O osso astrágalo (ou tálus) localiza-se no médio-pé e articula-se atrás com o calcâneo, do lado externo com o cubóide e à frente com os 3 coneiformes. Este ossodesempenha umpapelimportante na manutenção da arcada plantar.
As fracturas do astrágalo podem ser:
Fracturas arrancamento: são as mais comuns e têm geralmente associadas lesões ligamentares, como resultado de uma força de torção brusca aplicada ao médio-pé.Essas fracturassãocomummentetratadas de forma conservadora, com excepção da fractura arrancamento dainserção dotendão tibial posterior(fractura da tuberosidade), que deveser reparadacirurgicamente, especialmente seodeslocamento do fragmento ósseo for superior a 1 cm.
Fracturas do corpo do astrágalo: estão geralmente associadas a outras lesões da articulação médio-társica. Podem ser classificadas em:
Tipo 1 é uma fractura do corpo do astrágalo sem luxação.
Tipo 2 é uma fractura oblíqua com luxação medial do médio-pé.
Tipo 3 é uma fractura cominutiva com deslocamento lateral e ante-pé.
Todas as fracturas do corpo do astrágalo com 1 mm ou mais de deslocamento exigem a redução aberta e fixação interna.
Fracturas de stress: são geralmente associadas à prática desportiva, principalmente em jovens atletas do sexo masculino. Estas fracturas são problemáticas porque não sãoevidentesnas radiografiassimples, o que leva muitas vezesa umatrasonodiagnóstico, quepoderesultar emdorincapacitanteprolongada. Numestudo recente o tempo médio para o diagnóstico e tratamento de uma fractura de stress do astrágalo rondou os 4 meses.
Sinais e sintomas/ Diagnóstico
Sensibilidade no dorso do pé, do lado interno logo abaixo da linha do tornozelo.
Dorcom os movimentos de eversãopassiva einversãoactiva
Leve inchaço no dorso do pé, do lado interno logo abaixo da linha do tornozelo.
É essencial uma boa avaliação clínica do pé e tornozelo paraajudarno diagnósticode uma fractura doastrágalo. Umraio-Xé geralmentenecessário paraconfirmar o diagnóstico eavaliaragravidade da lesão. Nas fracturas de stress (em que não há história de traumatismo), por vezes, nãoaparecenosraio-X iniciais, exames adicionais (TAC ou RM) podem ser necessários.
Tratamento
O tratamento em fisioterapia, imediatamente após a lesão e enquanto o diagnóstico não está confirmado, consiste e controlar os sinais inflamatórios, através de:
Descanso: Evite caminhar ou estar muito tempo de pé. Se tiver de o fazer utilize canadianas. Andar a pépodesignificarum agravamento da sua lesão.
Gelo:Apliqueuma compressa de gelona árealesada, colocando umatoalhafinaentre ogeloe a pele. Use o gelopor 20minutos e depoisespere pelomenos40 minutosantes de aplicar gelonovamente.
Elevação:O pédeveser elevado um poucoacima doníveldo seucoraçãopara reduzir oinchaço.
O tratamento médico dasfracturasdo astrágalo vai dependerdotipo de fracturae da extensão dalesão. Nas fracturas em que não haja desalinhamento entre os topos ósseos e nas fracturas de stress, 4 a 6 semanas de descarga, com o uso de canadianas é geralmente suficiente para a consolidação óssea.
Para as fracturas em que os dois topos da fractura estão desalinhados o ortopedista realizará o realinhamento da fractura por manipulação cuidadosa sob anestesia seguida de cirurgia para fixação interna (utilizando placas e parafusos) no caso de se tratar de uma fractura instável. Nesta situação, após a cirurgia segue-se imobilização gessada com bota protectora mais canadianas por um período não inferior a 4 semanas.
