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How Heated Stones Massage Can Help Muscular Pain

Thu, 18 Dec 2025 15:16:33 GMT

The use of heated volcanic basalt stones with massage is an ancient technique rooted in centuries-old healing traditions from the Far East that has been used for over 10000 years (2). At the Leagrave Therapy Clinic, heated stones massage involve using the combination of heat and calming power of touch to create a restorative experience for the body and mind. The therapist applies massage via heated, smooth volcanic basalt stones on the body, the stones are warmed to a comfortable hot temperature that is tolerable for the client to avoid burns and used by the therapist in conjunction with traditional massage techniques.

Six Reasons for A Heated Stones Massage

A question regularly asked is how does heat help whilst massaging? The heated stones help to sooth and provide a a deep soft tissue massage into taught muscles which aids to accelerate the relaxation of tight muscles and tendons, improve circulation and reduce stress. The warmth with massage can offer:

1.) Muscle tension relief and pain
2.) Reduce stress and anxiety: massage is known to help lower cortisol levels and increase endorphin levels, your 'feel good hormones' thus help stress by increasing serotonin which helps regulate mood and sleep (1). Heat has a calming effect on the nervous system and prompts blood pressure, heart rate, and breathing to slow down which can help contribute to the feeling of relaxation and the dulling of brain activity that heat brings to the body (1).
3.) Boost circulation by improving blood flow and help deliver oxygen nutrients: increased blood flow brings fresh oxygen, nutrients and lymph to distressed tissues and cleanses the body through the increased removal of toxins and in this way, heat can helps restore tissue strength and health (1).
4.) Increased flow of blood and lymph to the area of application: heating the surface of the skin can increase the ability of the immune cells to destroy germs (1).5.) Improve sleep quality by providing deep relaxation.
6.) Massage stimulates a series of local biochemical reactions in the body, which increase the neural activity in the spinal cord which has an effect on the perception of pain and fatigue (2).

How It Works

The heat of the stones and their solidarity help muscles to relax and for therapists to apply deeper, more precise pressure if desired with their hands or with stones.
The heat contained in the rocks can help relax nerves and may improve chakra flow if placed on chakra centre’s on the body (3). Different techniques used with the warm stones include effleurage, petrissage and frictions over trigger points which are areas of tension on muscles that have persistent, recurring or continued intermittent pain caused by injury, tension or lack of muscle stretching which can thus cause tension or illness (3).
The warm basalt stones are placed on the tense areas to produce warmth on the muscle and can assist manual work. Clinically, many clients report to prefer the use of warm stones or massage implements as they find the process less painful and the massage techniques can help specific points of pain.

Reference

1. Jones and Bartlett Learning https://samples.jblearning.com/9781284223026/9781284286786_CH02_Marketing_Sample.pdf [online] Last visited 18/05/2025.
2. Ramova, E. L. P. (2021) Volcanic Stone Massage and Its Benefits, South Asian Research Journal of Applied Medical Sciences, 3; 5: 1-3.
3. The Wiltshire School of Beauty and Holistic Therapy Diploma in Stone Therapy Massage Training Manual, https://www.wsbht.co.uk/wp-content/uploads/2012/10/Stone-Therapy-manual-Guild4.pdf [Online] Last visited 18/05/2025.

Sports Massage for Sciatica

Wed, 03 Dec 2025 20:51:55 GMT

How Sports Massage Can Help With Sciatic-Related Pain

Sports massage is moe than just relaxation, it uses targeted techniques to address muscle tension, improve circulation, and reduce nerve irritation. For conditions involving the sciatic nerve, heel pain, plantar fascia stress, and hamstring tightness, sports massage can play a supportive role in treatment and recovery.

1. Sports Massage Can Reduce Muscle Tension Around the Sciatic Nerve

The sciatic nerve often becomes irritated when surrounding muscles are excessively tight. The piriformis, gluteals (buttock muscles) and hamstrings are key culprits. Sports massage can:

Relieve tension in these muscle groups and thus reduce pressure on the nerve.
Improve tissue pliability, allowing freer movement and reducing “trapped nerve” sensations.

2. Sports Massage Can Help with Heel Pain and Plantar Fasciitis

When sciatica causes referred pain into the heel or contributes to plantar fascia strain sports massage can help by:

Mobilising the calf muscles (gastrocnemius and soleus), which often shorten and increase strain on the fascia.
Improving blood circulation in the lower leg and foot, supporting tissue healing.
Breaking down adhesions and scar tissue in the fascia itself, if plantar fasciitis is present.

3. Sports Massage Can Relieve Hamstring Strain and Stiffness

Chronic sciatic irritation can leave the hamstrings feeling persistently tight or painful. Sports massage techniques such as deep tissue strokes, deep trigger point release, and myofascial work can:

Reduce protective spasms in the hamstrings.
Restore flexibility and joint range of motion.
Enhance recovery when used alongside stretching and strengthening exercises.

Hamstring Pain and Muscle Tension

The hamstrings lie directly along the sciatic nerve’s pathway at the back of the thigh and attach from the pelvis to the inner knee. Chronic sciatic irritation can cause hamstring tension, protective spasms or chronic pains that feel like a muscle injury. Over time, the body may respond to nerve irritation with increased muscle tension in surrounding regions such as the glutes, hamstrings, calves, and even intrinsic foot muscles creating a cycle of discomfort. This explains why sciatica often feels like an overwhelming combination of muscular and nerve pain rather than a single, isolated problem as the whole leg and foot and the lower back can be painful all at the same time.

Why This Connection Matters

Recognising the role of the sciatic nerve in heel and hamstring pain is essential for accurate diagnosis and effective treatment. Approaches such as nerve mobilisations, targeted stretching, strengthening exercises, postural correction and medical interventions (where necessary) can address the root cause rather than just the symptoms. Left untreated, sciatic irritation can be prolonged, perpetuate chronic pain, limit mobility within the spine and lower limbs and place unnecessary strain on the musculoskeletal system.

4. Promoting Nervous System Relaxation

Massage doesn’t just affect muscles, it also influences the nervous system. By calming overactive pain signals and promoting parasympathetic activity, sports massage may:

Reduce the perception of pain.
Encourage muscle and joint relaxation in the entire lower limb.
Provide relief by 'breaking the cycle' of nerve irritation which leads to muscle guarding and in turn worsens discomfort.

Summary

Sports massage should be viewed as part of a holistic approach rather than a stand-alone cure. When combined with corrective exercise, posture work, physiotherapy or medical care where needed, massage can accelerate recovery, reduce pain and restore joint and muscular function.

References

Hopayian, K., Song, F. Riera., R., Sambandan, S. (2010) The clinical features of the piriformis syndrome: a systematic review, European Spine Journal, 19; 12: 2095–2109.
Riddle, D. L., Pulisic, M., Pidcoe, P., Johnson, R. E. (2003) Risk factors for plantar fasciitis: a matched case-control study, Journal of Bone and Joint Surgery, 85; 5: 872–877.
Stafford, M. A., Peng, P., & Hill, D. A. (2007) Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management, British Journal of Anaesthesia, 99; 4: 461–473.
Tarulli, A. W., & Raynor, E. M. (2007) Lumbosacral radiculopathy, Neurologic Clinics, 25; 2: 387–405.

The Impact of Spine Misalignment

Wed, 11 Jun 2025 11:59:38 GMT

How Spinal Alignment Impacts Other Joints Within the Body

Spinal alignment is a fundamental aspect of human health and movement, the spine provides structural support for the body and its significance includes:

The housing of the central nervous system.
Facilitates movement and balances mechanical forces throughout the musculoskeletal system.

When the spine is optimally aligned, it supports efficient posture, movement and organ function. A compromised spinal alignment can cause a cascade of mechanical and functional issues that can affect joints not only within the back, but also joints such as the shoulders, elbows, hips, knees, and ankles. The alignment of the spine is thus a cornerstone of overall physical well-being.

 The Spine as a Central Axis

The spine functions as the central axis of the body, connecting the skull to the pelvis and facilitating communication between the brain and the rest of the body via the spinal cord. A properly aligned spine maintains the natural curves; cervical (neck), thoracic (mid-back), lumbar (lower back), and sacral all of which distribute body weight and absorb shock. These curves are designed to support efficient biomechanical motion and reduce stress on associated muscles, ligaments, and joints.

When these natural curves are disrupted, due to poor posture, injury, repetitive stress, or structural deformities, a compensatory patterns begin to emerge. These patterns often extend beyond the spine itself, placing undue stress on peripheral joints listed below.

Shoulder and Elbow Dysfunction

Spinal misalignment, particularly in the cervical and thoracic regions, can directly influence shoulder and elbow mechanics. For example, forward head posture and rounded shoulders, common in individuals who spend long hours sitting behind screens and computer use, commonly alter the alignment of the upper spine. This change can affect the scapula’s position and movement, leading to shoulder impingement, rotator cuff injuries, or tendinitis.

Moreover, if the thoracic spine is excessively curved (kyphosis), the range of motion in the shoulders becomes restricted. This can force the muscles and ligaments of the upper limbs to overcompensate, which in turn may cause overuse injuries in the elbows. Even conditions like tennis elbow can sometimes be traced back to improper spinal posture affecting arm mechanics.

Impact on the Hips, Knees, and Ankles

Spinal alignment also influences the pelvis and lower limbs. Misalignment may include a pelvis that may tilt anteriorly (forwards) or posteriorly (backwards) which can lead to an imbalance in leg length or altered gait mechanics. This has a direct impact on the hips and knees. For instance, excessive lumbar lordosis (curvature of the lower back) can tilt the pelvis forward which may tighten hip flexor muscles and put strain on the knees. Misalignment in the hips often transfers abnormal forces down the kinetic chain, affecting knee tracking and leading to conditions such as patellofemoral pain syndrome (PFPS) or iliotibial (IT) band syndrome.

Similarly, spinal misalignment can alter weight distribution in the feet, leading to improper foot strike and ankle instability. Over time, this may result in plantar fasciitis, achilles tendon issues, or even frequent ankle sprains. Since the human body moves as an integrated unit, any dysfunction at the top of the chain (spine) will invariably affect the structures below.

The Neurological Connection

Beyond mechanical implications, spinal alignment is important for neurological health as the spinal cord runs through the vertebral column and branches out into nerves that control all voluntary and involuntary functions. Misalignment can cause compression or irritation of spinal nerves, leading to radiating pain, numbness, or weakness in the limbs. This neurological component underscores the importance of spinal health not only in terms of movement, but also sensation and coordination.

Postural Screen Assessment

At the Leagrave Therapy Clinic, assessment may involve performing a postural screen, as can be seen above, to help both the practitioner and client understand the postural positioning of the body. The screening may also help both to understand whether the client favours weight bearing on one lower limb more than the other or, likewise, whether the spine or pelvis favours side bending or rotating to one direction more than the other. This simple analysis can then determine whether these compensations are causing the client's presenting problem.

Thus, spinal alignment is not merely a matter of posture, it is a key determinant of full-body health and function. The spine’s alignment affects the mechanical efficiency and neurological integrity of the entire musculoskeletal system. Shoulder, elbow, hip, knee, and ankle issues often originate from or are exacerbated by poor spinal posture and alignment. Therefore, maintaining spinal health through practices such as proper ergonomics, physical therapy, core strengthening, and regular movement is essential. A healthy spine sets the foundation for a body that moves well, feels strong, and avoid injury.

Dry Needling

Sat, 17 May 2025 19:23:33 GMT

How Dry Needling (Medical Acupuncture) Can Help For Neck and Back Pain

Dry needling (DN) is growing to become a popular intervention used in clinical practice for the management of myofascial trigger points (MTrPs) and treating conditions related to mechanical neck and back pain (1). The treatment method involves a thin acupuncture needle that penetrates through the skin, subcutaneous tissue and muscles (5). The puncture technique causes local muscle tremors which aims to relax the treated area and encourage the reduction of local tension and pain (5).

DN is developed along the theory of Myofascial trigger points (MTrPs) and differs to conventional acupuncture or traditional Chinese medicine which otherwise involves placing acupunctures needles that relate to the meridians. DN involves a minimally invasive procedure consisting of inserting a high quality, sterile and disposable needle into a myofascial trigger point (MTrP) without injecting or extracting any substances.

What Are Trigger Points?
A myofascial (muscle tissue) trigger point (MTrP) is defined as a hyper irritable area within the skeletal muscle which has become hypersensitive. They are palpable nodules located in a taut band of muscle fibres and the area is painful when subjected to mechanical deformation through either compression, stretching, muscle contraction or other related stimuli (2). Trigger points produce pain locally in a referred pattern and often accompany chronic musculoskeletal disorders (2).

DN & Chronic Neck Pain

Herna ́ndez-Secoru ́n et al., (2023) supported the conclusion that dry needling (DN) can improve pain and functional capacity in patients with chronic neck pain at short and mid-term intervals. According to the study's findings, DN showed to be more effective when compared with other therapies including stretching, manual therpy, myofascial release and TENS with ultrasound in both men and women (4). The study found that patients over 40 years old benefitted more than those below 40 years of age (4).

DN & Lower Back Pain

A study by Rajfur et al., (2022)assessed the effectiveness of dry needling for reducing pain intensity and improving functional efficiency in patients with chronic lower back pain due to the L5-S1 discopathy. They found that dry needling effectively reduced pain and improved range of motion of local joints in patients with chronic lower back pain (5). Hu et al., (2018) found evidence to reveal that DN is more effective for alleviating pain intensity and functional disability at post intervention in lower back pain (3).

References

1. Aleid, A. M., Aljabr, A. A., Aldanyowi, S. N., AlAidarous, H. A., Aleid, Z. M., Alharthi, A. S., Alsubaie, M. N., AlOraini, L. I., Almoslem, A. R., (2025) Mutair, A. A. (2025) Dry Needling for Mechanical Neck Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials , Surgical Neurology International (SNI), 16; 44: 1-8.

2. Alvarez, D. J., Rockwell, P. G., (2002) Trigger Points: Diagnosis and Management , American Family Physician, 65; 4: 653-660.

3. Hu, H. T., Gao, H., Ma, R-J., Zhao, X-F., Tian, H-F. Li, L. (2018) Is dry needling effective for low back pain? A systematic review and PRISMA-compliant meta-analysisMedicine, 97; 26: 1-10.

4. Hernandez-Secorun, M., Abenia-Benedı ́, H., Borrella-Andre ́s, S., Marque ́s-Garc ́ıa, I., Lucha-Lo ́pez, M. O., Herrero, P., Iguacel, I., Trica ́s-Moreno, J. M., Hidalgo-Garcı ́a, C. (2023) Effectiveness of Dry Needling in Improving Pain and Function in Comparison with Other Techniques in Patients with Chronic Neck Pain: A Systematic Review and Meta-Analysis , Pain Research Management, 1-14.

5. Rajfur, R., Rajfur, R., Kosowski, T., Walewicz, K., Dymarek, R., Ptaszkowski, K., Taradaj, J. (2022) The effectiveness of dry needling in patients with chronic low back pain: a prospective, randomized, single‑blinded study , Scientific Reports, Nature Portfolio, 12; 15803: 1-11.

Dry Cupping Therapy

Thu, 08 May 2025 12:24:17 GMT

This is a subtitle for your new post

Dry cupping is also known as 'wind cupping' via sucking the skin and massaging a tight muscular area without removing blood or cutting the body's skin and thus differs to 'wet cupping' (3). Dry cupping is good for people who are afraid of needles and blood as the therapist does not make any incisions of the skin (3).

