The Revolutionary Bone that No One Talks About

It was a beautiful sunny day, not too hot with a nice cool breeze. As I jogged along the trail that passes through the meadow by my house, taking in the thousands of bright blue chicory flowers, I reflected on how lucky I am to live in such a beautiful place, to have a healthy body…. OUCH!

My knee was bugging me again, as it sometimes does when I’ve been running a lot without much cross training. Not that long ago I may have endured it, knowing that I would do some manual therapy or soft tissue work when I got home to try and coax my body back into a better alignment. Maybe I would have checked out my running form-making sure my core was engaged, and that my cadence was just right.

But today I know more. Thanks to the postural restoration institute, or PRI for short, I have such a deeper understanding of how so many things affect our movement and anatomy. I knew that the best thing I could do was just be more aware of the left side of the trail as it whizzed past. As I did that, my knee instantly felt much better.

Wait whaaaat??? Yup. Seriously. I simply became more aware of my left peripheral vision, which made my knee feel better.

Little disclaimer here…this is not to say that everyone who goes running will instantly be painfree by looking to the left, everyone has unique needs and nuances.

That said… it is a good idea to be aware of your peripheral vision when running and in general…more on that later.

But WHY??? Why would what I’m doing with my eyes affect my knee pain?

It’s all because of this special bone at the center of our head called the sphenoid.

Before we get into what this could possibly have to do with my knee, we should first ask ourselves…

Why Is the Sphenoid Bone So Special?

Here are just a few reasons…

The sphenoid bone attaches to our jaw, our eyes, and our ears.
The nerves that tell us to rest or digest or fight or flee or freeze pass through this bone.
The main arteries that supply blood flow to your brain pass through this bone.
The position of this bone determines the amount of pressure on your brainstem, which contains the apparatus to help your body organize movement.
The pituitary gland, which performs life-sustaining functions, nestles nicely into a tiny protective saddle in the sphenoid bone.

I could keep going, but I think you get the point. This bone is responsible for a lot of important stuff!

Even just a tiny tweak in the position of the sphenoid could cause all sorts of repurcussions, many of which seem completely unrelated.

What Might Tweak a Sphenoid’s Position?

The way your teeth touch matters big time to your sphenoid.
- The sphenoid interacts with your top and bottom teeth via muscles and nerve endings, but even the bony position of your jaw and maxilla (the bone that holds your top teeth) push against the sphenoid in certain ways. Not to mention, the periodontal ligament is HIGHLY sensitive to pressure and gives you lots of reference as to where you are in space. This neural information is then processed by your BRAINSTEM (remember that guy?) And what’s between your teeth and your brainstem? The sphenoid.
- Have you ever had dental work done and had the position of your tooth end up just a little higher or lower? If you have, you know it. Your body knows it. Everything feels off, you can’t relax until that tooth is back to where you like it! That’s the sensitivity of the periodontal ligament and the sphenoid position at play.
Head injuries and concussions.
- I don’t think I really need to explain why a blow to the head can affect sphenoid position and surrounding function. But what most people don’t realize is that you don’t have to hit your head to get a concussion. Whiplash, blast exposure, falls, all these things can result in jostling the contents of the skull.
How you use your eyes.
- Remember, the muscles that move your eyes around attach to your sphenoid. If you use your eyes the same way most of the time (like staring at a screen, for example), this can pull on the sphenoid.
The neck.
- The poor head is at the whim of what the neck is doing. And the neck is at the whim of what the body is doing underneath it! Think of a house that is built on clay. When first built, everything is nice and level. But then, after a big rainstorm, different parts of the clay expand at different rates due to the moisture, and the foundation starts to shift and become unlevel. Of course everything above the foundation will also become unlevel. Similarly, if your body is imbalanced below your sphenoid, you will likely also have imbalance above.

Of course there are other situations where certain visual or dental changes (surgical or otherwise) can affect how you hold your body below, because, unlike a house, the body’s roof (the cranium) has just as much of an effect of where the foundation (rest of the body) sits due to all the sensory input we get from our head telling us where we are in space.