No período após imobilização gessada deve ser iniciado um programa de fisioterapia. As técnicas que revelam maior eficácia nesta condição:
Semanas1e 2: opaciente participa desuasactividadesnormais da vidadiária(AVD), tratamento com mobilização articular, fortalecimento muscular e massagem dos tecidos moles
Semanas 3e4: Inicio gradual de corrida e treino proprioceptivo em carga (desde que não desperte dor ou outros sintomas)
Semanas 5 e6: Fase reservada a reintrodução do atleta à prática desportiva. A intensidade dos exercícios é gerida respeitando a sensação de fadiga ou cansaço local do atleta.
Exercícios terapêuticos para a fractura do astrágalo
Os seguintesexercícios são geralmente prescritos apósa confirmaçãode que afracturaestá consolidada. Deverão serrealizados2 a 3vezespor diaeapenasna condição denãocausaremouaumentaremos sintomas.
Flexão/extensão do pé
Deitado, com o calcanhar fora da cama, puxe a ponta do pé e dedos para si, depois empurre pé e dedos para baixo.
Repita entre 15 e 30 vezes, desde que não desperte nenhum sintoma.
Adução/adbução do pé
Puxe o pé para cima e para fora, e depois para cima e para dentro.
Repita entre 15 e 30 vezes, desde que não desperte os sintomas.
Flexão resistida do pé
Sentado, com o elástico na ponta do pé. Puxe a ponta do pé para cima, depois deixe o pé voltar lentamente à posição inicial.
Repita entre 8 a 12 vezes, desde que não desperte nenhum sintoma.
Antesde iniciar estes exercícios você deve sempre aconselhar-se com o seu fisioterapeuta.
Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005(2):CD000450.
Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg. 2000 Mar-Apr;39(2):96-103.
In honour of the recent World Nursing Day, Debashis Sarkar looks at five things process excellence professionals can learn from nurses.
You all would probably agree that nursing is probably among the noblest profession on earth. Since Florence Nightingale laid the foundation of transforming nursing from that being a domestic service to that of a profession in nineteenth century, nurses have been serving humankind.
Every time I see a nurse in action, it amazes me to see how caring and compassionate they are as they navigate through multiple duties which could be as varied as comforting patients with pain, delivering babies, changing saline bottles, inserting a catheter, consoling the relatives of someone who has just died, cleaning soiled patients, listening to the traumatic stories of patients and so on.
Nurses are real heroes who work behind the scenes to keep us all healthy while keeping patient’s needs central to everything that they do. For nurses patients are their customers and the commitment with which they serve is something that many of us would have felt. We often don’t realize but they help us to navigate some of the most difficult moments of our lives.
So in honour of the recent World Nursing Day (May 12th), what are some of the things which process excellence professionals learn from nurses? While the list can be large I have picked five of the most relevant:
#1: Advocacy
As a patient advocate, a nurse stands up for the patient’s needs and makes sure that the care provided is in their best interests. As nurses continually interact directly with the patients they are well placed to understand what impact decisions about care will have on their patients.
Process Excellence Professionals (PEX Pro) also need to be advocates - but of the customers (i.e. the end customer) of the process. When we’re improving only a part of a process we can sometimes forget the impact on the end customer and this can be quite disastrous. For instance, if we’re looking at improving the accuracy of the “cash cheque” process at a bank branch we want to make sure that we’re focussing on the entire experience. Otherwise, measures we put in place to improve accuracy may make the process less efficient and pleasant from the customer’s point of view. When facilitating improvements, it’s imperative to always keep this customer in mind and think of any process from their perspective.
#2: Patience
Having patience is the hallmark of a good nurse. In an emotionally charged environment like a hospital, a nurse needs to be calm and manage the difficult emotions of patients on one side, ensure hospital’s need for being operationally efficient are taken care off and also carry out the instructions of a demanding doctor. Under such circumstances if a nurse looses his/her calm, things can go awry. Hence, it requires a nurse to always keep the larger picture of compassion and care in mind and not to do anything that could make them dysfunctional and impede rational thinking, despite all the stress and workplace and managing the various constituents.
What process professionals need to learn from here is that they need to be patient as they try managing the various stakeholders. Sometimes these individuals could be irrational, demanding and even rude. It’s important to keep calm and not get emotional about these reactions. You must always keep the larger objective of the process excellence endeavour and demonstrate emotional resilience to manage varied situations.