Cupping is an ancient massage technique and was arguably first performed and invented by the the ancient Egyptians. The Ebers Papyrus, also known as an Egyptian medical papyrus of herbal medicine was written in c. 1550 BC and is one of the oldest medical textbooks in the Western world (1). The ancient scripture describes the Egyptians using cupping and mentions similar practicing employed by Saharan Peoples. In ancient Greece, Hippocrates (c. 400 BC) used cupping for internal disease and structural problems (1).

in old text books of Traditional Chinese Medicine (TCM) from over 1000 years ago. Dry cupping by fire is a classic cupping technique called 'ba guan zi', which involves placing the cup over the 'anashi' or a painful area or acupuncture point along an energy meridian (1, 3).

Dry cupping is the only form of cupping performed at the Leagrave Therapy clinic and performed by suctioning oxygen out of a glass cup via fire (also known as Bilnaar). The glass is placed at a certain tight muscular area.

What Does It Do?

Dry cupping is considered a complementary or alternative medicine (CAM) in Western Medicine (4). It is believed that dry cupping can enhance blood flow and alleviate pain intensity caused via blood stasis which can improve physical function. The high negative pressure created during cupping can accelerate blood and lymph flow, heighten oxygen and metabolism within local tissues, reduce inflammation and toxic substances (4).

Overall, cupping therapy aims to loosen tight connective tissue or the fascia that covers muscle and stimulate local blood flow to the skin's surface which stimulates tissue relaxation and improves cell-to-cell communication (1).

Does It Work?

Lower Back Pain
A recent study by Zhang et al., (2024) found that cupping is effective for reducing pain along with sensory and emotional pain. For lower back pain, the effectiveness of cupping was related to differing classifications of LBP and the location of cupping performed. The study found evidence to suggest that cupping therapy reduced functional disability immediately improved sensory and emotional pain which sustained after 24 hours and up to 2 weeks post-intervention.
Overall, their study found that cupping surpassed medication and usual primary care in reducing pain (Zhang).

Neck Pain
This study by Kim et al., (2018) performed a literature review in non-Asian and Asian databases including places whereby cupping is popular and widely used such as Korea, China and Japan. Similarly to the above study, they found cupping therapy found clinics to find a significant reduction in pain. joint function and quality of life.
The effectiveness, however, is related to factors such as cupping technique intensity, location, technique use and duration which affected the level of the study's evidence. Overall, the study concluded that cupping can be a 'potentially effective and safe therapy for neck pain'.

References:

Jadhav, D. K. (2018) Cupping Therapy: An Ancient Alternative Medicine. J Phy Fit Treatment & Sports; 3; 1: 555601. DOI: 10.19080/JPFMTS.2018.03.555601.
Kim, S., Lee, S-H., Kim, M-R., Kim, E-J., Hwang, D-S., Lee, J., Shin, J-S., Ha, I-H., Lee, Y. J. (2018) Is cupping therapy effective in patients with neck pain? A systematic review and meta-analysis, BMJ Open, 8: 1-13.
Tanjung, Q. F., Ishadi, H. (2022) The Medical Perspective of Dry Cupping and Wet Cupping: Effects and mechanisms of action. Journal of Society Medicine, 1; 1: 31-35. DOI Link ( https://doi.org/10.25217/ji.vxix.xx )
Zhang, Z., Pasapula, M., Wang, Z., Edwards, K., Norrish, A. (2024) The Effectiveness of Cupping Therapy on Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Control Trials , Compelementary Therapies in Medicine, 80; 103013: 1-13.

Video Demonstration:

Degenerative Disc Disease

Thu, 03 Oct 2024 17:02:56 GMT

Pathology, Cause and Management

Intervertebral Disc

Function

The intervertebral disc makes up one fourth of the spinal column and can be described as pads of fibrocartilage-based structures found between the vertebral bodies within the spine (Donnally and Hanna, 2023). They connect the vertebrae and provide spinal mobility during particular movements whilst flexing forward and rotating the spine (Alomari et al., 2009). They provide support, flexibility and minor load-sharing (Donnally and Hanna, 2023). Vertebral discs act as a shock absorber between vertebrae and help mechanical stresses to be transmitted throughout the spine during movement from the lower limbs all the way up into the neck and skull (Alomari et al., 2009).

Disc Anatomy

The intervertebral disc is composed of two parts; an outer strong ring called the annulus fibrosus that surrounds a soft gel-like inner substance called the nucleus pulposus consisting of 80% to 85% water in normal/ non pathological cases.

Degenerative Disc Disease

Degenerative disc disease (DDD) is not a disease but a condition within the intervertebral disc.

Most intervertebral disc degenerations are asymptomatic with that patients can have the problem diagnosed (from scans) but not experience pain. This can make it difficult for physical therapy practitioners to diagnose and manage without the relevant medical imaging e.g. Magnetic Resonance Imaging (MRI).

Back pain symptoms related to intervertebral disc degeneration are caused by pathological changes with mainly being disc desiccation or a 'drying out' of the water content within a disc. The condition causes the following:

Fibrosis; a thickening or scarring of tissue.
Disc narrowing causing a reduction of disc height and/ or width.
Can cause the annulus to bulge, fissure or undergo degeneration.
Arthritis within the vertebrae.

Can This Create Nerve Irritation?
Progression can cause the disc to bulge and create pressure and irritation to neighbouring spinal nerves. This can lead to individuals experiencing tingling (paraethesia) into the limbs of the body such as the arms and fingers for if the region is affecting areas of the neck or buttock, thigh or toes for if occurring within the lower back. Recent studies have shown that atrophy and muscle weakening can gives rise to disc degeneration and cause pain and instability within the spine. The ageing process for degenerative disc disease can cause mobility issues and a reduced spinal shock-absorbing capability. Research has found disc degeneration and lumbar multifidus muscle atrophy to be commonly correlated, particularly at spinal disc levels L3-L4 (Cosmic et al., 2019).

Possible Causes

In most cases, disc desiccation happens from ageing. Other reasons include:

Trauma such as accidents
Sudden weight loss
Hereditary cause

Diagnosis
Intervertebral discs at some certain segmental levels undergo more degeneration than others which implies that mechanical stress plays a role in disc degeneration (8). The occurrence of dessicated or dried up discs mostly appear within the lower back or lumbar discs, in particular the lower three to four discs i.e. between L3-L4, L4-L5, L5-S1 and S1 (2).

However, any part of the spine can develop disc degeneration (11). As Griffith et al., (2007) highlight, Magnetic Resonance Imaging (MRI) is the most widely used method for assessing intervertebral disc degeneration. Based on proton density, water content, and chemical environment, an MRI depicts disc hydration and morphology (6).

How Serious Is It? Will I Need Surgery?
Within most cases, the majority of individuals diagnosed with the condition will not require surgery. Surgical intervention should be reserved for those with either neurological deficits, degenerative spondylolisthesis, or pain limiting daily functions (4) . Operative intervention of the lumbar spine include discectomy with fusion, total disc replacement or by immobilisation of the affected vertebrae (4). Surgery is offered only to one in every 2000 back pain episodes in the UK; the incidence of surgical treatment is five times higher in the USA (12).

Treatment

Therapies are designed to reduce pain and treatments are mainly conservative and palliative ranging from analgesia, corticosteroid injections, local anaesthetic and manipulation therapies all with the main aim of returning patients to work (13).

Physical therapy aim to strengthen neighbouring muscles around the affected joints before 'hands on' Spinal Manipulation Therapy (SMT)' can be considered as a treatment option, patients will need to be screened for possible serious pathology.

Osteopathy

Various physical therapy modalities might be applied. Osteopathic treatment may include gentle hands on joint mobility and articulation treatment techniques of the spine and surrounding tissues. The of use of hands on stretching and gentle joint motion mobilisation techniques might be applied along with exercise programs and electrical stimulation therapy such as interferential therapy, remedial massage techniques and modified lifestyle advise e.g. related to weight loss and smoking cessation.

Dynamic Lumbar Stabilization Program (DLSP)

Kessler et al., (2021) use of Dynamic Lumbar Stabilisation Program (DLSP) which aims to re-educate individuals' spinal posture. If observed and corrected early enough, reducing a lordotic lumbar curvature and neutralising the spine can improve body mechanics during every day living activities which can help slow down or lessen the degenerative process. According to their study, this has a high success rate (by up to 92-96%) with patients being able to return to work pain free. It also helps strengthen and retrain the deep multifidus muscle within the lumbar spine which helps spinal stability during movement and is associated with chronic lower back pain for if weak or atrophied (8).

The study by Faur et al., (2019) found that the percentage of lumbar multifidus muscle atrophy is particulalry higher within the lower spinal levels L5 and S1. They concluded a low correlation and significant association between the grade of lumbar disc degeneration and the degree of lumbar multifidus muscle fatty atrophy. They discovered a higher fatty atrophy score in women and a greater incidence of disc degeneration in men (4).

Exercise Prescription

Exercises aims to improve the coordination between the abdominal and back muscles. Motion and strength training will help increase the strength and stability of muscles within the pelvic floor and for those that support the spine and pelvis. Stabilisation exercises increase the body's capacity to resist higher loads in the degenerative discs and reduce injury as muscular tissue reduces at a rate of 1 kg per year after the age of 40 and replaced by fatty tissue (1).

Training exercises performed one to three times per week reduces pain and should be continued once pain has subsided and patients are able to return to their jobs/hobbies or activities and are able to cease the use of analgesics (5). The Williams method involves stretching the back extensor muscles and strengthening abdominal muscles to relieve pressure placed on the lumbar intervertebral discs (5).

References

1. Alomari, R., Corso, J. J., Chaudhary, V. Dhillon, G. (2009) Dessiccation Diagnosis in Lumbar Discs From Clinical MRI with a Probabilistic Model, Research Gate, https://www.researchgate.net/publication/221624161_Desiccation_Diagnosis_in_Lumbar_Discs_from_Clinic... [online].

2. Brzuszkiewicz-Kuzmicka, G., Szczegielniak, J., Baczkowicz. (2018) Age related changes in shock absorption capacity of the human spinal colum n, 13: 987-993.

3. Donnally, C. J., Hanna, A., Varacallo, M. (2023) Lumbar Degenerative Disk Disease , StatPearls Publishing LLC [Online], Last visited 12/01/2024.

4. Faur, C., Patrascu, J. M., Haragus, H., Anglitoiu, B. (2019) Correlation Between Multifidus Fatty Atrophy and Lumbar Disc Degeneration in Low Back Pain, BMC Musculoskeletal Disorders, 20; 414: 1-6.

5. Gąsiorowski, A., Zagórski. J. (2013) Strength training in the treatment of degeneration of lumbar section of vertebral column, Annals of Agricultural and Environmental Medicine, Vol 20; 2: 203–205.

6. Griffith, J. F., Wang, Y-X. J., Antonio, G. E., Choi, K. C., Yu, A., Abuja, A. T., Leung, P. C. (2007) Modified Pfirrmann Grading System for Lumbar Intervertebral Disc Degeneration , Spine, 32; 24: pp E708 –E712.

7. Hawkins, J. L., Denson, J. E., Miley, D. R., Durham, P. L. (2018) Nicotine Stimulates Expression of Proteins Implicated In Peripheral and Central Sensitisation, Neuroscience PMC, 290: 115-125.

8. Kessler, R., Haase, C. Dean, D. (2021) An Osteopathic Approach to Patients with Degenerative and Herniated Discs, The AAO Journal, 31; 2: 35-41.

9. Kos, N., Gradisnik, L., Velnar, R. (2019) A Brief Review of the Degenerative Intervertebral Disc Disease, 73; 6: 421-424.

10. Lee, B. H., Moon, S-H., Suk, K-S., Kim, H-S., Yang, J-H., Lee, H-M. (2020) Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review, Asian Spine, 14; 5: 682-693.

11. Medline Plus (2016) Medline Plus: Trusted Health Information for You, National Library of Medicine, Degenerative Disc Disease, [Online] https://medlineplus.gov/download/genetics/condition/intervertebral-disc-disease.pdf last visited 11/01/2024.

12. Meyer , F., Börm , W., Thomé , C. (2008) Degenerative Cervical Spinal Stenosis , 105 (20): 366–372.

13. Urban, J. P. G., Roberts, S. (2003) Degeneration of the Intervertebral Disc , Arthritis Res Ther, 5; 120.

14. Xin, J., Wang. Y., Zheng, Z., Wang, S., Na, S., Zhang, S. (2022) Treatment of Intervertebral Disc Degeneration, 14: 1271–1280.

15. Yanagishishita, M. (1993) Function of Proteoglycans in the Extracellular Matrix, 43; 6: 283-293.

Sacroiliac Joint and Lower Back Pain

Wed, 06 Dec 2023 01:00:00 GMT

Common Pain Presentations, Cause and Treatment Options

Pain felt near or around the the two dimples within the lower back might indicate sacroiliac joint (SIJ) related pain. Injuries to the sacroiliac joint can occur from various etiologies with most cases of SI joint injury caused via either repetitive microtrauma or acute trauma (11).
There are two sacroiliac joints in the body which are located between the iliac bones and the sacrum. They connect the spine to the hips and help provide a major role for support, stability and shock absorption during impact whilst walking and lifting.

SIJ pain is commonly an underappreciated but a common cause of chronic lower back pain (LBP) and pelvic girdle pain (PGP). Various different presentations of related pain can make a diagnosis challenging, but understanding the condition's anatomy, clinical presentation and methods for assessment is important to make an accurate diagnosis, determine the source of pain and increase the likelihood of optimising a successful and faster recovery (2).

Anatomy

The sacroiliac joint consists of articular surfaces; the sacrum and iliac bones (figure 2). The sacrum is a large triangular bone situated at the base of the vertebral column and comprises of five fused vertebrae wedged between the two iliac bones. Iliac nerves exit the foramen anteriorly and posteriorly (figure 2).

The primary purpose of the SIJ is to maintain stability which is achieved by the union of the iliac ridge surface which 'sits' on the depressed sacral surface (6). The joint's movement is also minimised via the dense ligamentous network and surrounding muscle attachments which guide movement and enhance the stability to the pelvic bones (6).

Interesting Biomechanics of the SIJt

Limited movement of the sacroiliac joint has been explained by the theory of form and force closure which establishes stability in the sacroiliac joint. A combination of the pelvic anatomy, ligamentous and muscular forces help 'lock' the joint and prevent movement.

Form Closure refers to stability provided by the overall structural boney shape of the sacroiliac joint with relation to the surrounding tissues such as the capsule and ligaments and is derived by the triangular shape of the sacrum which allows the bone to fit neatly between the innominates (or ilia) ‘like a keystone in a Roman arch’ (12).

The surrounding ligaments (namely the sacrotuberous and sacrospinalis) help aid stability and minimise shearing of the SI joint. Ageing increases joint friction and helps the formation of interlocking ridges. The roughening of joint surfaces help the joints to 'lock' better together (12). The theory indicates that some individual's SI joints are more naturally stable than others', as their overall shape helps withstand certain forces.

Force Closure

Refers to surrounding tissue structures that hold the SI joint together and include the muscles and ligaments that cross the area of the SI joint and the thoracolumbar fascia (a big sheet of connective tissue that supports the lower back).