Don’t believe me? try standing on one foot. Got it? Good. Now try doing that with your eyes closed. Little harder? That’s because you’re getting information about where you are relative to the ground from your eyes, not just your feet.

Also, I have to say that if you had a head injury or dental work or vision work, this does not doom you to a life of a crooked sphenoid! It can certainly have an effect, but in most people it is manageable with the right program of manual therapy and movement techniques.

So back to my knee. Why did being aware of my left visual field help my knee?

At a purely structural level, there is some effect of letting my eye position change to pull on my sphenoid in a different way.

On a deeper, subtler, neurological level, being aware of the left does several powerful things.

Firstly, it reminds my body to become centered instead of pulling to the right, which I do (and most people do) because of our anatomy and the way our brains are wired. This is especially important for me since I have had a head injury which included broken facial bones.

Secondly, it opens up my left peripheral vision, which creates a sense of expansiveness in my body, thus allowing the sphenoid and surrounding bones to spread and widen. This takes pressure off of all those neural and vascular structures, and lets my body relax out of a state of tension.

When our bodies are held in a tense and protective state, we can’t rotate well through our torso. A side to side alternating activity like running absolutely requires the ability to rotate. If you can’t rotate at your trunk, your body will do it somewhere else. For me, it was my knee.

As soon as I let my left visual field soften and open, my body got a signal (or many signals, rather) to reposition itself into a more optimal position, subconsciously. I could rotate better, breathe better, and didn’t need to put any extra torque on my knee.

Well, I know this is a pretty heady conversation (get it? Heady? Skull? Ok I know, too punny) but it is one worth having.

Because sometimes you do all the right things and still aren’t feeling better or where you want to be with your sport, your breathing, your health, or your ability to do the things you want to do.

When that’s happening, it’s time to look at what’s happening from the neck up to determine if something there could be inhibiting your progress.

Here’s a simple but powerful technique to try that will help with restoring sphenoid position.

April 21, 2020April 22, 2020

Whiplash, Pain, and the Brain.

Earlier this week it snowed a lot. Then it melted, and froze overnight. And when I took my dog out for her morning walk, well, you can probably guess what happened. I didn’t make it 20 feet from my door before my feet slid out from under me on a patch of ice and I landed hard on my butt, with my head being painfully snapped back. I was, of course, a little stunned and went back to my house to survey the damage. No broken bones, just some bruises. Over the next few days I monitored myself for signs of concussion, which , thankfully, there were none, but what I did have was a painful stiffness and ache in my neck when I tried to move my head. “Oh great,” I thought. Whiplash.

When I first walked into my house after slipping on the ice, these were the thoughts in my head, “oh no, you have a delicate neck. This is going to be so bad. You are going to be dealing with this for months. What if you have another concussion? That’s going to really mess you up…” and on and on.

Luckily, I had the knowledge and training to know that these thoughts would be the most significant factor in my speed and completeness of my recovery. Even though it was hard, I started to change my self talk. I said to myself, “this is not that bad. You’ll get over it soon with a couple days for your strained muscles to heal. You didn’t hit your head, and there are no signs that anything is seriously wrong. You’re going to be ok.”

At first, I didn’t believe these words I told myself, but I kept up with it. And, over the course of the day, I started believing a little bit of it. But more importantly, my body felt less tense and guarded. Now, three days later, my neck pain is almost completely gone. I didn’t have to go to a chiropractor or have needles stuck in my neck. I didn’t have to do any special exercises except some breathing to calm my nervous system. I didn’t even have to change my daily activities and still did what I would usually do, including exercise.

Of course, it’s not always that easy, and it has not always been the case for me to get over neck pain that quickly. I have had many neck injuries of varying severity, and the pain of them has plagued me for many years of my life. I tried everything, acupuncture, chiropractic, and of course several physical therapists. Those all helped, but my neck pain never really went away until I changed the way I thought about my pain. I know, I know, it sounds like I’m saying, “it’s all in your head.” Which is just not true. But, it is true that a lot of it is in how your head and your body talk to each other.

Pain and the Brain

You see, the brain determines levels of threat, and sends signals to our body on what to do accordingly. When your brain perceives high threat, it starts emitting neurotransmitters that tell your body to tense, to breathe more shallowly, and halt healing processes.

