By Willem Kramer

Several months ago I shared an article “The fall of the postural-structural-biomechanical model in manual and physical therapies; exemplified by lower back pain.” with about twenty of my colleague therapists and asked for their feedback and opinion. The reactions I received or the lack thereof actually surprised me.

For those of you who didn’t read the article in question, the text composed by Eyal Lederman questions, based on statistical analysis in regard to PSB factors and lower back pain, the validity of the often used and currently very popular postural-structural-biomechanical (PSB) model. According to Lederman the therapists applying the model falsely assume structural imbalances and asymmetries to be the cause of (lower back) pain. He thinks to prove this by sharing statistical research that fails to confirm a relationship between several postural-structural-biomechanical properties and (the occurrence of) lower back pain. While questioning the relationship between lower back pain and trunk asymmetries, low muscle strength, lumbar lordosis, disc degeneration, short (tight) hamstrings and psoas muscles he emphasizes the importance of what he refers to as the “biological reserve” (stress-resistance or adaptability as I prefer calling it).

The death of Socrates – to stimulate “grey thinking” and reduce a limited view of pain, dysfunction and injury I advice my students to study not only anatomy, neurology and physiology but philosophy also.

To my surprise nearly all inquired colleagues – most of which look at their clients especially through a pair of PSB model glasses – regarded Lederman’s opinion simply as wrong or avoided discussing it all together. One often heard argument opposing Lederman’s ideas was, “I’ve applied the PSB model with success, which proves it does work therefore proving Lederman wrong.” Although understandable, this explanation doesn’t make much sense when thinking of the many influences (known and unknown) we exert during our treatment and exercise sessions and all that follows (known and unknown) in reaction to them. We can never say, beyond a doubt, what it is that makes our clients feel better. Unsettling as it might be, even the most knowledgeable therapists among us can merely make an educated guess, no more.

Only one colleague had the brightness of mind to imply that Lederman’s point of view was a righteous one. He argued that questioning the validity (or for that matter the existence) of one single, strongly distinct and fenced approach to all pain problems, and lower back pain in specific, was justified. There is after all far more to consider than only the postural-structural-biomechanical (postural, structural and biomechanical) variables of our clients suffering (lower back) pain. He concluded, “The PSB model is just a single approach to physical complaints, one of many.”

What struck me as odd is that of all inquired colleagues merely one thought to think of the complexity of (lower back) pain, all the possibly involved factors (known and unknown) and the possible solutions and/or remedies (known and unknown). Surely he could not be the only therapist realizing that no client is alike, pain comes in many different shapes and forms, is influenced by many internal and external factors and might therefore be approached from many different angles and eased in many different ways.

Although the reasons for the absence of an all encompassing answer from all my colleagues are likely manifold, I think I might have received more enlightening feedback if only Lederman would have reached a hand. Instead, he makes the same unfortunate mistake as those he tries to educate. By seemingly denying the possible use of the PSB model all together he displays a limited point of view equal to those who only work according to the very model he questions. I can’t help but think that his rather one-sided deliberation is probably not conducive to starting a useful discussion but instead shuts the door on exchanging thoughts. It would have been great if he’d have mentioned that, “although the PSB model might be effective at times – this despite the fact that certain statistics seem to prove otherwise – there is far more to consider, for example the biological reserve or stress-resistance of our clients”.

Be that as it may, I think the regrettable form in which Lederman shares his ideas does not excuse my colleagues from displaying an equally black and white train of thought – we should know better.

While I do not expect all of us to agree with every therapy philosophy, approach or technique I do feel we should at least acknowledge that there is more than we agree with, more than we know about, more than we (think we) understand and more than we are comfortable with. Just like stories, our clients and the pain they experience have many, many sides to them – as therapists maybe our thinking should be just as multifaceted.

By Lauran Neergaard, Associated Press.

WASHINGTON — Spine surgeon Anders Cohen puts a lot of stock in patients’ expectations of pain relief. He prefers to operate only on those who “grab you by the collar and say, `I can’t take it anymore.’”

New brain research proves doctors like Cohen are onto something: Pessimism can override the effectiveness of even powerful treatments. You’ve heard of the placebo effect, the healing power of positive belief. This is the “nocebo” effect, the flip side, almost its evil twin.

And while the self-fulfilling prophecy of negative thinking isn’t nearly as well studied, some scientists say it’s time for doctors to start paying a lot more attention to their patients’ outlook.

“We all know that many treatments work for some people but not for others,” says neuroscientist Dr. Randy Gollub of Massachusetts General Hospital. Instead of stressing only the percentages, “say, `I have every reason to believe that you could be one of the people who will respond.’”