Force closure also arises from the contraction of the ‘inner’ and ‘outer’ myofascial units, or ‘core’ muscles which help to stabilise the pelvis, lumbar spine and hip joints or ‘lumbo-pelvic-hip complex' (12). Force closure of the SI joints may reduce and suffer as a result of problems such as (12):

1. Muscle weakness or atrophy.

2. Inadequate recruitment of muscles during movement, which can also result in muscle weakness.

3. Uncoordinated contraction and relaxation of muscle systems, resulting in failure to provide adequate stability and a consistent control of motion (12).

Compensatory movement patterns that a patient might start to use can cause muscle imbalances and weakness. Impaired muscle tension and control can result to abnormal stresses on the musculoskeletal system and may lead to eventual overuse and further imbalance of certain muscle groups surrounding the lower back, buttocks and knees (12).

Overall, adequate combination of force and form closure helps provide stability and strength for the SI joint. It could be theorised that pain occurs when either one of these mechanisms might be disturbed (figure 3).

Presentation and Pain Patterns

Diagnosing and treating SIJ dysfunction can be challenging with its inconsistent presentation, however, the most consistent factor for identifying SIJ pain is unilateral pain below the fifth lumbar vertebra or 'L5' (6).

SIJ commonly presents with localised referred pain including (6):

· Lower buttock pain, which is as common as 94% of all cases (6).

· Lower lumbar region pain (72%).

· Lower extremity (50%)

· Leg pain

· Groin and inner thigh pain (14%)

· Hip pain

· Muscle spasms, with the most common muscle groups involving the hamstrings, hip flexors and quadriceps (6).

Symptoms can be described as dull and achy to sharp and stabbing sensations and aggravating factors may include all types of physical activity such as bending, climbing, lifting and rising from a chair or car (6).

Causes of SIJt Pain

Biomechanical Adaptations
As a protective mechanism, the brain will make the body compensate and adapt whilst we regularly perform our day-to-day bodily movements, such as walking and sitting, long after an initial injury to help avoid further injury. People who present themselves with sacroiliac joint pain often report that the pain came on gradually and that there was no memorable incident or 'sudden onset'.

Altered movements and compensations that lead to a gradual, slower increase in intensity of symptoms is otherwise termed as an "insidious onset" (1). This means that The biomechanical adaptations can lead to muscle imbalances by becoming either overactive and hypertonic or underactive and hypotonic which can lead to muscle group tightness and weakness.

Trauma
Sacroiliac joint pain can be as a result to acute trauma from activities such as heavy or prolonged lifting and bending, repetitive torsional (rotational) strain, a fall onto the buttocks or a rear-end motor vehicle accident.

Overuse
Chronic repetitive shear or torsional (rotational) forces may also result to sacroiliac joint dysfunction with participating in activities such as performing the golf swing, throwing sports such as baseball, tennis, bowling, constant sitting or lying on the affected side.

Other Causes
Injury to any of the surrounding structures of the SIJ can be a source of pain. Other causes may include (2):

Arthritis.
Spondyloarthropathies (e.g. ankylosing spondylitis (AS), reactive arthritis, psoriatic arthritis, and enteropathic arthritis (EnA)).
Ankylosing spondylitis (AS): an inflammatory rheumatic disease that involves the spine and SI joint and manifests as spondylitis and sacroiliitis (3).
Leg length discrepancy; anatomic leg length discrepancies should be determined as early in treatment as possible so that the appropriate modifications can be accomplished (11).
Lumbosacral transitional vertebrae (LSTV).
Gait and biomechanical abnormalities.
Persistent strain/ low grade trauma (e.g. jogging)
Scoliosis.
Pregnancy - one sided weight bearing, exaggerated lordotic posture, third-trimester hormone-induced ligamentous relaxation, pelvic trauma associated to parturition (2).
Spinal surgery.

Treatment Options

Overall, there is no gold standard for treatment, leaving clinicians to use their experience in making recommendations (11).

Acute Phase (1–3 Days)
Often, SIJ pain presents as a progressive problem with fluctuations in symptoms. Thus, acute injuries are often associated with a direct trauma such as a fall or increased frequency or intensity from performing a from a specific activity. The patient may experience symptoms only during certain activities, including sports or exercise.

During the acute phase , anti-inflammatory medications and icing are helpful. Relative rest after an acute injury assists with pain control. This includes restricting running or excessive walking, as these activities often provoke SIJ pain. Identifying the activity that may aggravate symptoms is important, especially in those with progressive onset of symptoms. In general, avoiding activities that require single leg stance activities such as bowling, skating, running, and stair-stepping would be helpful to alleviate symptoms. Correcting asymmetries in muscle length or stiffness should start as soon as possible and performed pain free.

How Might Osteopathy Help?
Hands-on treatment techniques including mobilisation of the SIJ can be quite helpful in restoring function along with articulation, manipulation or mobilisation of neighbouring joints; muscle energy and active release therapy (11). Treatment of patients with significant muscle weakness, poor endurance, or both may need to focus on stabilisation through strengthening of muscles. Special care should be taken with early treatment of the pregnant patient, as aggressive stretching or mobilization can further aggravate symptoms secondary to pregnancy-related joint hypermobility (11).

Recovery Phase (3 Days to 8 Weeks)
When pain levels are manageable, biomechanical deficits or studying compensatory movement patterns become the focus of rehabilitation to further understand tissue overload complexities. Muscles that are commonly found to be shortened (or tightened) include the front and inner thigh muscles (i.e. rectus femoris, tensor fascia lata, hip adductors), lower back, outer abdominal and deep buttock muscles (i.e. quadratus lumborum, piriformis, obturator internus, and latissimus dorsi).

Particular attention is given to the piriformis muscle's length, continued inflexibility of this muscle is often thought to be part of the source of recurrent pain. Muscles that are commonly found to be weakened with chronic sacroiliac joint pain include the gluteus medius, gluteus maximus, lower abdominals, and hamstrings. Exercise prescription from the manual therapist are given throughout the course of treatment to help reduce the muscle length or tension.

Sacroiliac Joint Belts can be used to provide compression and thereby proprioceptive feedback to the gluteal muscles. Vleeming et al6 reported that SIJ belts applied to cadaver models reduced SIJ rotation by 30%. Clinically, it makes sense that SIJ belts can be especially helpful in patients with SIJ hypermobility or significant muscle weakness. Care must be taken to insure that the patient is able to apply the belt appropriately. The SIJ belt should be secured posteriorly across the sacral base and anteriorly, inferior to the anterior superior iliac spines. Patients are usually instructed to wear the belt during walking and standing activities. However, patients with significant pain and weakness often find the belt helpful in reducing symptoms when worn during sedentary activities as well.

Orthotics and shoe modifications .
A shoe lift to correct a functional leg length discrepancy can be helpful during the acute stage to manage pain but should be approached with caution, as functional leg length discrepancy should be corrected with muscle rebalancing and not orthotic intervention (11). An inappropriate shoe lift can promote adaptive muscle imbalances, which may initially be asymptomatic but can cause problems later because of a shift in force transmission. Anatomic leg length discrepancies should be determined as early in treatment as possible so that the appropriate modifications can be accomplished.

Cortisone and Nerve Block Injections
Sacroiliac joint injections might be considered for if the patient’s progress plateaus or if the physical therapy program cannot be advanced because of pain provocation. Injections can also be used diagnostically if performed under fluoroscopic guidance (11).

Surgery Considerations and Fixation
Special consideration should be given to individuals with joint hypermobility. SIJ arthrodesis and percutaneous joint fixation has been used for instability (11).
However, long-term outcome studies suggest that it is unknown what happens to surrounding articulations such as the lumbar spine, contralateral SIJ, and hip long after an SIJ fusion.

References

1.) Clayton, P. (2016) Sacroiliac Joint Dysfunction and Piriformis Syndrome The Complete Guide for Physical Therapists, Lotus Publishing, Chichester England.

2.) Cohen, S. P., Chen, Y., Neufeld, N. J., (2013) Sacroiliac Joint Pain: A Comprehensive Review of Epidemiology, Diagnosis and Treatment, Expert Reviews Ltd, 13; 1: 99–116.

3.) Cohen, S., P. (2005) Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis and Treatment, Anesth Analg, 101: 1440-53.

4.) Gutke, A., Ostgaard, H. C., Oberg, B. (2006) Pelvic Girdle Pain and Lumbar Pain in Pregnancy: a Cohort Study of the Consequences in Terms of Health and Functioning. Spine 31(5), 149–155.

5.) Ha K, Lee J, Kim K (2008) Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion. Spine 33:1192–1198.

6.) Hamidi-Ravari, B., Tafazoli, S., Chen, H., Perret. (2014) Diagnosis and Current Treatments for Sacroiliac Joint Dysfunction: A Review, Current Physical Medical Rehabilitation, Springer Science and Business Media New York; 2: 48-54.

7.) Hansen, H. C., Helm, S. (2003) Sacroiliac Joint Pain and Dysfunction, Pain Physician; 6: 179-189.

8.) Ivanov AA, Kiapour A, Ebraheim NA, Goel V. Lumbar fusion leads to increases in angular motion and stress across sacroiliac joint: a ﬁnite element study. Spine 34(5), 162–169 (2009).

9.) Kibsgard, T. J., Rohrl, S. M., Rosie, O., Sturesson, B., Stuge, B. (2017) Movement of the sacroiliac joint during the Active Straight Leg Raise test in patients with long-lasting severe sacroiliac joint pain, Clinical Biomechanics; 47: 40-45.

10.) Ostgaard, H. C., Andersson, G. B., Karlsson, K. (1991) Prevalence of back pain in pregnancy. Spine, 16 (5), 549–552.

11.) Prather, H. (2003) Sacroiliac Joint Pain: Practical Management, Clinical Journal of Sport Medicine, Lippincott Williams & Wilkins, Inc., Philadelphia; 13: 252–255.

12.) Sahin, O., Harman, A., Akgun, R. C., Tuncay, I. C. (2012) An Intraarticular Sacroiliac Steroid Injection Under the Guidance of Computed Tomography for Relieving Sacroiliac Joint Pain: A Clinical Outcome Study with Two Years of Follow Up, Turk Rheumatol, 27; 3: 165-173.

13.) Schamberger, W. (2012) The Malignment Syndrome: Diagnosing and Treating A Common Cause of Acute and Chronic Pelvic, Leg and Back Pain, Churchill Livingstone Elsevier.

14.) Slipman, C. W., Sterenfeld, E. B., Chou, L. H., Herzog, R., Vrestilovic, E. (1998) The Predictive Value of Provocative Sacroiliac Joint Stress Maneuvers in the Diagnosis of Sacroiliac Joint Syndrome,

15.) Snijders, C. J., Hermans, P. F. G., Niesing, R., Spoor, C. W., Stoeckart, R. (2004) The Influence of Slouching and Lumbar Support on Iliolumbar Ligaments, Intervertebral Discs and Sacroiliac Joints, Clinical Biomechanics.

16.) Szadek, K. M., van der Wurff, P., van Tulder. M. W., Zuurmond, W. W., Perez. R. S. (2009) Diagnostic Validity of Criteria for Sacroiliac Joint Pain: a Systematic Review, The Journal of Pain, 10; 4: 354-368.

17.) Yoshihara, H. (2012) Sacroiliac Joint Pain After lumbar/ lumbosacral Fusion: Current Knowledge, Eur Spine J, Springer-Verlag, 21: 1788-1796.

Back Pain Vs The Office Desk

Sun, 25 Jun 2023 09:06:48 GMT

Working From Home & Sitting More?

Why It's Time To get Moving Again...

COVID has meant office workers are spending even more time in a seated position as reduced hours in the office has reduced commuting time. The combination of lockdowns and prolonged sitting has taken a toll on individuals to get motivated to get back in the gym or follow their weekly routined physical activity program and it's our job to get you motivated to stay active.

Here's Why...

It has been estimated that the modern day adult generally spends up to as much as 6 to 8 waking hours or 45-50% of our living day in a seated position (gasp!) (18).

Questions regularly asked questions from us therapists is 'how can our daily habit of staying seated at a desk for long periods affect our body posture and its function in the short and the long term?'

A short answer is; there is a growing causal relationship between prolonged sitting and lower back pain (LBP).

The Science...

A seated posture increases intra-discal pressure and stiffness within the lumbar spine (lower back), reduced strength of our lower back muscles along with a reduced metabolic exchange which can lead to excessive body weight (i.e. we put on weight) (16).

Prolonged Sitting and Lower Back Pain...

More studies are showing that occupations that involve prolonged sitting have a high incidence of LBP and it is not surprising that back and pelvic pain are the most common complaint among office workers.

Because musculoskeletal (MSK) pains related to occupations are common in society, they are also referred to as work related musculoskeletal disorders (WMSDs) . Sedentary work is defined as occasionally lifting no more than ten pounds, and sitting with occasional walking and standing. In occupational science, a static body posture is defined as a posture held for more than four seconds (15).

Various studies have investigated the effect of prolonged sitting, awkward posture and the repetitive motions that we put our bodies on a daily basis related to WMSDs(4). But, there remains various gaps unfilled when it comes to finding a universal solution of how to lessen our joint aches and pains after a day's work sitting in the office.

What Happens To Our Spine After Prolonged Sitting?

The link between back pain and prolonged sitting has been attributed to the required adoption of a flexed curvature of the lumbar (lower back) and thoracic (mid back) spines (6).

Body postural demands for seated tasks generally require an upright torso and a moderately flexed lumbosacral (LS) region. Whilst sitting performing deskwork, we tend to adopt a flexed lumbar posture which increases on average by approximately 5 degrees over the course of a working day (figure 1). This may result to ligament laxity via the discs narrowing from a loss of fluid content (2).

McGill and Brown (1992) found that residual creep-stretch within muscles and ligaments remains for a period of time after prolonged lumbar flexion whilst sitting or being in a slumped posture. This study’s main finding was that individuals who spend long periods of time sitting, especially in a slumped posture, and then suddenly go on to perform demanding heavy lifting activities within a short period of time after are at a greater risk of a hyperflexion injury to the disc and ligaments (21).

For example, if a lorry driver, gardener, courier or warehouse shipper/receiver should sit for long hours and all of a sudden requires the activity of unloading a truck full of cargo or heavy boxes, it is strongly recommended to stand, walk, stretch and warm up the lower back muscles first for a few minutes prior to performing demanding manual exertions to avoid unnecessary injury.

Sitting and Vertebral Column Creep - What Is That?

Creep is the progressive deformation of a structure within the vertebral column which has been under a constant load over time (26). Creep response in the vertebral column is thought to be caused by the gradual arrangement and increased stress placed on viscoelastic tissues which places a negative effect on collagen fibres, proteoglycans and the water content in the intervertebral discs, spinal ligaments and zygapophyseal joint capsules (26).

The load placing stress on an area within the vertebral column is usually below the level required to cause complete tissue failure. During creep, the segments are usually at their maximum limited range of movement and the spinal column (or segment) will continue to deform in the direction of load (26). Sitting for long periods with a poor posture over several years has its repercussions. A head protruded forward with a kyphotic upper back with rounded shoulders whilst typing or mousing at a desk will encourage both the neck and back to gradually be inclined to reside in this position during a standing posture.

