to the thorax with use of the arm.  If the shoulder blade doesn’t have that stability, then the rotator cuff must work much harder, rather like walking in sand rather than on a hard surface makes your legs work harder.  That can, in turn, lead to rotator cuff tendinitis.

What does this have to do with my neck pain?

The serratus anterior isn’t the only upward rotator of the shoulder blade, it’s just the best one.  If it’s weak, the body goes looking for another way to accomplish the movement, and the next muscle in line is the upper trapezius.

The upper trapezius - look familiar?

Unfortunately, the upper trapezius is not particularly good at creating upward rotation of the shoulder blade, so in this role it has to work extremely hard, and so can become quite painful.  It also attaches into the skull and upper neck, and so significantly compresses those structures when it is activated.

How would I know if my serratus is a problem?

Anybody with shoulder pain should certainly have their serratus anterior strength assessed by a physical therapist, as serratus anterior weakness and/or inhibition is extremely common to a range of painful shoulder conditions.  The serratus anterior should also be examined for most patients with neck pain, particularly those who find that their pain is brought on by use of their arms – i.e. experiencing neck pain with lifting, carrying, cleaning, etc.

What can I do about it?

Like most muscles, serratus anterior strength is very activity-specific.  A common pattern is that a patient may be able to generate significant force into protraction – the ‘punching’ motion, but have much less strength with upward rotation of the shoulder blade.  And if there is a strong compensatory pattern already in place it can be quite difficult to re-establish a more efficient movement pattern.  So, while the internet has many serratus anterior exercises a short Google search away, people with symptoms are best advised to seek the guidance of a physical therapist, who can identify the specific pattern of weakness that may be present and design an individualized exercise program to address it.

If you’re in Flagstaff or northern Arizona and want this type of evaluation, then please call us at 928-556-9935 or email us for an appointment!

 

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