Scientists already know the placebo effect is real. They can measure it in studies that compare real drugs to dummy pills, where those given the fakes have noticeable improvements to pain and other symptoms.

But could a gloomy outlook really harm? British and German researchers performed the most sophisticated study yet to tell. They strapped a heat-beaming device onto the legs of 22 healthy volunteers, zapping it until people rated their pain at nearly 70 on a scale of 1 to 100.

Then the researchers hooked up an IV to give them the powerful morphine-like painkiller remifentanil. Typically used for surgery patients, it works rapidly but also is metabolized rapidly, able to be switched on and off as researchers alternated between giving the drug or plain fluid.

The volunteers’ brains were scanned as they described how much pain, and pain relief, they experienced at different times. When the researchers induced the burn and surreptitiously turned on the drug, the volunteers said their pain improved a fair amount. The painkiller was working, expectations aside.

Here’s the mind over matter: The researchers next told the volunteers they were about to inject the painkiller even though they’d never turned it off. Those pain ratings dropped even more – meaning expectations of relief doubled the drug’s painkilling benefit.

Finally, the researchers lied again, saying they were stopping the drug and that pain would probably increase. Sure enough, the volunteers’ pain levels soared back up to almost their pre-treated level as grim expectations canceled out the effect of a proven and potent painkiller. Anxiety levels fluctuated similarly.

Why? The brain scans tell the tantalizing tale – showing changes in neural pain networks that prove the people really did experience the changes in pain that they reported.

Moreover, expecting more pain fired up sections of the brain that control mood and anxiety, the researchers recently reported in the journal Science Translational Medicine. In contrast, anticipating pain relief fired up different regions previously found active in people given placebos.

It’s a small study, dealing just with pain. But the results may apply to a range of drug therapies, especially in chronic diseases because so many of those patients are conditioned by months or years or frustrating treatment failures, concluded lead researcher Dr. Ulrike Bingel of Hamburg’s University Medical Center, who teamed with Oxford University researchers for the study.

Learning how anxiety influences pain is crucial to understanding this nocebo effect – how you get the pain you expect, said co-author and Oxford neuroscientist Irene Tracey, in a recent review of the science of expectations in the journal Nature Medicine.

It’s by no means a novel concept. Previous research has found people given a dummy pill can experience the side effects of the medication they thought they were getting.

While there’s a lot yet to learn, for now doctors should at least try building closer relationships with their patients to encourage trust in recommended treatments, said Mass General’s Gollub.

“Building these strong, positive expectations for doing well are part of what comes from believing in your treater as someone who cares about you,” she said.

Directly managing patients’ expectations – spelling out exactly what will happen at different points to take away some of the fear – also can help, said Cohen, chief of spine surgery at Brooklyn Hospital Center in New York. He teaches new doctors not to promise surgery patients they’ll wake up free from pain because – while the old back pain may be fading – they’re going to hurt from the operation.

When someone says, “`Wow, it’s just like he told it was going to be, this guy told me the truth,’ now you’ve got this bond of confidence,” Cohen said. “You’re partnering with your patient.”

UFC veteran Todd Duffee took his DREAM interim heavyweight championship fight with Alistair Overeem on short notice, but he was sent home with even less warning.

Duffee charged across the ring at the opening bell, but Overeem stood firm in the face of the charge and set up his striking attack. After a few missed punches from Duffee, Overeem delivered a stunning right hand to the temple and a knockout left hook to the chin that saw his opponent fall through the ropes on the way to the canvas.

The whole process took just 14 seconds.

With the win, Overeem (34-11) wraps up a stellar 2010 in which he defended the Strikeforce heavyweight title, claimed the K-1 World Grand Prix title and now the DREAM interim heavyweight championship. Meanwhile, Duffee (6-2), while certainly to be commended for taking on such a tall order, is now winless in his past two outings.

Source: MMA Junkie

Strikeforce heavyweight champion Alistair “Demolition Man” Overeem has his kickboxing crown at last.

Overeem won the K-1 World Grand Prix 2010 today in Japan by winning three fights in increasingly rapid fashion. The victory makes Overeem the first man to hold titles simultaneously for major promotions in mixed martial arts and kickboxing.

His hardest fight was the quarterfinal opener against heavy underdog Tyrone Spong. The first round saw Spong deliver several hard shots to the body, but he couldn’t sustain the pace. Overeem took over in the second round, and forced the referee to deliver a standing eight-count to Spong in the third.

Overeem’s last two bouts ended quickly.

He put away Golden Glory teammate Gokhan Saki in 2:33 by breaking his right elbow with a kick to advance to the final.