This is actually really good. For example, let’s say you’re a wild human and you get attacked by a tiger. You find yourself bleeding and injured, and your brain knows that it needs to get your muscles tensed and ready to go so that you can hoof it back to your village before you die in the middle of the prairie. (Do tiger’s even live on prairies? Anyway, you get the idea). Your brain, in that moment, is not worried about healing. Healing occurs when you get back to the village and your wounds can be tended, you are safe.

But what if you never get to the village? What if the stress of getting attacked by a tiger is replaced with the stress and worry that’s associated with chronic neck pain, the fear that you will never get better, the threat of having to deal with a stiff neck on top of all the other things you are having to deal with in your life right now?

In this scenario, your body never gets a signal to relax, to soften your tensed muscles, to release a cascade of neurochemical transmitters that promote healing. You become caught in a troublesome feedback loop: your muscles get’s tense, which causes your brain to percieve threat. As a result of that percieved threat, your body get’s more tense. And on and on, until you find yourself dealing with months to years of pain with no one able to explain to you why it won’t go away.

Getting out of the Cycle of Pain

I have been there, in that loop. I have a tendency to go back there, maybe it’s just how I’m wired. I have to actively, consciously, change the way I think about my body and pain in order to subvert that loop. And it works. I also use relaxation techniques and mindfulness meditation practices to assist me in this process. But what has been so fascinating to me is that this is the missing link in healing from chronic pain, and, perhaps more importantly, preventing it in the first place.

This is not news to the medical community; there have been plenty of studies linking a patient’s outlook on recovery to how well they actually recover. This mind body connection is starting to become more popular in pain management, but in most cases it is not emphasized or even acknowledged in our healthcare system. Certainly, there are appropriate times to seek invasive modalities or even surgery, but shouldn’t we start with an intervention that is very low risk and potentially very high reward in regards to resolution of symptoms?

I have created some resources to help you manage your pain and to prevent yourself from developing chronic pain syndromes. It starts with being able to sense and feel your body, in a non-threatening way. This will allow your brain and body to get out of the cycle of threat and pain and back into fluid, alternating, reciprocating motion.

Getting Back in Your Body

A great place to start getting back in your body is with this simple 5 minute Guided Body Awareness Technique. (You should try it, it’s really relaxing!)

Five Minute Body Awareness Exercise.

Remember, pain is not just in your body, and it’s not just in your brain. Whoever says that mind and body are two separate things is just wrong. You can’t treat one and not the other and expect to change the patterns that we live in. If you find yourself in chronic pain, be kind and gentle with yourself. Reconnecting with the sensations in your body is the first step to letting go of these stuck patterns.

May you find ease in your body.

– Dr. Derya

January 6, 2020February 18, 2020

Am I still dealing with My Concussion?

When we think of a concussion, we often think about football players or someone who has taken a blow to the head. While this is where a lot of concussions happen, many more happen in ways that are less talked about. Whiplash, such as from a car accident, can cause a concussion as the brain strikes forcefully against the skull and shears neurons that descend from the brain. In the same way, a fall can cause a concussion – even without a blow to the head, especially in older adults.

Who Gets Concussions?

Concussions can occur in older adults who slip or fall (even without hitting their head!), children, athletes at all competitive levels, military personnel who sustain blast injuries, adults who slip on the ice getting into their car…etc. Basically, anyone can get a concussion.

What is a Concussion?

A concussion is a trauma to the brain significant enough to cause a brief change in mental status or consciousness. Recovery for a concussion has a natural healing time of 4-6 weeks. That means that unless you have signs that you will need rehab immediately, often the best course of action to take during that time is resting appropriately under observation of medical provider.

That said, in my experience there is a lot of confusion about what appropriate rest means, and furthermore what is appropriate is unique to each individual. Too much rest is not helpful, and too little is certainly not helpful, and either of those could be harmful or delay recovery. So please, if you or someone you know has had a concussion (or you even suspect they had one) get clarity on what “rest” means from a provider who is well versed in concussion rehab.