If individuals sustain a flexed lumbar spine posture whilst performing deskwork, the passive flexion stiffness (PFS) of the lumbar spine can reduce over time because of viscoelastic creep or stress-relaxation in the posterior lumbar tissues (3). Increased intervertebral joint laxity with sustained flexion loading can attribute to fluid loss in the intervertebral discs. Reduced PFS can increase the risk of a hyperflexion injury during instances whereby prolonged sitting is followed by tasks that involve full lumbar flexion (3). Beach et al., (2004) concluded that it can only take up to one hour of sitting for PSF to occur and increase the risk of injury if full flexion movements are attempted after.

The amount of axial compression and flexion creep increases with age, but the amount of creep depends upon the magnitude and direction of load application. The vertebral column does and can recover when the load is removed but at different rates. It is no surprise that as we grow older, the rate of recovery is slower and tissues take more time to heal (25). The difference in the loading and unloading of segments in the vertebral column is known as ‘hysteresis” (25).

A small scale study conducted by Oliver and Twomey (1995) suggests that brief periods of sustained extension loading within the lumbar spine during occupational activities, such as painting ceilings or undesired standing postures can cause significant creep to the viscoelastic tissues.

In disc height loss, associated creep in severe cases can lead to altered morphology of the neural foramina where the nerves pass through the holes within vertebrae which can result to nerve impingement. This has been shown in an animal model to initiate pain with nerve root compression. More moderate cases of creep can still create strains in the passive tissues in the intervertebral joint such as the disc or articular capsule sufficient to generate pain from compressive loading.

The Importance of Staying Mobile Throughout Office Hours

The term 'if you don't use it, you lose it' applies here, as when we sit for long hours various muscle groups essentially weaken over time and this is clinically very evident during a physical examination.

The study by Snijeders et al., (1995) found that individuals use a small level of oblique abdominal muscle activity when subjects are seated or stood during a stooped posture, but had strong activity when sitting in extreme flexion. They found limited or no activity in the erector spinae, gluteus maximus (buttock) and biceps femoris (hamstring) muscles during erect postural sitting. The activity of the internal obliques was high whilst the external obliques showed moderate activity. In passive sitting on an office chair with a hard seat and a back rest all records showed little or no activity within these muscles, except the internal and external obliques. Reduced oblique abdominal muscle activity tends to occur whilst sitting on a soft car seat compared to sitting on a hard seat of an office chair (28).

Mid Back Mobility

Reduced thoracic mobility has been observed in individuals who spend more than 7 hours a day sitting and performing less than 150 minutes (2 ½ hours) of physical activity each week (17). This study found that there was a reduction of thoracic spine mobility by as much as 10% for individuals who sat for more than 7 hours per day and perform less than the recommended level of physical activity per week (2 ½ hours) (18).

Arm Rests

It is also interesting to note that studies have found arm rests on chairs to reduce the level of actitvity of upper trapezius and neck muscles. A study on dentists found significantly reduced right sided anterior deltoid activity (by 68%) with the use of fixed arm supports whilst they were compared to working without arm supports (4).

Visser et al. (2000) studied the effect of using arm supports in visual display unit work on physical workload. They reported significantly lower levels of upper trapezius muscle activation when typing with the use of arm supports compared to typing with no arm supports.

Good Sitting Posture

Upright sitting (i.e. neutral posture) is associated with high muscle activity, which during prolonged sitting has been associated with muscle fatigue and pain (18). Conversely, slumped kyphotic sitting has been associated with increased spinal load from the body tending to posteriorly tilt the pelvis which is then counterbalanced by excessive contractions of the dorsal spinal muscles (17). Slumped sitting has also been associated with greater head/neck flexion, anterior translation of the head and increased cervical erector spinae muscle activity in comparison with upright sitting (8).

The Effect of Posture Whilst Sitting & Standing

Studies have shown that our bodies respond differently when we are sitting relaxed e.g. at home watching television to sitting at a desk at work and concluded that spinal loading whilst working in a sitting position is higher than spinal loading in a relaxed sitting posture (18, 19).

Patients with chronic lower back pain have been found to demonstrate poorer postural control of the lumbar spine than healthy individuals along with a pelvic asymmetry which creates further changes to soft tissue tightness (1).

During standing, research has shown that compressive loads on the lower back is minimal, however, prolonged static standing has been associated to the reporting of lower back pain and disc height loss (15).

Certain jobs such as cashiers, bank tellers and casino dealers spend a majority of their workday standing. These roles tend to lead the worker adopting awkward postures, reduced trunk motion and increased repetitive upper extremity tasks (15).

What Chair Suits Who?

Springer (2010) has a rather modern approach with how seating should be with relation to spinal biomechanics by fundamentally asking future ergonomic seating arrangements to consider ‘what should a chair do?’

1.) Support a person’s body as an individual - As explained above, accepting that we all have different body types, shapes and sizes, the design of a chair needs to accommodate the range of individuals who will be using it.

2.) Support activity – When considering task seating, what people do, how they do it and for how long are essential pieces of information. Chairs should support all the activities in which people engage, not just one primary activity.

3.) Promote movement – A chair should promote movement and encourage the natural movements of the body as it provides support. Movement should not require conscious effort. Chairs should move with the user, and make it easy to move (13).

4.) Enable performance – An ergonomic office chair should facilitate, support and enable effective performance.

5.) Be easy to use – adjustments made must be simple and easy to use. Experience shows that the majority of people do not want to have to think about their chair when they are trying to work or activate a control to change its positioning and these controls are seldom used (24).

6.) Do no harm – A chair should not allow for discomfort, stress, pain or injury and should not constrain postures or force positions.

Posture in the field of dentistry has been greatly explored as they are more prone to musculoskeletal (MSK) diseases especially within the cervical and lumbar spines (15). Dental nurses and dentists are a type of health care profession that require a high skill job in awkward sitting positions during clinical activity such as bending their head anteriorly and laterally repetitively over long periods (28).

Various seats have been compared and analysed to find out which is the optimum chair to sit on for long periods whilst we work. There is evidence that the “ideal” ergonomic 90˚ sitting posture (knee angle and hip angle) actually increases the passive tension of hamstring muscles, causing a posterior pelvic rotation and resulting in a kyphotic sitting posture of the lumbar spine.

However, ergonomic recommendations, radiographic studies, and analyses from physical therapist and laypersons indicate that a sitting posture with a slight anterior tilt of the pelvis and lumbar lordosis may reduce the incidence of low back pain most efficiently.

The saddle stool (Figure 2) has been studied amongst the field of dentistry and has conflicting conclusions drawn for its effects on the spine. A study by Gadge and Innes (2007) found that the saddle seat was associated with significantly less lumbar discomfort but associated with more hip/buttock discomfort.

Da Silva et al. (2017) found that a saddle seat seems to promote a healthy posture, regarding maintenance of lumbar lordosis which is otherwise associated with lower disc pressure and suggested that it instead provided less physical workload to the arms and trunk during dental work. The literature does not yet provide a consensus on whether the saddle seat is a superior alternative to the conventional seat for maintaining optimal posture. In the context of the activities undertaken within this study, the standard stool has the least preferable combination of posture and muscle activity. It could be predicted that this type of seating will result in greater risk of lower back symptom reporting amongst dentists.

De Bruyne et al., (2016) compared the effect of using three different stool types on muscle activity and lumbar posture among dentists during certain dental screening tasks and discovered that individuals tended to sit with less lumbar flexion (-6°) than on a standard A-DEC DOCTOR’S STOOL (4°) or Ghopec (1°) stool. Findings also included the Ghopec stool tending to facilitate a less flexed lumbar position compared to the saddle stool which seemed to result in a hyperlordotic posture (9). Another interesting observation was that the presence of a backrest helped reduce the activation of the abdominal muscles and the study concluded that to recommend neutral posture, the Ghopec stool was considered the most suitable of the 3 stools that they investigated.

Another study by Grooten et al., (2013) found that the pelvis tends to be held in a posteriorly tilted position whilst seated on an office chair. They also concluded that the pelvis is in more of an anterior tilted position whilst standing and sitting compared to stable and unstable sitting on a Back App Stool or whilst seated on a saddle stool (16).

Annetts et al., (2012) investigated the effect of four different office chairs (saddle, vari-kneeler, swopper and standard) on the postural angles of the neck and lumbar-pelvic regions. They discovered that no chair seemed to consistently produce an ideal posture across all regions of the spine and they concluded that individuals' needs should be made priority when it comes to chair selection.

As a conclusion, the biomechanics of sitting mainly focuses on measuring the position of the spine, pelvis, muscle contractions, pressure distributions and boney contact on the seat currently being used. In general, there is no universal, ‘correct’ posture or no one “right way” to sit as each individual is different with individual heights, body type and shapes (26). Modern ergonomic research should take different body types into consideration and the nature of working behaviours that people adopt whilst sitting (whilst at work) (29).

How Might Osteopathy Help?

Primary focus when patients arrive are placed on posture and overall spinal health, particularly within the neck and upper mid back. Treatment may involve soft tissue and gentle osteopathic joint mobility techniques applied to the sternum, chest, mid back and neck. Breathing techniques and realistic home exercise programs are commonly prescribed with the idea of helping circulation within tired postural muscles.

References

1.) Akkarakittichoke, N., Janwantanakul, P. (2017) Seat Pressure Distribution Characteristics During 1 Hour Sitting In Office Workers With and Without Chronic Low Back Pain, Safety and Health at Work, OSHRI; 8: 212-219.

2.) Annettes. S., Coales, P., Colville, R., Mistry, D., Moles, K., Thomas, B., van Deursen, R. (2012) A Pilot Investigation into the Effects of Different Office Chairs on Spinal Angles, Eur Spine J, Springer, 21: 165-170.

3.) Beach, T.A., Parkinson, R.J., Stothart, J.P., Callaghan, J.P. (2005. Effects of prolonged sitting on the passive flexion stiffness of the in vivo lumbar spine. Spine J. 5, 145–154.

4.) Bolderman, F. W., Bos-Huizer2, J. J. A., Hoozemans, M. J. M. (2017) The Effect of Arm Activity, Posture, and Discomfort in the Neck and Shoulder in Microscopic Dentistry: Results of a Pilot Study, IISE Transactions on Occupational Ergonomics and Human Factors, 5: 92 – 105.

5.) Chaiklieng, S., Suggaravesiri, P. (2015) Ergonomics Risk and Neck Shoulder Back Pain Among Dental Professionals, Procedia Manufacturing, Elsevier; 3: 4900 – 4905.

6.) Callaghan, J.P., Dunk, N.M. (2002) Examination of the flexion relaxation phenomenon in erector spinae muscles during short duration slumped sitting. Clin. Biomech. 17, 353–360

https://www.clinbiomech.com/article/S0268-0033(02)00023-2/pdf

7.) Caneiro, J. O’Sullivan, P., Burnett, A., Barach, A., O’Neil, D., Tveit, O., Olafsdottir, K. (2010) The Influence of Different Sitting Postures on Head/Neck Posture and Muscle Activity, Manual Therapy, 15; 1: 54-60.

8.) Dankaerts, W., O’Sullivan, P., Burnett, A., Straker, L. (2006). Altered patterns of superficial trunk muscle activation during sitting in nonspecific chronic low back pain patients – importance of subclassification. Spine 31, 2017–2023.

https://pdfs.semanticscholar.org/4116/423bd11c5b01241a9c922ff83a532ed7b892.pdf

9.) De Bruyne MA, Van Renterghem B, Baird A, Palmans T, Danneels L, Dolphens M. Influence of differentstool types on muscle activity and lumbar posture among dentists during a simulated dental screening task. Appl Ergon 2016; 56:220–226.

10.) Dunk, N. M., Callaghan, J. P. (2005) Gender-Based Differences in Postural Responses to Seated Exposures, Clinical Biomechanics, Elseiver, 20: 1101–1110.

https://www.clinbiomech.com/article/S0268-0033(08)00317-3/pdf

11.) Dunk, N. M., Kedgley, A. E., Jenkyn, T. R., Callaghan, J. P. (2009) Evidence of a pelvis-driven flexion pattern: Are the joints of the lower lumbar spine fully flexed in seated postures? Clinical Biomechanics; 24: 164-168.

12.) Engels, P., Hokwerda, O., Wouters, J., de Rujter, R. (2018) The Saddle, in the Riding School and in the Dental Practice- An Analysis of Motion-Sequence and Function, OHDM, 17; 6: 1-10.

13.) Festervoll, I. (1994) “Office seating and movement” in Lueder, R. & Noro, K. (eds) 1994. Hard Facts About Soft Machines: The Ergonomics of Seating. London: Taylor & Francis. pg 418 –421.

14.) Gouvêa, R. G.,, Vieira, W. de A., Paranhos, L. R., Bernardino, I. de M., Bulgareli, J. V. Antonio., Pereira. C. (2018) Assessment of the Ergonomic Risk from Saddle and Conventional Seats in Dentistry: A Systematic Review and Meta-Analysis, Plos One, Assessment of the Ergonomic Risk in Dentistry, pp. 1-18.

15.) Gregory, D. E., Callaghan, J. P. (2008) Prolonged standing as a precursor for the development of Low back discomfort: An Investigation of Possible Mechanisms, Gait and Posture, Science Direct, 28: 86-62.

16.) Grooten (2013) Is Active Sitting As Sitting As We Think? Taylor and Francis, Ergonomics, 56; 8: 1304-1314.

17.) Gupta N, Christiansen CS, Hallman DM, et al. (2015) Is objectively measured sitting time associated with low back pain? A Crosssectional Investigation in the NOMAD study. PLoS One; 10:3.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0121159&type=printable

18.) Heneghan, N. R ., Baker, G ., Thomas, K ., Falla, D ., Rushton, A . What is the Effect of Prolonged Sitting and Physical Activity on Thoracic Spine Mobility? An Observational Study of Young adults in a UK university setting.

19.) Leivseth, G., Drerup, B. (1997) Spinal Shrinkage During Work in a Sitting Posture Compared to Work in a Standing Posture. Clin Biomech; 12: 409–18.

https://www.clinbiomech.com/article/S0268-0033(97)00046-6/pdf

20.) McGill, S. M., Brown, S. (1992) Creep response of the lumbar spine to prolonged full flexion. Clin Biomech; 7: 43–6.

https://www.clinbiomech.com/article/0268-0033(92)90007-Q/pdf

21.) McGill , S. M., Hughson, R. L., Parks K. (2000) Lumbar Erector Spinae Oxygenation During Prolonged Contractions: Implications for Prolonged Work. Ergonomics; 43: 486–93.

https://physoc.onlinelibrary.wiley.com/doi/pdf/10.1113/expphysiol.2006.033696

22.) Mork, P. J., Westgaard, R. H. (2009) Back Posture and Low Back Muscle Activities In Female Computer Workers: A Field Study, Clinical Biomechanics, Elseiver, 24: 169-175.

https://www.clinbiomech.com/article/S0268-0033(08)00317-3/pdf

23.) Nadine M. Dunk a,*, Angela E. Kedgley b , Thomas R. Jenkyn b , Jack P. Callaghan. (2009) Evidence of A Pelvis-Driven Flexion Pattern: Are the Joints of the Lower Lumbar Spine Fully Flexed in Seated Postures?

https://www.clinbiomech.com/article/S0268-0033(08)00348-3/pdf

24.) Nicola R Heneghan,1 Gemma Baker,2 Kimberley Thomas,3 Deborah Falla,1 Alison Rushton. (2018) What is the effect of prolonged sitting and physical activity on thoracic spine mobility? An observational study of young adults in a UK university setting, BMJOpen; 8.

https://bmjopen.bmj.com/content/bmjopen/8/5/e019371.full.pdf

25.) Oliver, M. J., Twomey, L. T. (1995) Extension Creep In the Lumbar Spine, Clinical Biomechanics, Elseiver Science Limited, 10; 7: 363-368. https://www.clinbiomech.com/article/0268-0033(95)00001-2/pdf

26.) O’Sullivan, K., McCarthy, R., White, A., O’Sullivan, L. and Dankaerts, W. (2012) Lumbar Posture and Trunk Muscle Activation During A Typing Task When Sitting on A Novel Dynamic Ergonomic Chair, Ergonomics, Taylor and Francis; 1-10.7

27.) da Silva, V. A., Pedro, M. F., Campos, J. C. R. (2017) Biomechanical Study of Dentists Posture When Using A Conventional Chair Versus A Saddle Seat Chair, SPEMD, rev port estomatol med dent cir maxilofac, 58; 1: 39-45.