In the other semifinal bout, 40-year-old Peter Aerts scored an upset by winning a majority decision over defending champion Semmy Schilt, who was hoping to win a record fifth title.

But Aerts had little left for Overeem, who overwhelmed him from the start with punches and kicks from varied angles. The referee halted the bout as Aerts reeled on the ropes just 1:07 into the fight.

The conclusion of K-1′s annual event could free up Overeem to compete in Strikeforce in the first half of next year. The U.S. mixed martial arts promotion wants him to face its top heavyweights, including Fabricio Werdum, Fedor Emelianenko and Antonio “Bigfoot” Silva.

Overeem’s pursuit of a kickboxing title for the last few years has resulted in only sporadic appearances in mixed martial arts. A victory in May over Brett Rogers has been Overeem’s only Strikeforce title defense since winning the belt more than three years ago.

Source: USAToday

For the past several months Erik has been helping Strikeforce Heavyweight Champion Alistair Overeem, one of the MMA fighters he works with, prepare for the K-1 World Grand Prix Final in Seoul. You can see Alistair receive treatment and workout in “Episode 6: Trainings Camp”.

Episode 6: Training camp from THE REEM on Vimeo.

In 2007 Abu-Hijleh, M. F. and Harris, P. F. published a paper on the deep fascia of the distal leg, ankle and dorsal foot. Dissecting 14 limbs they examined arrangement, fiber orientation and collagen content.

Among other findings they list the following.

The deep fascia of the distal leg, ankle and dorsal foot forms a continuous sheet containing thickened bands or retinacula. It is anchored to the subcutaneous surface, the tibia and fibula (both malleoli), the tarsal and metatarsal bones.

The Superior Extensor Retinaculum (SER) seems variable in width and thickness. A clearly defined band as generally illustrated is not found. The observed thin bands, possibly representing the SER, run from the tibia to the fibula, crossing the anterior compartment of the distal leg.

Instead of the familiar Y shape the Inferior Extensor Retinaculum (IER) is observed to have an X shape (9 out of 14) or is formed by a central thick node-like band (5 out of 14). Based on dissection findings Abu-Hijleh suggests a physical connection between the IER and the spring ligament.

Several additional bands are consistently found.

The Extensor Digitorum Brevis Retinaculum (EDBR), a band crossing the belly of the muscle connecting with the IER and fascia over the abductor digiti minimi.

The Proximal Extensor Hallucis Retinaculum (PEHR), a band crossing the distal tendons of the extensor hallucis longus and brevis and the distal tibialis anterior attachment (specifics are not given) at the tarsal/metatarsal level. This band connects with the abductor hallucis (its fascia) and the (dorsal) interosseous fascia of the foot.

The Distal Extensor Hallucis Retinaculum (DEHR), a band crossing the distal tendons of the extensor hallucis longus and brevis at the distal metatarsal level. This band also connects with the abductor hallucis (its fascia), the (dorsal) interosseous fascia of the foot and the DLPF.

The Disto-Lateral Pedal Fascia (DLPF), a band crossing the distal tendons of the extensor digitorum longus and brevis at a distal metatarsal level. This band connects with the abductor digiti minimi (its fascia), the (dorsal) interosseous fascia of the foot and the DEHR.

Malleolar Fascia (MF), oblique transverse bands on the tibial and fibular sides, crossing over the malleoli. Both bands connect with the SER.

In regard to collagen fiber disposition, using polarized light a “crisscrossing or woven mesh pattern” is observed. This pattern is observed in all specimens from the distal lower leg to the dorsum of the foot. Histological sections show collagen fibers with elongated nuclei and confirm the “crisscrossing or woven mesh pattern”.

From Theory to Practice
Based on Abu-Hijleh’s research we can opt to consider the individual thickened bands (retinacula) and fiber orientation when treating the deep fascia of the distal lower leg, ankle, dorsum of the foot and its related organs.

Because of the PEHR and DEHR, abductor hallucis, extensor hallucis longus connections we can, for example, consider the abductor hallucis when addressing a flexor hallucis related problem. And the “crisscrossing or woven mesh pattern” might require us to “aim” our therapy and exercises in more than a single direction.

For more details and first hand details please read:
Abu-Hijleh MF, Harris PF. Deep fascia on the dorsum of the ankle and foot: extensor retinacula revisited. Clin Anat. 2007 Mar;20(2):186-95.

Our colleague Camiel is on tour with the Street Legends. Led by soccer superstar Edgar Davids the Legends travels from Holland to South Africa. On their way from Amsterdam to Capetown they challenge the best street soccer teams. You can follow them on Street Soccer Tour Channel.