Symptoms of a concussion can be vague and are different for each person. Many people never end up seeking care or are misdiagnosed. Catching a concussion early is very important because the research supports that early intervention results in much better outcomes.

Early Symptoms of Concussion

Headache
Neck Pain
Mood changes
Fatigue
Sleepiness
Nausea
Dizziness
Difficulty Sleeping
Sensitivity to light/sound
Double/blurred vision
Confusion
Balance deficits
Focus/memory deficits

Post-Concussion Syndrome

Many patients, especially those who were not diagnosed or did not receive rehab or proper guidance early on, end up with long lasting symptoms that they just accept as “part of their life now.”

Once it has been 3 months since the original injury, these patients technically no longer have a concussion, but rather post-concussion syndrome, which indicates chronic symptoms. However, patients often don’t realize that these symptoms are still treatable and are not something that they have to live with!

So why do symptoms persist for so long with post-concussion syndrome? The body and brain find ways for you to keep doing what you have to, by compensating for deficits rather than addressing root causes. For example, when you have a deficit in the part of your nervous system that tells your brain where your body is in space, you compensate by relying on vision for balance. This works okay for a while, but dizziness occurs when your vision is over stimulated, such as when you are trying to look around while hiking, or are in a visually stimulating space such as the grocery store, or when you can’t access your vision well, like in a dark movie theater.

Symptoms of post-concussion syndrome

Dizziness
persistent headaches and/or neck pain
reduced tolerance to lights/sounds
feeling unsteady, especially when walking or in busy environments
fatigue
a sense of fogginess or feeling “not quite right.”

What can be done to help?

When a person experiences dizziness or balance deficits, the affected systems need to be trained with specific exercises at optimal dosages. Over time, these treatment strategies reduce your symptoms by teaching your body to move away from compensation and strengthen the parts of your system that have become weakened.

As I mentioned before with rest, knowing exactly how much to do and when is key for achieving recovery. Doing too much can overwhelm your system, whereas not doing enough will not result in any gains. That’s why working with someone trained in concussion rehab is essential for you to continue to improve without exacerbating your symptoms.

Longer-term Symptoms of Untreated Concussion:

Loss of libido
Low blood pressure
Loss of mensturation
Fatigue
Muscle weakness
Growth problems (children)
Weight gain
Early dementia
Chronic headaches/dizziness

Long term symptoms of concussion can affect multiple systems of the body.

What to do if you experience a concussion:

Decrease your screen time.
- Try to spend less time looking at a computer screen, phone, or i-pad.
Allow yourself rest.
- After a concussion, most people feel the need to sleep more than usual. This allows the brain to heal. Give yourself permission to spend extra time sleeping.
Continue to engage in light aerobic exercise.
- While vigorous physical exertion may worsen symptoms and delay healing, light aerobic activity can help you heal faster. If you are not sure how much to exert yourself safely, a physical therapist can perform an exertion test to determine how you respond and give you guidelines for how to exercise on your own.
Listen to your symptoms.
- Stimulating environments and even changes in head position can provoke symptoms. If you notice triggers like these, allow yourself to experience mild symptoms but avoid situations that cause symptoms to become severe.

Important Note: Depression and anxiety are one of the most common symptoms following concussion. In 90% of cases these symptoms resolve with time. However, in some cases these symptoms can be more severe or persistent, especially if there is a history of depression or anxiety, or presence of stressful life events. Many patients benefit from more in depth care in this arena, such as meeting with a psychotherapist in addition to physical therapy to achieve full recovery.

Dr Derya Anderson has extensive experience working with patients who have had a concussion. She also has attended continuing education courses (below) that are specific to concussion management:

May 2019 Stress, Movement and Pain. Speaker: Seth Oberst, PT, DPT

July 2018. Concussion: Vestibular System Abnormalities and Ocular Motor Examination. Taught by Susan L. Whitney, DPT, PhD, NCS, ATC, FAPTA

March 2018. Concussion Basics. Assessment, Screening and Risk Factors. Taught by: Anne Mucha, PT, DPT, MS, NCS and Susan Whitney, DPT, PhD, NCS, ATC, FAPTA