Also, just like it can take a long time for a patient to get well, process professionals must be aware that the culture of process thinking takes time to grow and embed in an organisation. There is no magic formula to make it happen. One has to be at it and over a period of time it becomes a part of the organisational fabric.
#3: Passion for education
Nurses are just not care givers but also health educators who play the role of educating patients on what need to be done to maintain a healthy life. They also act as teachers for other budding nurses, provide mentorship to fellow nurses and provide latest knowledge and information from fields such as medicine, medical technology, customer-service, healthcare legislations etc , so that nurses are updated.
Like nurses, process professionals must focus on continual learning and teaching. They need to focus on creating cadre of change agents who can contribute in process excellence efforts. A successful process excellence deployment is one in which process efforts have become a part of business-as-usual activities of an organisation. And this would happen through repeated training and awareness facilitated by PEX Pros.
For a nurse every day is different. They face a wide array of situations. Patients can come in one of the most vulnerable and dark moments which makes them often unpredictable and irrational. There could be days a patient may arrive with complex medical condition which could be a matter of life of death. There could be varying medical procedures that they need to administer. To summarize a nurse’s life is filled with uncertainty and they need to wade through varying operational environment for which they need to demonstrate adaptive leadership.
This is a great learning for PEX professionals who also need work in varied settings. For a process professional no day is the same. Sometimes you can be dealing with an aggressive sales team or a demanding CEO, the next it’s an indifferent shop-floor worker or disengaged staff. Successful PEX professionals are just not “tool-heads” but change leaders adept in adaptive leadership.
#5: Detail orientation
Nurses are detailed oriented. They have a great eye for details so that even little things are taken care of that can impact a patient’s health. Missing even a small dose of medicine or a step in a medical procedure could be fatal. An effective nurse can decipher even minor symptoms which could indicate the deterioration of a patient’s health. It’s the little things that the nurses do contribute towards healthy recovery.
Like nursing professionals, process excellence leaders also need to have an eye for details. It’s the focus on little things that ensures a great outcome. While embarking on a process endeavour a PEX leader should list all the small and big things that need to be addressed to make sure the final results are desired. For example, if the focus is enhancing customer experience in a fine dining restaurant; the focus has to be on food quality, food presentation, aroma, ambience, wait times, staff-friendliness, staff-knowledge, interaction with chef, valet-parking, location of the restaurant, approach to reservation, display of food history etc. It’s all these little things that add up to experience.
To summarize, if nurses are responsible for quality of human life, the work of process excellence professionals is to ensure the health of an organisation by focussing on the process management system.
A corrida está entre os exercícios físicos mais queridos das pessoas. Hoje, ao contrário do que acontecia na Grécia antiga, onde o desporto era praticado apenas por um grupo restrito de homens, ela encontrou adesão em diversas camadas sociais, faixas etárias e profissões.
Não é para menos: a corrida traz uma série de benefícios que ultrapassam o plano físico. Além de emagrecer e combater diversas doenças, como hipertensão e diabetes, quem corre tem mais chances de sorrir para a vida, pois aumenta a auto estima e o bem-estar. Quer saber por que mais a corrida virou moda?
Acompanhe 11 motivos:
É democrático
Para correr, não precisa ser um exímio atleta. Aliás, boa vontade é mais bem-vinda do que habilidades específicas quando o assunto é corrida.
Mas, atenção: isso não quer dizer que o desporto não exige cuidados. “Qualquer pessoa pode correr, só que sempre respeitando suas condições físicas atuais e crescendo dentro do treino diário”, explica o personal trainer Edson Ramalho. Wanderlei de Oliveira, corredor e criador da CORPORE (Corredores Paulistas Reunidos), alerta que pessoas que estão cinco quilos acima de seu peso ideal podem ter problemas ao praticar do desporto, já que, a cada passada, o impacto nas articulações é de três vezes o seu peso.