28.) Snijders, C. J., Bakker. M. P., Vleeming, A., R, Stoeckart, R., Stam. H. J. (1995) Oblique Abdominal Muscle Activity in Standing and in Sitting on Hard and Soft Seats, Butterworth Heinemann, Clinical Biomechanics; 10; 2: 73-78. https://www.clinbiomech.com/article/0268-0033(95)92042-K/pdf

29.) Springer, T. (2010) The Future of Ergonomic Office Seating, Knoll, Knoll Workplace Research, pp. 1-10.

30.) Vink, P., Porcar –Seder, R. Page de Pozo, A, Krause, F. (2007) “Office chairs are often not adjusted by end users” Proceedings of The Human factors And Ergonomics Society 51st Annual Meeting. Santa Monica, California: HFES. pg 1015 –1019.

Trigeminal Neuralgia & Related Symptoms

Fri, 04 Feb 2022 15:18:41 GMT

Cause, Anatomy & Treatment Options

Overview

T rigeminal neuralgia (TN) is a common type of severe chronic facial disorder characterised by brief electric shock-like (paroxysmal) pains in one or more divisions of the fifth cranial nerve (the trigeminal nerve (V)). The condition is also termed 'tic douloureux' as the pain can cause individuals to distort or wince their face from the severe pain (7). The intense pain in the face caused by TN is also known as the 'Suicide Disease' or Fothergill's disease.

The maxillary and mandibular nerves are the lower two branches of the Trigeminal nerve and are most commonly affected. TN reportedly has an annual incidence of 4 and 27 per 100,000, the pain is commonly unilateral or happens on one side of the face and may be mistaken for dental problems (9).

The International Association for the Study of Pain (IASP) defined TN as “a sudden, usually unilateral, severe, brief stabbing and recurrent episode of pain in the distribution of one or more branches of the fifth cranial nerve” (9). The frequency, duration, and severity of these painful attacks gradually increase, and often become resistant to medication. Thus, the neuralgia can often become chronic and severely affect the quality of life, cause cognitive disturbances such as anxiety and depression in patients with TN (9).

Symptomatology

Symptoms of TN are excruciating pain that can be triggered by light touch or mild stimulation from normal activities such as (11):

Brushing teeth
Talking
Chewing
Applying make up
Encountering a light breeze
Smiling
Touching the skin lightly
Washing
Shaving
Blowing the nose
Drinking hot or cold beverages

TN pain is characteristically sudden, unexpected and short lasting and can reoccur various times throughout the day or happen in a series of attacks. Individuals may also report continous pain or aching or dull burning background pain within the areas that the nerve supplies sensation (11).

In the early stages of this condition the individual may experience short, mild attacks. But trigeminal neuralgia can progress and cause longer, more-frequent periods of searing pain. Overall, women are more affected by this condition than men, and it is more prevailing in the aged people who are above 50 (13).

Anatomy of the Trigeminal Nerve

After the trigeminal nerve leaves the brain, it divides int o three smaller branches that extend to different territories and control sensations throughout the face (Figure 2). The branches join at the trigeminal ganglia which are located within the Meckels cave of the cranial cavity.

· Ophthalmic Nerve (V1): The first branch controls sensation in a person's eye, upper eyelid and forehead.

· Maxillary Nerve (V2): The second branch controls sensation in the lower eyelid, cheek, nostril, upper lip and upper gum.

· Mandibular Nerve (V3): The third branch controls sensations in the jaw, lower lip, lower gum and some of the muscles used for chewing.

Each branch provides sensation to different areas of the face and depending on which branch and which part of the nerve is irritated, trigeminal neuralgia pain can be felt anywhere in the face. Most commonly, symptoms are felt in the lower part of the face and the intensity of the pain is exceptional with some people reporting it to be more severe than experiencing a heart attack, passing a kidney stone or even giving birth.

Branches V1, V2, and V3 of the trigeminal nerve exit the cranium through the superior orbital fissure, foramen rotundum, and foramen ovale, respectively (2).

Figure 3 shows the small neural branches o f the trigeminal nerve (V); the Infraorbital nerve (ION), Supraorbital nerve (SON), the supratrochlear nerve (ST) and the mental nerve (M).

The Supraorbital Nerve (SON): Is one of two branches of the frontal nerve which itself, is a branch of the ophthalmic nerve (V1). The SON travels anteriorly above the levator palpebrae superioris muscle and exits the orbit via the supraorbital foramen within the superior margin of the orbit (19). The SON then ascends onto the forehead and divides into the medial (SONm) and lateral (SONl) branches of the SON (Figure 3).

The Supratrochlear Nerve (ST): The other branch of the frontal nerve is the supratrochlear nerve which passes above the superior oblique muscle and exits the supratrochlea notch to provide sensory innervation to the forehead and upper eyelid (19) (Figure 3).

The Infraorbital Nerve (ION): A branch of the maxillary nerve (CN V2) that travels through the orbit, enters the infraorbital canal and exits out onto the face via the infraorbital foramen providing skin sensation to the middle of the face (19) (Figure 3).

The ION divides into four main branches; the inferior palpebral (IP), the external nasal (EN), the internal nasal (IN), and the superior labial branches (SLm and SLl) .

The Mental Nerve (M): branches from mandibular nerve (CN V3 ), it emerges from the mental foramen in the mandible and divides into three branches with one branch descending to the skin of the chin via the Mental branch nerve (M). The other two branches ascend to the skin of the lower lip via the lateral (ILl) and medial inferior labial branches (ILm)(19) (Figure 3).

Causes

The International Headache Society (IHS) describes two classifications of TN: classical or primary and symptomatic or secondary (15).

Classical or Primary TN
Classical or primary TN is due to a vascular compression of the trigeminal root by tortuous or aberrant blood vessels (13).

Primary trigeminal neuralgia has been linked to the compression of the trigeminal nerve, typically in the base of the head where the brain meets the spinal cord. This is usually due to contact between a healthy artery or vein and the trigeminal nerve at the base of the brain. This places pressure on the nerve as it enters the brain and causes the nerve to misfire (15).

Accoriding to Gerwin (2020), the vessel most commonly compressing the trigeminal nerve root is the superior cerebellar artery (SCA) , as identified by high-resolution magnetic resonance imaging (MRI). The anterior inferior cerebellar artery (AICA) , the basilar artery , and an ectatic vertebro-basilar artery have also been implicated in some patients. The trigeminal nerve can also be compressed by veins, particularly the superior petrosal and transverse pontine veins (6).

Symptomatic or Secondary TN

Secondary Trigeminal neuralgia is caused by pressure on the nerve from a tumor , Multiple sclerosis, a cyst, facial injury or another medical condition that damages the myelin sheaths (15).

Symptomatic TN can be related to cerebello-pontine angle tumours which compress the trigeminal nerve root. Multiple sclerosis (MS) is typically associated with TN (2-4% of patients with TN) (13).

Treatment

Non-Surgical Treatments

There are several effective ways to alleviate the pain, including a variety of medications which are generally started at low doses and increased gradually based on patient’s response to the drug (13). Sodium channel blockers of either Carbamazepine or Oxcarbazepine are effective in most TN cases for treating symptoms. However, they can cause possible side effects of dizziness, double vision, drowsiness and nausea. Oxcarbazepine may be preferred for the minor risk of drug interactions and tolerability (13).

Surgery

If medications have proven ineffective in treating TN several surgical procedures may help control the pain, however, microvascular decompression of the trigeminal nerve root is the most effective and long-lasting treatment. Surgical treatment is divided into two categories: 1) open cranial surgery or 2) lesioning procedures. In general, open surgery is performed for patients found to have pressure on the trigeminal nerve from a nearby blood vessel, which can be diagnosed with imaging of the brain, such as a special MRI. This surgery is thought to take away the underlying problem causing the TN. In contrast, lesioning procedures include interventions that injure the trigeminal nerve on purpose, in order to prevent the nerve from delivering pain to the face. The effects of lesioning may be shorter lasting and in some cases may result in numbness to the face.

How Might Physical Therapy Help?

Overall, the evidence of manual therapy for the relief of TN is low, however, there are case studies who report to have had their chronic symptoms significantly improved or resolved despite receiving surgery or primary care interventions first.

Acupuncture - Case Study

A previous case study by Sert et al., (2009) reported that acupuncture treatment helped relieve their symptoms after having received 5 treatment sessions. A 66 year old lady who suffered from chronic TN pain on the left side of her face for over 25 years found that acupuncture helped relieve her symptoms completely despite trying primary care intervention methods first. The primary care methods included medication (carbamazepine, gabapentin and valproic acid), nerve block and radiofrequency rhizotomy of the infraorbital branch of the trigeminal nerve (15).

However, research has concluded that although acupuncture may have some positive effects on Trigeminal Neuralgia, the level of evidence is low or very low and a firm conclusion can not yet be drawn on the efficacy of acupuncture for Trigeminal Neuralgia (15).

Deep Tissue Massage & Acupuncture - Case Study

Another case who suffered from TN was studied by Omar and Bakar (2020) who found that acupuncture with massage therapy had significantly improved their symptoms after four treatment sessions. The massage applied involved using deep pressure along the distribution of the trigeminal nerve around the regions of the ear, maxilla, mandibular, and forehead. The massage aimed to stimulate the nerve by repeatedly stroking along the distribution of the V2 trigeminal nerve. Dry needling was executed at five location points, namely the temporalis muscle, the junction of the temporo-mandibular joint and along the lower end of the maxillary bone including masseter muscle (12).

Spinal manipulation and Chiropractic Care - Case Study

Another case study who received chiropractic care and suffered from chronic TN pain was written by Rodine and Aker (2010). In this particular case, there was evidence to suggest that there were three sources of pathology contributing towards the individual's pain including; neck pain caused by degenerative disc disease (DDD), temparomandibular joint (TMJ) syndrome and trigeminal neuralgia (15). The chiropractic practitioner observed the relief of symptoms by performing ultrasound electrotherapy, manual therapy of manipulation and mobilisation, soft tissue therapy techniques and home exercises.

Osteopathic Treatment & Cranial Osteopathy

Some individuals might find relief from osteopathic treatment application to the cranium, in particular the cranial base with myofascial trigger points to the masseter and temporalis muscles (2).

References

Birnbaum G and Iverson JDalfampridine may activate latent trigeminal neuralgia in patients with multiple sclerosis.Neurology 2014;83(18): 1610-161
Campbell, S., M., Winkelmann, R. R., Walkowski, S. (2014) Osteopathic Manipulative Treatment Novel Application to Dermatological Disease, Clinical Aesthetic, 5; 10: 24-32.
Crevier-Sorbo, G., Brock, A., Rolston, J. D. (2019) Trigeminal neuralgia plus hemifacial spasm caused by a dilated artery: a case of painful tic convulsif syndrome, Lancet, 394, e36.
Cruccu G, Gronseth G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. (2008) AAN‐EFNS guidelines on trigeminal neuralgia management. European journal of neurology; 15 (10): 1013-28.
Dalessio D, J. (1982) Trigeminal neuralgia. A practical approach to treatment. Drugs; 24 (3): 248-55. Physiotherapy/Physical Therapy. Available from: Physiotherapy / Physical Therapy.
Gerwin, R. (2020) Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome—An Evidence-Based Narrative Review and Etiological Hypothesis, MDPI, 17, 7012.
Headache Classification Committee of the International Headache Society (IHS) (2013) The International Classification of Headache Disorders. Cephalalgia; 33:629–808. 3rd edn.
Kataria, S., Ahmed, Z., Ali, U., Ahmad, S., Awais, A. (2020) Trigeminal Neuralgia Induced Headache: A Case Report and Literature Review, Cureus, 12; 7: 1-4.
Khanal, D., Khatri, S. M., Anap, D. (2014) Is there Any Role of Physiotherapy in Fothergill's Disease. Journal of Yoga & Physical Therapy. 1; 4 (2): 1.
Kim, J.I., Kim, H.J., Lee, J.J., Jun, J.H., Choi, T-Y., Lee, M. S. (2018) Acupuncture for the treatment of trigeminal neuralgia A protocol for the systematic review of randomized controlled trials, Medicine, 97; 11: 1-3.
Longo, D. L., et al., (2017) eds. Trigeminal neuralgia, Bell's palsy, and other cranial nerve disorders. In: Harrison's Principles of Internal Medicine. 19th ed. New York, N.Y.: McGraw-Hill Education; 2015. https://accessmedicine.mhmedical.com. Accessed June 5.
Omar, W. A. W., Bakar, N. L. A. (2020) Improvement of trigeminal neuralgia after massage therapy and dry needling , Malaysian Journal of Medicine and Health Sciences ;16 (102): 81-83.
Maarbjerg, S., Stefano, G. D., Bendsten, L., Cruccu, G. (2017) Trigeminal Neuralgia; Diagnosis and Treatment, Cephalalgia, International Headache Society, 37, 7; 648-657.
Reeta, Kumar U, Kumar V, Alam M, Islami D, Lal W et al (2016). A Survey to Observe the Commonly Used Treatment Protocol for Trigeminal Neuralgia by Physiotherapist. International Journal of Physiotherapy; 3 (5): 643-646.
Rodine, R. J., Aker, P. (2010) Trigeminal Neuralgia and Chiropractic Care: A Case Report, JCCA, 54;3: 177-186.
Sert, H., Usta, B., Musla, B., Gozdemir, M. (2009) Successful Treatment of a Resistance Trigeminal Neuralgia Patient By Acupuncture, Clinics, 64(12): 1225–1226.
Truini. A (2015), Trigeminal Neuralgia, Journal of Headache and Pain, 16; A42.
Trigeminal neuralgia. Available from: https://www.physio.co.uk/what-we-treat/chronic-pain-fatigue/trigeminal-neuralgia.php (Accessed on 2nd October, 2020).
Wikipedia (2022) [online] https://en.wikipedia.org/wiki/Mental_nerve#:~:text=The%20mental%20nerve%20is%20a%20branch%20of%20the%20posterior%20trunk,mental%20foramen%20in%20the%20mandible.&text=These%20branches%20communicate%20freely%20with%20the%20facial%20nerve. (last visited 07/02/2022).