March 2018. Clinical Subtypes Following Concussion: A conceptual Framework for Evaluating and Managing Concussion. Taught by: Anne Mucha, PT, DPT, MS, NCS and Susan Whitney, DPT, PhD, NCS, ATC, FAPTA

October 2017 Vestibular Dysfunction- An algorithmic based Evaluation and Treatment. Speaker: Barry Morgan, PT

March 2017 Innovative Approach to the Management of the Cervical Spine: Maximizing Outcomes in Fewer Visits. Speakers: Jeff Ryg, PT, DPT, OCS, FAAOMPT. Kristen Carpenter, PT, DPT, OCS, FAAOMPT

November 2015 Orthopedic and Neurologic Perspectives on Concussion/Mild Traumatic Brain Injury Management. Speakers: Wendy Kriekels, PT, DPT, NCS, David A. James, PT, DPT, OCS, SCS, CSCS, Michael R. Greher, Ph.D., ABPP-CN, Katherine S. Dahab, MD, CAQSM, FAAP

Nov 2015 APTA SIG Event: The Role of Physical Therapy in Concussion Care. Speaker: Ann McNamara, PT, MPT, CCCE

November 6, 2019August 29, 2021

The Posture Myth: Why Straighter is not Better

Most of us remember being told to “sit up straight!” or “shoulders back, chin up!” as a child or maybe more so as a teen. While this advice was given with the best intentions, it may not have been that helpful. Don’t get me wrong, I’m not advocating the slumped computer posture with shoulders rounded and head poking forward.

This is certainly not a biomechanically sound posture and can lead to all sorts of dysfunction and pain. In an effort to avoid this unsightly slump, we may find ourselves in a position I call “reverse slumping.” This is the tendency to pull the front lower ribs up and push the chest forward. While this may look more upright, it is an overcorrection, and can be more problematic than helpful.

The Problem

So what’s wrong with a lifted chest and elevated front lower ribs? The problems that arise are largely due to how we breathe, and the important relationship between the ribcage and the pelvis. The Postural Restoration Institute has defined the relationship between the breath and function. Below is my meager take on their extensive understanding of the topic. For more information check out https://www.posturalrestoration.com/.

1. Poor oxygenation. If our front lower ribs are “flared” up and out, the mid-upper back is essentially closed off and becomes flat. This causes many problems, one of which is poor oxygenation. The human body is designed to breathe into the back mid and lower ribs, not just the front. These back middle and lower regions of the lungs have the largest area of lung tissue, and the highest blood flow to lung tissue ratio. This means that this area is very important for getting oxygen from your lungs to the rest of your body. When this is closed off (by pushing front ribs up) we are forced to breathe shallowly into our front upper chest, which may recruit neck muscles to help inhale and result in increased neck tension (among other issues). Further, it is harder to get air out because the chest is in a hyper-inflated state. This means less new, oxygen-full air in. Theoretically, if you improve the expansion of your mid back, you will use oxygen more efficiently and fatigue less quickly with sport and daily living.

2. Altered neck and shoulder mechanics. The spine is not meant to be straight, rather it has natural curves that allow a springy quality for shock absorption. When the front ribs are pushed up, the upper back spine becomes flat. This destabilizes the shoulders, as the shoulderblades are designed to function on an egg-shaped surface, not a flat one. As a result, the muscles that manage the shoulderblade cannot function optimally, thereby changing the mechanics of the shoulder in an adverse way. Many of the muscles that attach to the shoulderblades also attach to the neck spine and can create increased tension in the neck area if they are not functioning well.

The muscles that attach to your shoulderblades, back, and neck can become strained and painful with poor posture.

A flat upper back also burdens the point where the upper back spine meets the neck spine. The neck spine is naturally curved and is designed to follow the curve of the upper back. However, if the upper back is now flat, the spring-like shock absorbing factor is lost. Furthermore, the juncture from upper back spine to neck spine becomes vulnerable due to a sharp corner instead of a nice smooth curve between the vertebrae. This can create pain and sensations of tension in this area.