Emagrece
Em uma hora de corrida, é possível queimar, aproximadamente, 600 calorias – pode variar para mais ou menos, levando em consideração o preparo físico de cada indivíduo, o que ajuda no combate ao sobrepeso. Para que essa queima aconteça, o personal trainer Edson Ramalho aconselha que a pessoa corra, no mínimo, 30 minutos, em frequência cardíaca máxima de 60% a 80%. Só assim a gordura se torna o combustível primário, ou seja, é queimada.
Para saber sua frequência cardíaca mínima e máxima, basta seguir a seguinte fórmula:
(220 – sua idade) x 0.6 = frequência cardíaca mínima
(220 – sua idade) x 0.8 = frequência cardíaca máxima
Por exemplo, se a pessoa tem 30 anos, sua frequência cardíaca durante o exercício pode variar de 114 a 152 batimentos por minuto.
Aumenta sua força
Quer ter glúteos firmes? Correr ajuda! Segundo o personal trainer Edson Ramalho, quem corre tem toda a musculatura inferior trabalhada, o que inclui pernas, glúteos e músculos do abdómen.
Melhora o condicionamento físico
O personal trainer Edson Ramalho conta que, depois de duas ou três semanas, já é possível sentir a diferença da corrida no condicionamento físico. Até mesmo tarefas corriqueiras, como subir escadas, tornam-se mais fáceis. Como resultado, os afazeres ficam menos cansativos e mais prazerosos.
Controla doenças
Diabetes, hipertensão, asma e colesterol alto são apenas algumas doenças que podem ser mantidas a rédeas curtas com ajuda da corrida. Tudo isso acontece graças ao condicionamento físico que a atividade proporciona. Sendo uma atividade aeróbica, a corrida de longa duração e baixa intensidade condiciona o coração. Segundo o médico do desporto Ricardo Munir Nahaf, da Sociedade Brasileira de Medicina do Exercício e do desporto (SBMEE), depois de algum tempo de prática, seu organismo passa a economizar energia para realizar algumas tarefas. Essa economia gerada pelo condicionamento físico é que impede que ele se sobrecarregue, facilitando o controle de pressão, colesterol e peso.
Nocauteia o diabetes
Vale enfatizar que a prática da corrida por diabéticos pode, em alguns casos, dispensar o uso do remédio de controle da doença.
A já conhecida síndrome metabólica – síndrome que agrupa problemas de saúde como pressão alta; aumento nos níveis de triglicérides, glicemia e mau colesterol (LDL) e diminuição do bom colesterol (HDL) está diretamente ligada ao sedentarismo e à gordura corporal, em especial a visceral. “Quando faz essa atividade, consegue metabolizar tudo isso”, afirma o médico do desporto Ricardo Munir Nahaf. Ele conta que, com a corrida, o remédio se torna mais efetivo e, em alguns casos, principalmente de diabetes tipo 2, pode até ser dispensado.
Dá um “chega pra lá” na osteoporose
Estudos indicam que correr propicia a mineralização (calcificação) óssea, ou seja, quem corre diminui as chances de ter osteoporose. O personal trainer Edson Ramalho explica que o impacto gerado pela corrida, desde que seguro, fortifica os ossos.
Aumenta o bem-estar
A produção de endorfina vinda da corrida é a principal responsável pela sensação de bem-estar que sucede a corrida. “Toda atividade física possibilita a produção de endorfina, então a pessoa aumenta a sensação de bem estar com a prática”, explica Antonio Carlos Amador Pereira, psicólogo da PUC-SP. Ele acredita que, por a corrida ser um exercício aeróbico, a sensação pode ser ainda mais forte.
Além disso, o fato de ser praticada ao ar livre potencializa ainda mais a sensação de bem-estar e diminui as chances de bater o clássico desânimo, já que não dá muito espaço para monotonia.
Promove o bom humor
Mais uma vez, a endorfina é responsável pelo desenvolvimento de um humor estável para aquelas pessoas que praticam esse desporto regularmente. Essa substância deixa a pessoa tranquila e bem-humorada. “O que acontece muitas vezes é que, quando essa pessoa não pode praticar, fica mal-humorada, quase como uma abstinência de endorfina”, ilustra o psicólogo da PUC-SP Antonio Carlos Amador Pereira, que também lembra que a corrida manda o estresse para o escanteio.
