Friday, July 15, 2016

Loading and Unloading the Body

The more I work on patients and athletes the more I kind of view therapy as learning what to load and what to unload and how to manage it.  Load can be another view of stress.  When you stress a muscle or joint you are asking it to bear the burden, "to bear the load."  When you are unloading the muscle or joint or area, you are taking away stress from the muscle or joint.  I think most pain in a muscle or joint is that to much stress/load is being applied to the muscle or joint.

I think a lot of therapy and therapist are good at unloading a joint or muscle.  I think therapy as a whole has done a very bad job of loading tissue.  I think most therapists are afraid to properly load tissue.  Without loading the body, no progress can truly be made.  Even acute injuries, if you understand the injury mechanism can be loaded for faster recovery.

An example would be a hamstring tear that occurred on a Friday, the athlete may be able to do slow dribbles on a Saturday. A few things are happening.  First, the hamstring is still involved.  There is a neural competency that is making the muscle stay active, but at such a slow speed as to not aggravate the injury.  Second, we are increasing blood flow, paramount for healing.  Third, we are beginning the slow process of keeping the skill set of sprinting ingrained.  Finally, we are giving the athlete active part in the recovery process.  This isn't passive, only relying on the therapist.  I think this may be as important as all of it combined.  Passive treatment can lead to woe is me, victim mentality.  When the athlete stays involved from the onset, an injury can be just something to overcome.

This doesn't even going into all the different workouts that may be able to be done upper body.  Perhaps even riding a bike slowly could be done right off the bat.  

Chronic problems need even more direct approach.  Lower back pain isn't about just unloading the stress from the back or hip.  It's about finding what needs to loaded to ultimately unload the lower back from that stress.  A runner that comes in with knee pain after 5 miles, most likely needs to learn to load the hip better, not unload the painful area.

Years ago Gray Cook came up with the "Joint by Joint" approach.  Essentially, alternating joints have different components of mobility and stability.  Mobile big toe, stable mid foot, mobile ankle, stable knee, mobile hip, stable lumbar, mobile thoracic, stable cervical, mobile upper cervical, stable elbow, mobile wrist.  

I think there is a general "Load and Unload" approach.  I think most people will agree that the joint by joint approach is correct it doesn't mean the hip at times won't need to be more stable in certain individuals.  I think the load/unload approach is even more general.  Just what I see that is more common.  

Muscles to unload (destress)          Muscles to Load (Stress)
abductor hallucis                               extensor hallucis
medial soleus                                    lateral gastroc/ tibialis anterior
vastus laterals                                   rectus femoris (end range)  
psoas                                                 lower ab and external obliques
adductor magnus                              glute max
semimem/semitendinosis                 biceps femoris
TFL area                                           glute med/min
lumbar erectors                                 lumbar multifidi
thoracic erectors                               latissimus dorsi 
pec sternal                                         pec clavicular
anterior delt                                      posterior delt
levator scapula                                  upper trap/lower trap
rhomboid                                          serratus anterior/ mid trap
brachialis                                          biceps 
forearm flexors                                 forearm extensors (end range)
triceps lateral/medial                        triceps long head
SCM                                                 deep cervical flexors

This is probably very similar to what you will find on what is phasic and what is tonic.  But, it's just my way of viewing what are some common patterns that I see.

The key point to understand is to figure out ways to start loading the tissue and get better at loading it, not just address the unloading of tissue.   This approach can work for all forms of scenarios.  How much load or work can a patient assimilate in one treatment?  How much load or work can you athlete handle in a workout.  What is the deload strategy?

We can view exercise as a global load on the human body and something like a desk job as unloading the human body.  This has to be brought into balance or the human body will not remain healthy.  When astronauts go to space, special measures must be taken as their bodies immediately start losing bone and muscle mass as gravity (load) is no longer upon them.  How much can we load an older individual to keep their bone mass healthy?

I often ask the question, what stretches or exercises have you done that makes you feel better or worse.  You will be surprised how often the patient has the answers, but doesn't realize it.  "I feel horrible every time I stretch my hamstrings, but I love doing lunges." Again, their giving clues as to how their body likes to loaded.  As a therapist when you start looking at the issue your patients or athletes are dealing with, start looking for a way to load them to unload them.  In my opinion this will bring longer lasting results.


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