3. Increased stress levels. When we are stressed, that really means our body is entering a “fight or flight” state, which means that there is some imminent threat, and we need to either fight or get away. Blood is shunted away from the core and immune function and digestion are halted as the body prepares to fight or flee. This threat could be anything from being chased by a mountain lion to a steady drip of small daily stressors, like traffic, aches and pains, worrying about money, etc. Our body simply does not distinguish what the cause of the stress is, the same pathways and neurotransmitters are stimulated in the case of a lion attack or spilled coffee. The “fight or flight state” has its purpose, however it is not healthy to remain in this state for prolonged periods of time.

The part of our nervous system that promotes our “rest and digest” state is governed by the vagus nerve which passes from the brain to the abdomen through the ribcage. This state allows the body to be calm and relaxed, allowing for sleep, healing, and digestion. When we are in this state, our breathing is full and deep, with the diaphragm moving through its full range of motion.(1) This is the state that we should be in most of the time.

So what does this have to do with posture? Well, if we push the front ribs up and close off the back of the ribcage, the sympathetic ganglia (the nerves that promote a “fight or flight” state and live along the upper back spine) become overly stimulated due to compression. Furthermore, with the front ribs elevated, the body is in a constant state of shallow inhales and exhales, which is correlated with higher stress levels and promotes release of stress hormones in the body.(2) What’s really amazing about our bodies is that this system works both ways. That is, just as the state of our nervous system causes our breathing patterns to change, we can similarly alter our nervous system by modifying the way we breathe.

4. Poor recruitment of deep abdominals, especially upon inhale. Even if you have six pack abs, that doesn’t necessarily mean you are using the abdominals in the way they are meant to be used. Deep to the well known “six pack” of the abdominals are deeper muscles that create a cylinder around the center of the body. These are breathing muscles. They attach to the lower rim of the ribcage and the upper rim of the pelvis. They create stability and order within the body as well as reduce pressure on the lower back spine and associated nerves. They allow us to be both stable and mobile when they function correctly.

When the front ribs are excessively elevated, the front of the pelvis is often tipped forward as a counterbalance. This places the deep abdominal muscles in the front of your body in a state of excessive length. Our muscles do not function very well (or hardly at all) from their most lengthened state. It’s like trying to pick up a heavy bag of groceries with your arm totally straight instead of slightly bent. It just doesn’t work as well.

A deep stabilizing muscle, called the transversus abdominus, helps us maintain neutral posture.

So then what is good posture?

Essentially, your rib cage should be egg shaped, and sit atop your level pelvis. The spine should be lengthened while maintaining its natural curves. In sitting, you can achieve this by:

Sit in a firm chair with your feet flat, knees and hips at 90 degrees.
Feel your sit bones (the boney protrusions at the base of your pelvis). You may need to lean forward and back a few times to find where you feel them most. When you are most aware of your sit bones pressing into the seat, this indicates that your pelvis is level. It may feel like your pelvis is slightly “rolled under.”
With a long, relaxed exhale breath through your mouth, allow your front lower ribs to drop down slightly. Pause a few seconds at the bottom of the exhale. There should be a sense of your front lower ribs coming down to the front top rim of your pelvis.
Maintain this position as you imagine your lower back ribs expanding with each inhale, and your lower front ribs moving down and back towards your spine with each exhale. Hint: pausing after your exhales for 3 seconds will make it easier to feel back ribs expanding.
Below is a video on finding a neutral sitting posture.

And there you are! If you are used to pushing your chest up, it probably feels like you are slouching when you come into a correct posture. To assure yourself that you are still sitting straight, you can use a mirror to see that you are indeed not slouching. If you can see yourself from the side in the mirror you may also notice that now you have a little more expansion in your lower back ribs. Good job!

References:

1. Russo MA, Santarelli DM, O’Rourke D. The physiological effects of slow breathing in the healthy human. Breathe (Sheff). 2017;13(4):298-309.
2. Hirotsu C, Tufik S, Andersen ML. Interactions between sleep, stress, and metabolism: From physiological to pathological conditions. Sleep Sci. 2015;8(3):143-52.
3. Tenney, R., KL Boyle, A DeBord. Influence of Hamstring and Abdominal Muscle Activation on a Positive Ober’s Test in People with Lumbopelvic Pain H. Posturalrestoration.com. Accessed January 26, 2019.