Biceps Tendinitis

Sat, 04 Dec 2021 16:57:27 GMT

Anatomy, Injury & Treatment Options

Biceps tendinitis is inflammation of the tendon around the long head of the biceps muscle in the bicipital groove. This is known as primary biceps tendinitis and occurs in 5% of patients with biceps tendinitis (3). Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff muscle tears or SLAP (superior labrum anterior to posterior) lesions (3). Patients often complain of a deep, throbbing ache in the anterior shoulder and repetitive overhead motions of the arm initiate or exacerbate the symptoms. The most common isolated clinical findings in biceps tendinitis is bicipital groove point tenderness whilst the arm is moved to 10 degrees of internal rotation (Figure 1). Pathology of the biceps tendon is most often found in patients 18 to 35 years of age who are involved in sports (3).

Stages

In the early stages of biceps tendonitis, the tendon often becomes inflamed and swollen, the tendon sheath can thicken or grow larger as the tendinitis develops and the tendon becomes dark red in color in the late stages due to inflammation (3).

Occasionally, a partial or complete tear of the tendon may occur from injury or damage. Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff tears or SLAP (superior labrum anterior to posterior) lesions. A complete tendon tear can result to a deformity of the arm (3).

Biceps tendinitis commonly occurs along with other shoulder problems. Other problems that often accompany biceps tendinitis include:

Arthritis of the shoulder joint
Rotator cuff tears
Tears in the glenoid labrum
Shoulder instability
Other diseases that cause inflammation of the shoulder joint lining.

Cause

As we age, most of our daily routine activities can cause wear and tear within the biceps tendon which may result to weakness overtime. Repeating the same shoulder movements over again throughout the day along with poor shoulder and upper back posture can be the cause for wear and tear. Biceps tendinitis can occur from sudden, serious load or strain to the tendon such as lifting a heavy item or performing DIY.

Primary impingement syndrome is considered the most common cause of biceps tendinosis or tenosynovitis (i.e., inflammation of the tendon sheath). This is a mechanical impingement under the coracoacromial arch caused by bone spur formation of the acromion or can occur from thickening of the coracoacromial ligament (3). It may also be caused by osteoarthritic spurs impinging on the bicipital groove (3).

Various jobs and activities can lead to overuse and damage to the biceps tendon. Repetitive overhead motion during certain sports such as swimming, tennis, and baseball can also put people at risk for biceps tendinitis.

Anatomy

Our shoulder is a ball-and-socket type joint made up of three bones: the upper arm bone (humerus), shoulder bone (scapula), and collarbone (clavicle).

Gross Anatomical Components:

Glenoid The head of our upper arm bone (humerus) fits into the rounded socket in our shoulder bone (scapula). This socket is known as the “glenoid”. The glenoid is covered with a soft cartilage known as the labrum. This cartilage helps the head of the upper arm bone fit into the shoulder socket.

Rotator cuff A collection of muscles and tendons keep our arm centered in the glenoid cavity. These tissues, called the rotator cuff, cover the head of upper arm bone and attach it to the shoulder blade.

Biceps tendons. The major muscle in front of our upper arm is known as the Bicep muscle which has two tendons that attach it to the shoulder blade bone. The long head of biceps attaches to the top of the shoulder socket (glenoid) and the short head attaches to a process on the shoulder blade called the coracoid process.

Long Head Bicep Tendon The long head of the biceps tendon (LHBT) originates approximately 50% from the superior glenoid tubercle and the remainder from the superior glenoid labrum (6). The attachment points for the long and short heads of the biceps can be read in figure 2.

Bicipital Groove The bicipital groove is an anatomic landmark that sits between the greater and lesser tuberosities and serves as a critical location of proximal biceps stability. The soft tissue components of the groove create a tendo-ligamentous sling to support the LHB tendon.

Blood Supply The blood supply to the LHB tendon occurs via the anterior humeral circumflex artery. Labral branches from the suprascapular artery may provide blood supply, especially to the proximal portion of the biceps tendon near its origin.

However, recent studies have shown that there is a relatively avascular zone in the region of the superior glenoid, which may contribute to the overall poor vascularity of the tendon. Examination of the LHB within the groove characteristically shows vascularity on the superficial portion of the tendon, whereas the gliding undersurface has been noted to be avascular (8).

Function of Long Head Biceps Tendon (LHBT) Function of Long Head Biceps Tendon (LHBT)

The main function of the biceps muscle is supination (turning the palm of the hand to face the ceiling) and elbow flexion. The muscle contributes approximately 10% of the total power in shoulder abduction when the arm is held in external rotation.
The function of the LHB tendon tends to play a passive stabilising role in the shoulder and it has been proposed that the stabilisation of the LHBT is dependent on the elbow's positioning (9).

Conservative Treatment & How Osteopathy Might Help

An osteopathic treatment might involve the practitioner assessing positioning and posture of the neck, shoulders and back along with performing clinical tests to understand which specific muscles or joint related compensations might be contributing to maintaining biceps tendonitis.

Your osteopath does not prescribe medications, but biceps tendinitis or tendinosis may respond to analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs), ice, rest from overhead activity (if perform related activities), or physical therapy.

Shoulder stability and posture related exercises might be prescribed along with specific muscle stretches. The goal of stretching is to regain a balanced range of motion without stiffness or pain in any position. Interestingly, Churgay (2009) believes that a stretching program should include stretching and exercising the hamstrings and lower back as well. A subtle loss of motion in the lower back and hamstrings may lead to a major imbalance of the shoulder-stabilising ligaments and the scapula (Churgay, 2009).

Corticosteroid Injection

If additional therapy is needed for pain relief, or if the diagnosis is in doubt, an injection of local anesthetic (e.g., 1% lidocaine with or without a mild corticosteroid solution) into the biceps tendon sheath and a referral might be suggested and considered.

Surgery

Surgery is only considered if conservative measures fail after than three months. Structures causing primary and secondary impingement may be removed, and the biceps tendon repaired if necessary. Debridement or arthroscopic shaving of torn fibers might be performed if less than 50% of the biceps tendon is torn (3). Biceps tenodesis may be considered in serious tears or rupture which involves the attachment of the torn biceps tendon to the bicipital groove or transverse humeral ligament with suture anchors or screws (3). A biceps tenotomy is also a possibility whereby the ruptured biceps tendon is removed from the glenohumeral joint, and tenodesis might be avoided without significant loss of arm function. Tenotomy is the procedure of choice for inactive patients 60 years and older with a ruptured biceps tendon. Tenodesis is a reasonable option for patients younger than 60 years, as well as active patients, athletes, manual laborers, and patients who object to a muscle bulge above the elbow.

References

Abrams, J. S. (1991) Special shoulder problems in the throwing athlete: pathology, diagnosis, and nonoperative management. Clin Sports Med. ; 10 (4): 839–861.
Ahrens, P. M., Boileau, P. (2007) The long head of biceps and associated tendinopathy. J Bone Joint Surg Br . 89 (8): 1001–1009.
Churgay, C. A. (2009) ) American Family Physician, 80; 50: 470-476.
Froimson, A.I. (1975) Keyhole tenodesis of biceps origin at the shoulder Clin Orthop Relat Res ; (112): 245–249.
Iagnocco, A., Filippucci, E., Meenagh, G., et al. (2006) Ultrasound imaging for the rheumatologist. I. Ultrasonography of the shoulder. Clin Exp Rheumatol ; 24 (1): 6–11.
Krupp, R. J., Kevern, M. A., Gaines, M. D., Kotara, S., Singleton, S. B. (2009) Long Head of the Biceps Tendon Pain: Differential Diagnosis and Treatment , Journal of Orthopaedic & Sports Physical Therapy, 39; 2: 55-70.
Mariani, E. M., Cofield, R. H., Askew, L. J., Li, G. P., Chao, E. Y. (1988) Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment. Clin Orthop Relat Res ; (228): 233–239.
Nho, S. J., Strauss, E. J., Lenart, B. A. et al., (2010) Long Head of the Biceps Tendinopathy: Diagnosis and Management Long Head of the Biceps Tendinopathy: Diagnosis and ManagementJournal of the American Academy of Orthopaedic Surgeons; 18: 11.
Varacallo, M., Mair, S. D. (2021) Proximal Biceps Tendinitis and Tendinopathy, StatPearls; https://www.ncbi.nlm.nih.gov/books/NBK533002/ [online] last visited 21/11/2021.

Text Neck

Tue, 26 Oct 2021 20:04:53 GMT

Symptoms and Presentation of Text Neck

Text neck is not an official medical diagnosis but a term commonly used to describe a repetitive stress injury that typically occurs over a period of time from excessive use of mobile devices. A study showed that smartphone users usually maintain head flexion of 33 to 45 degres whilst using a smartphone [1].

The term 'text neck' has arisen from individuals adopting a cervically flexied posture whilst using smart phones. There does seem to be controversy between studies as to whether there is a definitive association of text neck with the intensity of frequency of neck pain after use [1].

The most common presentation of Text Neck is neck pain, stiffness and soreness. The main symptoms include [2]:

Stiff neck: soreness and difficulty whilst moving the neck especially after long usages.
Pain: can be localized within the neck or may be diffused over an area and usually within the lower part of the neck.
Can be described as a dull ache in nature or sharp and stabbing in extreme cases.
Radiating pain: radiation of pain can often be described into the shoulders and arms.

A Greater Tilt Increases Forces on the Neck

Flexing the head forward to use a smartphone affects the spine directly. The above image shows how tilting the head forward to 30 degrees can place up to about 18kg of force on the neck. This increases to 24kg at 45 degrees and 28kg at 70 degrees. Damage caused by untreated text neck can be similar to occupational overuse syndrome or repetitive stress/strain injury [2].

Common Symptoms

Muscular weakness: shoulders muscles namely, trapezius, rhomboids and shoulder external rotators are often weak
Headache: sub-occipital muscle tightness can lead to tension type headaches.

Looking down at your cell phone too much each day can lead to:

Upper back pain ranging from a chronic, nagging pain to sharp, severe upper back muscle spasms.
Shoulder pain and tightness, possibly resulting in painful shoulder muscle spasm.
If a cervical nerve becomes pinched, pain and possibly neurological symptoms can radiate down your arm and into your hand.

In addition to these common symptoms there can also be [2]:

Flattening of the upper back reducing upper thoracic kyphosis
Early onset arthritis
Spinal degeneration
Disc compression
Muscle weakness
Loss of lung capacity

Management

Avoid excessive mobile phone usage and take frequent breaks.
Avoid prolonged static postures.
Position the device such that it reduces stresses both on the head/neck and the upper extremities by holding the device higher.
Avoid high repetitions of movements such as prolonged typing or swiping.
Avoid holding large or heavy devices in one hand for long duration such as heavy ipads.

Acute Cases

In acute cases, pain relief is the main goal and can be achieved by:

Regular neck movements: rotations and side bending

Simple neck and shoulder stretches are also important to improve blood flow and relieve tension, for example:

Stretches to Keep the Neck Healthy.
Tuck the chin down toward the neck, then slowly raise it up toward the ceiling.
Rotate the head so that it is looking out over one shoulder, then turn slowly and rotate in the other direction.
Rotate the shoulders in a clockwise direction while holding the arms down by the sides of the body; repeat in a counter clockwise direction.

Physical Therapy:
At the St Albans Therapy and Osteopathy clinic hands-on physical therapy might involve performing gentle passive mobilisations to the upper back as well as the neck along with stretching techniques as shown above (figure 2) to help reduce muscular tension and aid joint mobility. Soft tissue release techniques may also involve inhibition techniques to muscles under the skull (figure 1).

References

Correia, I. M. T., Ferreira, A. de S., PhD, Fernandez, J., Reis, J. J. F., Nogueira, L. A. C., Meziat-Filho, N. (2021 ) Association Between Text Neck and Neck Pain in Adults, SPINE, Wolters Kluwer Health, 46; 9: 571-578.
Kataria, J (2018) Text Neck - Its Effect on Posture, IJCRT, 6; 1: 2320-2882.

Scoliosis; Types, Assessment and Treatment

Fri, 02 Apr 2021 00:00:00 GMT

Types, Cause, Examination and Treatment

The term Scoliosis is a condition first described in detail by the Greek physician Hippocrates who took its name from the Greek word 'scolios' meaning 'crooked' (5). A scoliosis is normally considered if there is at least ten degrees of spinal angulation with lateral curvature shown on a posterior-anterior radiograph (4).

Scoliosis is the most common deformity of the spine with a direct effect on the thoracic cage and often consists of lateral displacement with associated rotation of the vertebrae (5). As the UK Scoliosis Association highlights, scoliosis is not a disease or contagious and 3 to 4 children per 1000 may require supervision (8).

Scoliosis can develop at any age but usually becomes most clinically evident during growth, growth spurts or rapid somatic growth (5). The condition can be classified broadly as congenital, neuromuscular, syndrome-related, idiopathic and spinal curvature due to secondary reasons (4).

Idiopathic scoliosis is the most common type and approximately accounts for 80% of scoliosis cases. Congenital scoliosis is caused by structural abnormalities of bone and neural tissues and is the second most common type and accounts for approximately 10% of cases ( 7). Neuromuscular, developmental, and tumor-associated scoliosis altogether constitute the remaining 10% . Currently, degenerative scoliosis and traumatic scoliosis are also considered important subcategories by those involved in management of the disease ( 7).

Scoliosis is usually classified as primary (i.e. idiopathic) or secondary. Idiopathic scoliosis is further classified according to the patient’s age, whereas secondary scoliosis is classified according to the cause.

- Infantile

- Young children (early onset)

- Older children (adolescent idiopathic)

- Adults (degenerative or de novo)

A scoliosis is classified with accordance to the side of its occurence into either left or right sided curves. Classification of scoliosis is dependent upon which region of the spine is affected and usually termed 'thorcaic', 'lumbar' or 'thoracolumbar'. The involvement of any of these areas is significant as organ function will need to be taken into consideration. For instance, the thoracic spine is primarily responsible for the respiratory and cardiovascular complications of scoliosis (4, 5). A lumbar spine scoliotic pattern can later affect an individual's pelvic floor strength, incontinence or can lead to bowel and bladder related disorder(s) (6).

It has been postulated that the condition might be related to proprioception or homeostasis disorders along with inheritance or genetics as well as metabolic, hormonal and biomechanical factors (1). It is worth noting that biomechanical or hormonal disturbances can cause reduced vertebral bone mass which can further progress spinal curvature (2).

Dextroscoliosis and Levoscoliosis

Dextroscoliosis is abnormal sideways curvature of the spine laterally displaced to the right and also known as a dextrocurvature (6) .

The above picture (Figure 1) shows a lumbar dextroscoliosis which characterises an S-shaped curvature of the spine, specifically the lower back region.
Thoracic dextroscoliosis is an abnormal curvature within the thoracic region of the spine that also curves laterally to the right.

When a spinal curve deviates to the left, it is known as levoscoliosis or levocurvature . A levoscoliosis can affect either the lumbar or thoracic regions of the spine and known as a thoracic levoscoliosis and lumbar levoscoliosis respectively (10).

Structural or Non Strucutral Scoliosis

Structural:
Scoliosis may be structural which is when the patient's spine has an anatomical physical curve that can be observed whilst the patient is standing or sitting.
Structural scoliosis can be idiopathic which tends to affect girls more than boys during adolescence. A UK study showed that scoliosis in girls over 8 years of age out numbered boys by almost 3 to 1 ( 4) . Idiopathic scoliosis can be further classified into infantile, juvenille and adolescent types or early and late onset (4).

Structural scoliosis can also be secondary to congenital or neurological disorders (e.g. cerebral palsy or paralysis), neuromuscular conditions, (e.g. Duchenne muscular dystrophy), tumours, trauma or syndromic conditions (e.g. Marafans syndrome and neurofibromatosis) (4, 5).