Deixa a auto-estima nos ares
Corrida é um desporto de superação. Segundo o psicólogo da PUC-SP Antonio Carlos Amador Pereira, quando o corredor consegue superar a si mesmo, a elevação da auto-estima é inevitável, já que a pessoa sabe quanta disciplina e esforço foram necessários para atingir uma meta. “A auto-estima está muito mais ligada a ser capaz”, expõe. O psicólogo também lembra que o desporto está relacionado ao combate à depressão. Há, ainda, o que o espelho te diz: não enxergar alguns pneuzinhos ou, quem sabe, caber naquela calça antiga é muito gratificante, como lembra o médico do desporto Ricardo Munir Nahaf.
Aumenta seu círculo de amizades
As pessoas costumam viver isoladas, como explica o psicólogo da PUC-SP Antonio Carlos Amador Pereira, o que não é nada bom. Correndo, conhece pessoas que compartilham objetivos similares aos seus e não deixarão de te incentivar quando o desânimo bater. “Outro lado positivo: não tem briga. As pessoas são solidárias, uma ajuda a outra, o que leva ao aumento do círculo de amizades”, lembra o corredor Wanderlei de Oliveira.
Foam rolling is very popular. Athletic trainers use it as a part of the warm-up. Physical therapists use it as part of their treatment strategy, often to improve extensibility of “short” tissues.
There is very limited evidence about what benefit, if any, foam rolling confers. But there are at least a few studies showing that it leads to short term increases in range of motion that are not accompanied by strength loss. (This is interesting because stretching interventions tend to show increased range of motion that are associated with a loss of strength and power.)
The purpose of this article is not to question whether foam rolling is effective for anything. I’m willing to assume that it is effective in some way for some people. It is hard for me to believe that so many intelligent trainers such as Mike Boyle would be singing its praises unless it was good for something. So I’ll give it the benefit of the doubt for purposes of this article.
The question that I want to answer in this post is the following: if foam rolling does work to reduce pain or improve mobility, what is the mechanism? I do not find the common explanations very convincing. But there is one (less commonly heard) explanation which I really like. Here’s my critical analysis of the different theories for why foam rolling works, including my favorite one.
1. Does foam rolling “improve tissue quality”?
This is one you will hear quite frequently, usually without any specifics as to which “qualities” are at issue. I think some people imagine that foam rolling can somehow smooth out bumps or incongruities in their tissues like a rolling pin over pizza dough. Of course, this explanation is usually intended for lay people and not scientists, so perhaps we can cut some slack about the lack of specifics. Perhaps the qualities to be improved involve the presence of fascial adhesions or trigger points. I’ll address those claims specifically below.
2. Does foam rolling lengthen or “melt” fascia?
For some reason people just tend to assume that foam rolling works by changing the fascia. I honestly have no idea why. A foam roller puts pressure on all the other tissues in the body, and they all communicate with the CNS, which controls how we move and feel. Isn’t the CNS the most obvious place to look for changes after foam rolling?
No, it always has to be the fascia!
But fascia is tough stuff. Sure it has some interesting adaptive properties, but at the end of the day its purpose is to form a solid structure for the body. Is it really plausible that we can significantly change our structure just by leaning on a foam roller a little bit? We must be made of stronger stuff than that. If fascia started to break down, or elongate, or “melt” every time it felt a little sustained pressure, we would be pretty fragile creatures. Every time we sat on a rock our posterior chain would lengthen. So for me the idea that foam rolling lengthens or melts some important structural stuff in our body does not pass the common sense test.
And, more importantly, the research does not support this idea either. There are a few research studies (here and here) which try to determine the degree of pressure necessary to cause permanent deformation in mature human connective tissue. The upshot is that if you want permanent change, you better be prepared (as Paul Ingraham notes) to “get medieval.” Steam roller maybe, foam roller, no. It’s not going to happen in any of the places where the roller is most commonly applied, which are usually the strongest parts of the body – the ITB band, lumbar fascia, plantar fascia, etc.