Non Structural:
Also known as a functional scoliosis with the latter to be caused from conditions such as lower limb disorders such as limb length discrepancy, herniated discs, hip dysplasia or limb deficiency syndromes.

The Nature of Scoliosis

Each curve of a scoliosis is classified as either having a convex or concave side as well as a primary and a secondary curve (5). The primary curve is usually stiffer and the curve site is classified with accordance to the location of the apical or apex vertebra in the coronal plane within either cervical, thoracic or lumbar spine (5).
The apical vertebra is the most rotated vertebra in the curve and the end vertebrae are the most cephalad and caudal whose superior and inferior surfaces have the most maximal tilt towards the concavity of the spinal (either concave or convexed) curve.

Cobb's Angle

The Cobb angle is useful for assessing initial stages of a scoliotic curve, whether there is an increasing magnitude and helps one to decide when or if it is appropriate to operate (4). The size of the curve within a scoliosis is assessed via the measurement of the cobb angle. Here, lines are drawn perpendicular to the transverse axes containing the upper and lower end vertebrae and where the lines intersect is the cobb angle. The angle can now be measured using specialised computer software.

Adolescent and Infantile Scoloisis

Infantile and juvenile idiopathic curves: infantile and Juvenile are terms used to describe curves that develop from ages 0 to 3 years and 4 to 10 years of age respectively. More recently the term “early onset’ has been used to classify curves that develop before the age of 10 years (5).
Although not (yet) proven, the rate or severity of scoliosis between boys and girls during pubertal stages might be associated with hormonal factors (in particular growth hormone) (7).

In the 1980's, adolescent idiopathic curves have been classified by King and Moe who found that there are five distinct curve patterns based on standing radiographs of the spine. The aim of this system was to determine a reliable method for selecting vertebrae for fusion. The curve types were stratified from I-V with type II and III being most common. Type II is a thoracolumbar curve while Type III is a thoracic curve. There is poor intra/inter observer reliability with this system. It also only assesses the curve in the coronal plane, does not address lumbar/thoracolumbar/double major/triple major curves and does not consider the 3-dimensional scope of the deformity (5).

Neuromuscular Scoliosis

As Koumbourlis (2006) highlights, neuromuscular scoliosis differs to idiopathic scoliosis. In idiopathic scoliosis, respiratory muscle dysfunction results to distortion of the thoracic cage. In neuromuscular scoliosis, the thoracic cage is distorted because of the underlying muscle weakness. Various neuromuscular disorders are clinically evident during early infancy with distortions observed within the thorax which can be severe (7). During this period of rapid lung growth and development, this can also cause severe impairment of the lung growth.

Further differentiation between the two types is that idiopathic scoliosis tends to stabilise (or progress at a lower rate) after the person reaches skeletal maturity.
However, neuromuscular scoliosis progressively worsens from the muscle weakness and complications are potentially greater because of problems such as chronic, recurrent aspiration pneumonia secondary to impaired clearance of airway secretions (7).

Some syndromes where scoliosis is likely to happen are connective tissue disorders (Marfan’s and Ehlers-Danlos syndrome), trisomy 21, Prada-Willi, Retts syndrome and Beale’s syndrome. Duchenne muscular dystrophy or spinal muscular atrophy can prevent or severely reduce muscle activation thus encouraging the development of muscle imbalance, muscle atrophy and the progression of a spinal scoliotic curvature (7).

Patients with these conditions often develop scoliosis or kyphosis, or both. As they grow and their trunk muscles become weaker, the spine gradually begins to collapse, which creates a long, C-shaped collapsing scoliosis.

For children who use a wheelchair, progressive curves can make it difficult for them to sit comfortably. Large curves (measuring 80 degrees or above) in the upper or middle parts of the spine may cause lung problems (8, 9).

Interestingly, the association of scoliosis with conditions known to be related to collagen abnormalities (e.g. Marfan syndrome) can be corroborated by the abnormalities in the amount of collagen associated with low glycosaminoglycan levels in the apical discs (7).

Signs and Symptoms

In the majority of cases, pain is not usually a reason for patients to seek further medical assistance but may present with either back or rib prominence pain (Haleem and Nnadi, 2018). Night is pain is an unusual complaint and should be referred for further imaging to rule out spinal tumour.

Other important features to keep in mind are balance and gait disturbance, bowel and bladder control or lack of and any other neurological deficit. These should alert the examiner to look for other pathological causes including tumours (both intra and extradural) and other central causes (e.g. syringomyelia) (5,7). Curve progression needs to be carefully monitored. The risk of curve progression depends on timing of growth spurts and also on the amount of growth remaining in each individual patient. In younger children (particularly those less than 10 years of age lung volume growth may be impaired and untreated severe or progressive scoliosis can lead to or worsen chronic restrictive respiratory disease.

Chiari malformations, Syringomyelia and spinal cord tethering are important associations with congenital and Early Onset scoliosis.

Treatment

Treatment for scoliosis is based on the type of scoliosis, magnitude of the curve, number of years of growth remaining and the patient’s opinion about the shape of their back (5,7). The trunk deformity and balance is also included in the decision-making process (5) report, the management and treatment of patients with either congenital, neuromuscular, syndrome-associated or idiopathic scoliosis younger than 10 years of age presents a number of controversies.

The treatment options for AIS include observation, bracing and surgery. While many other factors must be considered, the general goal is to keep curves under 50° during maturity.

Observation
Typically, observation is recommended for immature patients with curves of less than 25°. The most reliable method of monitoring growth is simple height measurements. Therefore, the primary physician often possesses this information from their annual examinations

Braces
Compliance and wearing time of braces seem to have a role in the effectiveness of bracing and although they do not permanently improve or correct spinal curves, they do try to prevent it from worsening (5). Braces include the Milwaukee brace, Boston brace and the Charleston bending brace (5,7).

Surgery
Surgery is usually performed during adolescence, but newer techniques have allowed good correction to be accomplished into early adulthood (5, 7). Surgical correction of idiopathic scoliosis is considered for curves greater than 45° in immature patients and for curves greater than 50° in mature patients. T he goals for surgical treatment include prevention of progression, improve spinal alignment and balance and help improve alignment between hips and shoulders and the head over the sacrum (5, 7). The spine is corrected with a combination of rods, hooks, screws and wires while being fused by bone graft – either from the patient, a cadaver or artificially The techniques for the correction and fusion change quickly; long-term results have not been obtained for the newest techniques. However, with older technology, good results have been found in a 20-year follow-up period (5,7).

How Might Ostoepathy Be Able To Help?

Once a clinical assessment has been performed by the practitioner, Osteopathy treatment may involve a wide range of different techniques and management will depend on the individual's case. Everybody is uniquely different and spinal curves will differ to each individual person.

One example of treatment management that might be chosen to apply are gentle joint mobilisation techniques for the thoracic and lumbar spine, pelvis and rib cage with the aim of increasing their joint range of movement. Soft tissue massage techniques and passive stretching might also be applied with the aim of reducing tension and compression within the associated shortened muscles and reduce pressures within the joints. Home exercises for patients are often advised to be performed.

References

1. Choudhry, M. N., Ahmad, Z., Verma, R. (2016) Adolescent Idiopathic Scoliosis, The Open Orthopaedics Journal, 10: 143-154.

https://openorthopaedicsjournal.com/contents/volumes/V10/TOORTHJ-10-143/TOORTHJ-10-143.pdf

2. Fadzan, M., Bettany-Saltikov, J. (2017) Etiological Theories of Adolescent Idiopathic Scoliosis: Past and Present, The Open Orthopaedics Journal, 11: pp. 1466-1489.

https://openorthopaedicsjournal.com/contents/volumes/V11/TOORTHJ-11-1466/TOORTHJ-11-1466.pdf

3. Francis, M. J. O., Sanderson, M. C., Smith, R. (1976) Skin Collagen in Idiopathic Adolescent Scoliosis and Marfan's Syndrome, Clinical Science and Molecular Medicine; 51: 467-474.

4. Haleem, S., Nnadi, C. (2018) Scoliosis: A Review, Paediatrics and Child Health ; 28: 5; 2019 – 217.

5. Janicki, J. A., Alman, B. (2017) Scoliosis: Review of diagnosis and Treatment; Orthopaedic Subseciality Article , 12; 9: 771 – 776.

6. Kim, H., Kim, H. S., Moon, E. S., Yoon, C-S., Chung, T-S., Song, H-T., Suh, J-S., Lee, Y, H., Kim, S., (2010) S coliosis Imaging: What Radiologists Should Know, Radiographics, 1823-1842.

7. Koumbourlis, A. C. (2006) Scoliosis and the Respiratory System: Paediatric Respiratory Reviews, Elsevier, 7: 152 - 160.

8. Perkins, J., Boyer, A., Mcleish, A., Grossnickle, K. (2013) Idiopathic Scoliosis and Pelvic Floor Dysfunction, IJTR, 19; 2.

9. Romano, M. Negrini, A., Parzini, S., Tavernaro, M., Zaina, F., Donzelli, S., Negrini, S. (2015) SEAS (Scientific Exercises Approach to Scoliosis): a modern and effective evidence based approach to physiotherapy specific scoliosis exercises, Biomed Central, 10: 3.

10. Scoliosis Association UK https://www.sauk.org.uk/types-of-scoliosis/syndromic-scoliosis

11. Stitzel , C. (2017) The Different Scoliosis Locations & Types of Spinal, [ONLINE], Curvatures, https://www.treatingscoliosis.com/blog/scoliosis-spinal-curvature-types/

12. Uden, A., Nilsson, I. M., Willner, S. (1980) Collagen Changes In Congenital And Idiopathic Scoliosis , Acta Orthop. scand; 51: 271-274.

Muscle Knots & Myofascial Trigger Points

Fri, 27 Nov 2020 17:31:17 GMT

What Are They, Cause, Physiology & Treatment Options

A regularly asked question is "what are (muscle) knots?", closely followed by "what causes them and how can they be avoided?".
A simple short answer is; muscle knots are small, nodule-like, hypersensitive areas which can be painful to touch and are mainly caused by overuse, stretched muscle from frequent and repetitive strain and especially caused by poor posture.

The medical term for muscle knots is myofascial trigger points (MTrPs) which occur when muscle fibres or bands of fascia tense and tighten (2). Trigger points are classified as either 'active' or 'latent'. Active trigger points are tender, spontaneously painful and refer to trigger points that do not necessarily need to be touched for them to be painful (7). This contrasts to latent trigger points which are only painful when somebody presses on the sensitive area, they may be associated with restricted ranges of movement and tenderness is not associated with spontaneous complaints of pain (7).

Xiaoqiang et al., (2014) describe MTrPs as hyperirritable regions located within muscle, fascia, or tendinous insertions, where local pain is perceived as a deep and aching palpable taut band with referred pain in the same or a distant position and local twitch responses (LTRs) may be felt during forceful palpation and/or via (acupuncture) needling.

Myofascial trigger points can cause pain and affect joint range of motion which is why individuals with hypersensitive trigger points should aim to treat them as early as possible.

Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is one of the most common chronic pain syndromes and often overlooked as a source of muscle pain, discomfort, and dysfunction. Myofascial pain often arises in postural related skeletal muscle which may refer to other areas of the body (3). Examples of postural tonic muscles may include deep back erector spinae muscles, gluteal (buttocks), and cervical (neck) muscles which seem to be involved more often than others (3).

Painful muscles surrounding connective tissue may either be described as being 'acute' with lasting less than 6 weeks or 'chronic' by lasting more than 3 to 6 month and be caused by the development of myofascial trigger points in muscle (MTrPs) (1).

Various individuals in all types of populations may suffer from myofascial pain, especially those who participate in sport, carry out a physically demanding trade or those who experience age related degeneration (7). Various traumas, such as contusions, sprains, and strains, may induce acute myofascial trigger points with their onset possibly initiated by repetitive micro-injuries, including overload and overuse of muscle which can often lead to chronic myofascial trigger points (7).

The current gold standard for the diagnosis of MPS is the physical examination as described in The Trigger Point Manual (5) (Figure 2):

Palpation of a taut band; Diagnosis of MPS has been tissue specific and anatomically based on palpation of the skeletal muscle for MTrPs.
Identification of an exquisitely tender nodule (MTrP) in the taut band.
Reproduction of the patient's symptomatic pain with sustained pressure.

The diagnosis of myofascial trigger points heavily relies on digital palpation which has several limitations as this lacks adequate sensitivity and specificity. The nature of the symptoms are highly dependent upon the individual's perception of its characteristic qualities (e.g., boring, aching, sharp, etc.), intensity, distribution, and duration (5). Accurate diagnosis is dependent on the examiner's clinical experience, index of suspicion, training, and palpation skills.

History of MPS as a Diagnosis

The discovery of myofascial trigger points and muscle knots can date back to Guillaume de Baillous (1538-1616) of France who was one of the first to write in detail about muscle pain disorders. In 1816, the British physician Balfour associated “thickenings” and “nodular tumors” in muscle with local and regional muscle pain (5). In 1843, Froriep coined the term “muskelshwiele” (muscle callouses) to describe what he believed was a “callus” of deposited connective tissue in patients with rheumatic disorders (5).

In 1904, Gowers suggested that inflammation of fibrous tissue (i.e., “fibrositis”) created the hard nodules and Schade (1919) later proposed that the nodules should be termed as “myogeloses” (5). In the mid 1900s, important work was conducted independently by Michael Gutstein in Germany, Michael Kelly in Australia, and J.H. Kellgren in Britain. By injecting hypertonic saline into various anatomical structures such as fascia, tendon, and muscle in healthy volunteers, Kellgren was able to chart zones of referred pain in neighbouring and distant tissue (5).

The U.S. physician Janet Travell, whose work on myofascial pain, dysfunction, and trigger points is arguably the most comprehensive to date. Travell and Rinzler invented the term “myofascial trigger point” in the 1950s after understanding that nodules can be present and refer regional pain to both muscle and overlying fascia accompanied by increased muscle tension and reduced joint flexibility (5).

MPS has also been associated with other pain conditions including radiculopathies, joint dysfunction, disc pathology, tendonitis, craniomandibular (jaw) dysfunction, migraines, tension type headaches, carpal tunnel syndrome, computer-related disorders, whiplash-associated disorders, spinal dysfunction, pelvic pain and other urologic syndromes, post-herpetic neuralgia, and complex regional pain syndrome (5, 6).

MPS Is Different To Fibromyalgia

MPS is known to coincide with other diseases and syndromes associated with pain, e.g. rheumatic diseases and fibromyalgia.
However, fibromyalgia differs with it being a widespread and symmetrically-distributed pain condition associated with sleep and mood disturbances.

The pain of MPS is usually local or regional and may be found in a limited number of select quadrants of the body
and are thought to present independently of mood or sleep abnormalities with recent studies indicating that MPS is associated with both mood and sleep disruptions (5).
The definition and pathogenesis of MPS, however, is still not fully understood and disagreement still persists as to whether MPS is a disease or process rather than a syndrome.

The Role of Muscle and The Cinderella Hyposthesis

The Cinderella Fibre Hypothesis was first proposed by Hagg (1990) which explains how low level muscle damage can happen via low-threshold motor units (MUs) within muscles which are continuously activated during low level static exertions (LLSEs) (3, 7). Types of LLSEs or exertions are typically utilized by occupational groups such as office workers, musicians, hair dressers and dentists.