3. Does foam rolling break up fascial adhesions?
Maybe a foam roller can’t lengthen the IT band, which is stronger than steel, but could it break up some little fascial adhesions that prevent sliding between different muscle groups? One of the studies I referenced above show that manual pressure might be enough to deform nasal fascia. Now I don’t see many people foam rolling their nose, but maybe there are tiny little adhesions between large muscles groups that are as weak and deformable as nasal fascia.
Again this seems highly speculative to me. How do we know where these adhesions are, or what angle will help break them? A foam roller is a blunt non specific instrument that delivers force in a diffuse manner into the tissue. Smash! Part of the job of fascia is to diffuse force, so it would be hard to target a specific point here. Also, the angle of pressure is always straight in. The foam roller would have limited ability to provide the kind of precise oblique force that might be able to slide one layer of tissue with respect to the other.
Another problem I have with the idea that foam rolling breaks up fascial adhesions is that the effects are often temporary. People do some foam rolling, they feel better for a while, and then tomorrow or even later that same day, they feel the need to roll the same area again. If the mechanism of effect is breaking fascial adhesions, then why do we need to repeat the process? Did the fascia knit itself back together again? The temporary nature of the results strongly suggests a nervous system mediated mechanism for efficacy, not a structural one.
3. Does foam rolling get rid of trigger points?
Many foam rolling proponents explain that proper procedure involves finding a “trigger point” and staying on that point for a while. Is foam rolling a way to treat trigger points?
It should be noted that the term trigger point means different things to different people. For some it just means a sore spot, but for others it refers to a specific pathology. The technical definition involves several elements such as a hyperirritable nodule within a palpably taut band that elicits a twitching response to snapping palpation. Trigger points are thought to be caused by some sort of metabolic crisis in the muscle cells which causes chemical irritation in the local area and for some unknown reason refer pain to other areas when pressed.
Trigger points are controversial to say the least. There is substantial debate as to whether they even exist. Whether they can be reliably identified is another debate. And whether they can be effectively treated is another. There are many recommended treatments – stretching, post-isometric relaxation, sticking needles into them, pressing on them, etc. I definitely don’t have the time or anything approaching the knowledge to address all these debates.
But given all these uncertainties, I’m disinclined to believe that foam rolling works by getting rid of a trigger point. There are just too many unanswered questions here. The experts in trigger point therapy will tell you that not every sore spot is a trigger point, that not all trigger points are clinically relevant, and that their identification and treatment takes practice and expertise. So I don’t think shotgun fascia smashing with a foam roller is a plausible trigger point treatment (assuming they exist and can be treated with pressure.)
4. Does foam rolling work by proprioceptive stimulation?
I often hear claims that foam rolling works by proprioceptive enhancement – stimulating mechanoreceptors in the muscles and/or fascia, such as golgi tendon organs, or muscle spindle fibers, or ruffinis, or pacinis, or Pacinos or DeNiros. This could have some beneficial effect of encouraging relaxation of muscular or fascial tone, or causing the brain to reorganize its sensory or movement maps in the local area.
I think this is a very plausible explanation and definitely on the right track. But I doubt it is the main mechanism which explains why people like to foam roll. If stimulating these mechanoreceptors explains the claimed benefits of foam rolling, then why wouldn’t you just stretch and move around, and get probably even more stimulation to these organs, but within the context of functional movements? Can the foam roller, which doesn’t really provide that much movement or stretch to the target muscle or fascia, provide more proprioceptive stimulation then functional movements like the squat, lunge or reach? I think not.
Perhaps what foam rolling has to offer over movement is novel proprioceptive stimulation. I think novelty is great and of huge potential benefit. It helps get the brain’s attention, which is what you need to do if you want the brain to change. But here’s something else that you need to do. You need to provide the brain with information that is relevant to something that the brain cares about. The brain cares about how to move your body through functional patterns such as squats, lunges and hip hinges. How is the information derived from foam rolling relevant to these tasks? The brain is not interested in information just because it’s novel. The information must also help it solve movement problems. Why would the nervous system be interested in how it feels to have a lacrosse ball jammed into your butt?
5. Does foam rolling work by diffuse noxious inhibitory control?
This is my favorite explanation. And this is probably the mechanism with which readers will have the least familiarity. Here’s a description of what it is, how it works, and why I think it’s the major reason for the potential efficacy of foam rolling (and many other forms of manual therapy).
Diffuse noxious inhibitory control (DNIC) is one of several varieties of “descending modulation”, by which the brain adjusts the “volume” on nociception (danger signals which originate in the body). DNIC means that the brain inhibits nociceptive signals from traveling up the spinal cord to the brain.
DNIC is reliably triggered by a sustained nociceptive input, such as immersing your hand in cold water. The inhibition is diffuse – it suppresses nociception not just from the local area, but distant areas as well. In other words, if your leg hurts, and you stick your hand in icewater for a while, the resulting DNIC will cause both the hand and the leg to hurt less. This dynamic of fighting pain in one area by creating it in another likely explains the success of many therapies, and is sometimes called counterirritation. The effect is temporary of course.
How powerful is the effect of DNIC? Very powerful. When a soldier loses a limb in battle, he will often feel no pain so long as the emergency persists, and DNIC is a major reason. David Butler refers to DNIC as the “drug cabinet in the brain.” Here’s a video where he explains this idea in a little more detail, including the fact that some of the drugs in the brain are stronger than morphine.
Pain expert Lorimer Moseley views descending modulation and DNIC as a way for the brain to “second-guess” the periphery about the threat posed by a particular stimulus. For example, if the periphery is communicating information suggesting there is a large amount of mechanical threat in a particular area, the brain, which has access to a wealth of additional information about what is actually going on in the periphery, may decide that the problem is not so serious, and therefore inhibit the transmission of nociceptive signals to the brain.
There is significant research showing that many chronic pain conditions such as fibromyalgia, irritable bowel syndrome, and TMJ are characterized by relative failure of the DNIC mechanism.
The effectiveness of DNIC in suppressing pain is highly dependent on the expectation that the counterirritant will have an analgesic affect. In this interesting study, researchers immersed the hands of participants in cold water, shocked them with an electric blast to the sural nerve, and then measured the level of nociceptive activity in the spine, as well as the self-reported pain level. Importantly, the participants were divided into two groups. The first group, called the “analgesia group”, was told that the cold water immersion would reduce the amount of pain they felt from the shock. The other group, called the “hyperalgesia group” was told the opposite – that the cold water immersion would make the pain in the leg worse.
The analgesia group experienced 77% less pain, and less spinal cord nociceptive activity than the hyperalgesia group, who experienced almost no reductions in pain or spinal cord nociceptive activity. In other words, expectation of relief was a huge factor in determining whether whether DNIC worked.
Now let’s put this all together. DNIC is a powerful but temporary way to reduce pain in one area by creating pain in another. It depends on a decision by the brain to ignore danger signals from the body. Expectation of benefit from the irritating stimulus plays a strong role.
There are several aspects of foam rolling that are very consistent with the hypothesis that its main benefit is achieved by creating DNIC. Rule number one in foam rolling is to find a sore spot and stay on it for some time. You need to create some pain. Of course, the pain is often a “good pain”, which is exactly the type of feeling that would correlate with the brain’s conclusion that the irritation is somehow beneficial – which is what gets DNIC going.
Foam rolling often creates pain relief, not just in the area of pressure, but in other areas as well. People also tend to feel more freedom of motion, which could easily be explained by suppression of nociceptive activity, which tends to create muscle guarding, stiffness, and compensatory patterns of movement.
Further, the results of foam rolling are often temporary and need to be repeated (and often repeated harder the next time- are people becoming addicted to the drug cabinet in the brain?) This suggests a CNS mediated mechanism.
So here is the story I tell about foam rolling. You put a foam roller into your butt and create some significant nociceptive signalling. The brain receives it and says something like: “OK, the butt is telling me that there is some danger down there right now. But I happen to know that this is a therapeutic situation because my trainer said so. So, let’s send some drugs down the spinal cord to block all this talk about danger. And, we’ll make this feel like a “good” pain, not an injury.” The drugs reduce pain and thereby improve movement temporarily.
Make sense?
Practical implications
Now some people will read this and say “well who cares about how it works, all I care about is that it works.” And in some sense that is fine, but this lack of curiosity ignores the potential improvements one might make to a therapeutic regime by understanding the real mechanism of effect.
If foam rolling really works by nothing other than DNIC, then perhaps it would be easier to get the same effect by just pinching yourself or putting your hand in ice water. Or maybe this would mess with expectations, which we know are important to get the effect.
Here’s another interesting question that arises from the consideration that foam rolling may work purely on the basis of DNIC. If the results are only temporary, can there be any progressive benefit? I think the answer is: it depends. Pain relief and improved movement open a window of opportunity that one might climb through. If you are feeling better only for an hour, this provides enough time to train movements that would not normally be accessible, learn new skills, develop new capacities, and reduce the perceived threat associated with certain movements. This could have permanent benefit. But of course if you just sit on the couch, the benefits would probably be temporary.
Here’s another question I have in regard to foam rolling. If the major reason it works is release of the drug cabinet in the brain, then can one become addicted? I have no real evidence of this, but I swear I’ve seen a disturbing pattern. Someone gets relief from a foam roller, and then graduates to the lacrosse ball, and then to the wooden ball, until they are bruising themselves with steel in an effort to get that fix! Avoiding this type of situation is one reason it’s a good idea to know why something works.
Conclusion
Well there’s a lot more to be said here, but I am out of time, and if you have already read this far you are a champion!
I’m sure some of my readers will point out that I missed one or two great explanations for why foam rolling works. If I did, then please post in the comments and I’ll try to address it in a further post.
One way or the other, let me know what you think in the comments. And pass this around!
Game-changing quicks result from solid, stable ankles.
“Developing ankle stability is of great importance for improving balance, speed, agility, quickness and change of direction,” says Sean Cochran, former strength and conditioning coach for the San Diego Padres and current strength coach to Phil Mickelson. “Ankle stability is a basic need for all athletes, because it’s the first joint used in the body’s balance system and begins the process of every major movement.”
Cochran recommends a 3-step progression to produce ankle stability:
1) Start by completing a set of a single-leg drills;
2) Repeat the same single-leg drill standing on an unstable surface like a Bosu, balance board, dyna disc or half foam roller;
3) Progress to more aggressive movements like hopping from foot to foot.
Try the following drills to develop necessary ankle strength and stability.
Stability Clock Reach: Level 1
• Place cones at 9, 12 and 3 o’clock
• Stand on left leg
• Bend at ankle and knee to touch cone at 9 o’clock with right hand
• Return to starting position and repeat movement for 12 and 3 o’clock
• Repeat sequence 10-15 times on left leg
• Repeat entire sequence standing on right leg and touching cones with left hand
• Repeat sequence 10-15 times on right leg
Stability Clock Reach: Level 2
• Same as Level 1 but perform while standing on unstable surface
• Perform 2 sets of 10-15 reps for each leg
Lateral Hop and Hold: Level 3
• Stand on left leg
• Hop to right as high and far as possible
• Land on right leg and hold position 3-5 seconds
• Hop to left as high and far as possible
• Land on left leg and hold position 3-5 seconds
• Perform 2 sets of 10-15 hops in each direction
A corrida está entre os exercícios físicos mais queridos das pessoas. Hoje, ao contrário do que acontecia na Grécia antiga, onde o desporto era praticado apenas por um grupo restrito de homens, ela encontrou adesão em diversas camadas sociais, faixas etárias e profissões.
Foam rolling is very popular. Athletic trainers use it as a part of the warm-up. Physical therapists use it as part of their treatment strategy, often to improve extensibility of “short” tissues.