These "Cinderella" fibers are small low threshold muscle fibres which can become continuously overloaded and more prone to develop into myofascial trigger points as they are activated for longer and are more likely to be metabolically exhausted before other fibres. A study by Treaster et al. (2006) supports the Cinderella Hypothesis by demonstraeting that low-level, continuous muscle contractions such as the upper trapezius muscles within office workers during 30 minutes of typing induced formation of MTrPs. These muscle fibres contrast to larger motor muscle fibres which do not work as hard and spend less time being activated.

The "Cinderella" fibre theory is of interest to know, however, it does fail to explain all aspects of injury related to LLSEs and although low-threshold muscle fibres may fatigue and become metabolically exhausted, this does not explain how the muscle pain occurs (6).

The Energy (ATP) Deficit Hypothesis

A widely accepted hypothesis for the pathophysiology of myofascial pain is the energy crisis hypothesis. Trigger points may develop because some initiating events or activity causes an excessive release of acetylocholine (ACh) from the motor endplates resulting in increased fibre tension and localised ischemia which restricts the blood flow and creates insufficient ATP synthesis needed to restore energy (3, 7).

The increased demand and reduced supply of ATP forms the energy crisis and encourages the release of neuroreactive substances and metabolic byproducts (i.e., bradykinin (BK), substance P (SP), serotonin (5-HT)) which causes the peripheral nociceptors (pain receptors) to become sensitive (3).

The increased demand and reduced supply of ATP forms the energy crisis and encourages the release of neuroreactive substances and metabolic byproducts (i.e. bradykinin (BK), substance P (SP), serotonin (5-HT)) resulting to peripheral nociceptors to become sensitive (3, 7). Without ATP, the sarcoplasmic reticulum does not function correctly and the muscle sarcomeres remain contracted as the lack of energy (ATP) means that the the actin and myosin cross-bridges cannot disengage or release (5).

ATP is also needed by the calcium (Ca2+) pump to remove calcium (Ca2+) from the muscle binding sites and restore them to the sarcoplasmic reticulum to the myoplasm which leads to the activation of the actin-myosin contractile system (3). This happens as Calcium (Ca2+) binds to troponin on the muscle which makes the muscle fibres contract. Localised areas containing "contraction knots" are believed to release sensitizing agents and additional acetylcholine (ACh) that cycles back to cause increased fibre tension. A feedback loop to maintain contraction is created and a self perpetuating cycle is established. Until this positive-feedback loop is interrupted, the muscle sarcomeres at the TrP remain in a shortened state and creates a local energy crisis.

Critique to the Energy Deficit Theory

There is no explanation for the initiating event that causes the excessive release of ACh to occur in the first place and this theory also assumes that the motor endplates are the focus of attention for trigger point development.

There is no evidence suggesting that the endplates are responsible for trigger point development.
This theory fails to explain why MTrPs are more prevalent at certain 15 muscle locations than others (5).

Muscle Overuse and What Happens When Hyaluronic Acid (HA) Levels Rise

Hyaluronic acid (HA) functions as a lubricant and HELPS muscle fibres to glide between each other without friction.
Muscle overuse or traumatic injury can cause the sliding layers start producing immense amounts of HA which then aggregates into supermolecular structures changing both its configuration, viscoelasticity and viscosity (2, 5).

Due to its increased viscosity, HA can no longer function as an effective lubricant and instead increases resistance in the sliding layers and leads to densification of fascia or abnormal sliding of muscle fibres (2, 5). An interference with sliding can impact range of motion and cause difficulty with movement, including quality of movement and stiffness. In addition, under abnormal conditions, the friction results in increased neural hyperstimulation (irritation), which then hypersensitizes mechanoreceptors and nociceptors embedded within the fascia (2, 5). This hypersensitization correlates with a patient's experience of pain, allodynia, paresthesia, abnormal proprioception, and altered movement.

Treatment for Myofascial Trigger Points (MTrPs)

Treatment for myofascial trigger points mainly aims to inactivate the trigger points by reducing muscle tone, correct biomechanical imbalances or defaults which may maintain local muscle tensions (7). Different treatment approaches might be considered for the management of MTrPs including the following:

Dry Needling or Medical Acupuncture
Myofascial trigger points might be punctured using acupuncture needles and create local twicth response (LTR).

Massage and Hand Manipulation
Physically locating the MTrPs and apply various massage skills.

Stretches and Home Exercises
Either performed via self stretching or passive stretching techniques performed by the therapist. Postural and strength exercises might also be prescribed to help correct muscle imbalances. Exercises also aim to restore muscle length and flexibility along with strengthening and stabilisation (7).

Osteopathic Spinal and Peripheral Joint Manipulations
Osteopathic manipulations might be applied with the aim to reduce the tension within the local tendons and muscle attachments and reduce stiffness within the joints. One example of a manipulation techniques can be viewed in the below applied for the neck.

References

1. Hoyle, J. (2006) EFFECTS OF POSTURAL AND VISUAL STRESSORS ON TRIGGER POINT DEVELOPMENT, MUSCLE ACTIVITY, BLINK RATE, AND DISCOMFORT DURING COMPUTER WORK , Ohio University, MSC.

2. Marieb, Elaine Nicpon; Hoehn, Katja (2007). Human anatomy & physiology . Pearson Education. p. 133. ISBN 978-0-321-37294-9 .

3. Minerbi, A., Vulfsons, S. (2018) Challenging the Cinderella Hypothesis: A New Model for the Role of the Motor Unit Recruitment Pattern in the Pathogenesis of Myofascial Pain Syndrome in Postural Muscles , Rambam Maimonides Medical Journal, 9; 3: 1-8.

4. Nall, R. (2020) How To Treat Muscle Knots, Medical News Today; [online] https://www.medicalnewstoday.com/articles/321224#_noHeaderPrefixedContent , last viewed 24/11/2020.

5. Shah, J.P., Thaker, N., Heimur, J., et al. (2015) Myofascial Trigger Points Then & Now: A Historical and Scientific Perpective. Physical Medicine and Rehabilitation, 7:746-61.

6. Treaster, D., Marras, W. S., Burr, D., Sheedy, J. E., Hart, D. (2006) Myofascial Trigger Point Development From Visual and Postural Stressors During Computer Work. J Electromyogr Kinesiol. Apr;16 (2) :115–124.

7. Xiaoqiang, Z., Shusheng, T., Qiangmin, H. (2014) Understanding of Myofascial Trigger Points , Chinese Medical Journal, 127; 24: 1-7.

Hamstring Strains and Hamstring Syndrome.

Tue, 17 Nov 2020 19:41:31 GMT

Management, Nature & Treatment

Figure 1. The origins and insertions of the hamstring muscles with the sciatic nerve

Hamstring related injuries are commonly known to be associated with individuals who participate in sport and according to Ahmad et al., (2013) they account for around 29% of all injuries (1). Further statistics have included hamstring strains to make up around 50% of muscle injuries in sprinters, are most commonly found in hurdling and have an immense reinjury risk of 12% to 31%.

However, severe hamstring muscle tightness can be found in individuals who do not participate in sport with being found within the professional and trading industries as they are crucial for postural control and every day activity. Wilson et al., (2017) note how hamstring related injuries may also frequently occur in middle-aged individuals engaged in everyday activities, often as the result of a fall.
Desk bound office workers who find themselves prolonged sitting for many hours during the day in endless meetings and computer typing also commonly gain tight hamstring muscles from long hours being in a seated position. The differentiation between a hamstring tear and proximal hamstring syndrome or 'hamstring syndrome' and attempting to explain 'why' will be analysed and further studied.

Anatomy

The hamstring muscles found at the back of the leg are three muscles which run down the posterior thigh; semitendinosus, semimembranosus, and biceps femoris (long head) (5). They assist with bending the knee and extending the hip and play an important role in the performance of daily activities such as controlled movement of the trunk, walking, running, and jumping.

They are also important for maintaining balance and posture control whilst we stand. They significantly affect flexibility of the body, and taught hamstrings may result to reduced trunk stability and balance due to improper adjustment of the gluteus maximus and abdominal muscles (10). Inflammation of the tendons where they attach can lead to hamstrings tendinitis and injury is commonly seen in athletes and runners whose stride lengths are too long.

Figure 1 shows the posterior view of the sciatic nerve exiting the pelvis via the sciatic notch under the piriformis muscle and continues distally, lateral to the ischial tuberosity . In the proximal thigh, the long head of the biceps femoris crosses obliquely over the nerve (10).
From the posterior view, the sciatic nerve exits the pelvis through the sciatic notch under the piriformis muscle, then continues distally, lateral to the ischial tuberosity which is in close proximity. In the proximal thigh, the long head of the biceps femoris crosses obliquely over the nerve.

Hamstring Muscle Strains and Their Classifications

The clinical presentation of patients with a hamstring injury is related to the grade, location, and mechanism of injury (Alzahrani et al., (2015). Individuals who experience an acute hamstring strain injury will typically describe sudden onset of sharp, stabbing or twinge-like posterior thigh pain. Athletes or individuals performing a sudden vigorous activity may describe an audible “pop” which has been reported primarily in type II (overstretched) hamstring strains. The muscle strain usually stops them from continuing the activity or sport and they may present with a "stiff-legged" gait pattern to avoid simultaneous hip and knee flexion ( 1). Chu and Rho (2016) explain how there are two main types of acute hamstring strains; Type I and Type II.

Type I Acute Hamstring Strain
Mainly occurs during high-speed running during the terminal swing phase of running, when the hamstring muscles eccentrically contract to decelerate the swinging limb and prepare for foot strike (3,6). The long head of the biceps femoris is most commonly involved in this type of injury at the proximal muscle-tendon junction.

Type II Hamstring Strain
Occurs during excessive lengthening of the hamstrings, are more common during activities such as dancing, slide tackling and high kicking that combine hip flexion with knee extension (3). The proximal tendon of the semimembranosus, close to the ischial tuberosity is mostly involved and recovery has been shown to be prolonged compared to type I hamstring strains .

Proximal Hamstring injuries
Mild strains at this are of the hamstrings are less likely to seek medical attention as their symptoms typically alleviate within a few days post injury.
Those who experience a moderate to severe injury typically describe a feeling or hear a pop in the posterior aspect of the proximal thigh and hip area, a tearing sensation associated with sudden onset of posterior thigh pain distal to the ischial tuberosity with difficulty weight-bearing. Within a few days after the injury, patients usually notice the presence of ecchymosis (bruising) over the buttocks and the posterior aspect of the thigh which can extend down into the leg (2) .

Patients often have difficulty sitting as a result of pain at the avulsion site. In the early phase of injury, walking can be problematic for as long as four weeks and running is often impossible. Some patients can also present with an element of neuropathic posterior thigh dysesthesia. This clinical presentation, called gluteal sciatica, is related to compression of the sciatic nerve resulting from hematoma, the retracted tendon stump, or scarring and typically involves mainly the posterior cutaneous branch of the sciatic nerve.

Distal Hamstring Injuries
can have a similar presentation to that of patients with proximal injuries. Patients often report weakness in knee flexion as well as feeling a pop or a snap in the posterior aspect of the thigh associated with pain and stiffness in the injured area that prevents them from weight-bearing. Depending on the degree of tear, patients may have loss of active knee or hip flexion and in some cases may have difficulty with active extension. In patients with an isolated biceps femoris rupture, pain can be localized to the lateral or posterolateral aspect of the knee. In addition, cramps and spasms in the posterior aspect of the thigh are not uncommon. Patients with chronic injuries usually present because of profound weakness rather than pain. In addition, some patients present with gluteal sciatica symptoms due to excessive scarring in the area of injury and subsequent sciatic nerve tethering.

Physical examination grading system:
Hamstring muscle strain injuries have traditionally been classified with respect to their clinical presentation via a grading system with:

Grade 1= mild muscle strain, characterized by overstretching but minimal loss of the structural integrity of the muscle-tendon (1).
Grade 2 = moderate strain having partial or incomplete tearing.
Grade 3 = severe occurrence with complete muscle rupture.

MRI grading system for muscle injury includes:

Grade 1 = muscle without fibre disruption.
Grade 2 = muscle fibre disruption less than half the tendon or muscle width (a partial tear).
Grade 3 = tendon or muscle disruption less than half its width with a complete disruption of the unit, including an avulsion injury from the ischial tuberosity (grade 3) (1).

No clinician or healthcare practitioner can accurately prognose the length or rate of recovery after an injury (lie most health conditions) and it should be highlighted that the above traditional clinical and general MRI classifications can only be used as a guide to predict the return to play or activity after a sports related hamstring muscle injury (1).

Several authors, however, have tried to attempt predicting athletes' length of recovery time before they can return to play or competition. Interestingly, proximal hamstring muscle injuries demonstrated a prolonged time to return to play. According to Ahmad et al., (2016), one study found that eighty three elite Australian rules football players with clinically diagnosed hamstring strains who had MRI features of a hamstring injury averaged 27 days missed from competition and those with no changes on MRI missed an average of 16 days (1).

Another classification system is based on the anatomical location of the injury, including (2):

Proximal (injury of the tendon origin at the ischial tuberosity)
Central (injury of the muscle belly, which is by far the most common pattern)
Distal (injury of the distal musculotendinous insertion and tendons)

Acute Proximal Hamstring Strain
Mild strains at this area of the hamstrings are less likely to seek medical attention as their symptoms typically alleviate within a few days post injury. Those who experience a moderate to severe injury whilst participating in an activity typically describe a feeling or hear a "pop" in the posterior aspect of the proximal thigh and hip area, a tearing sensation associated with sudden onset of posterior thigh pain distal to the ischial tuberosity with difficulty weight-bearing (2,3). Within a few days after the injury, patients usually notice the presence of ecchymosis (bruising) over the buttocks and the posterior aspect of the thigh can extend down into the leg (2,3).

Patients often have difficulty sitting as a result of pain at the avulsion site. In the early phase of the injury, walking can be problematic for as long as four weeks and running is often impossible. Some patients can also present with an element of neuropathic posterior thigh dysesthesia or altered sensations (1). This clinical presentation, called gluteal sciatica, is related to compression of the sciatic nerve resulting from hematoma, the retracted tendon stump, or scarring and typically involves mainly the posterior cutaneous branch of the sciatic nerve (1,2).

According Chu and Rho (2016), patients with chronic proximal hamstring tendinopathy do not usually recall a specific inciting event, and report gradual increase of pain in the posterior thigh. The pain is often described as tightness or cramping in the posterior thigh or deep buttock, located close to or at the ischial tuberosity ( 3). Pain can extend down the posterior thigh distally to the popliteal fossa and symptoms can be exacerbated with repetitive eccentric hamstring contraction, forward flexion of the trunk and with running and pain whilst sitting (3).

Distal Hamstring Injuries
can have a similar presentation to that of patients with proximal injuries. Patients often report weakness in knee flexion as well as feeling a pop or a snap in the posterior aspect of the thigh associated with pain and stiffness in the injured area that prevents them from weight-bearing. Depending on the degree of tear, patients may have loss of active knee or hip flexion and in some cases may have difficulty with active extension. In patients with an isolated biceps femoris rupture, pain can be localized to the lateral or posterolateral aspect of the knee (4,6,9). In addition, cramps and spasms in the posterior aspect of the thigh are not uncommon. Patients with chronic injuries usually present because of profound weakness rather than pain. In addition, some patients present with gluteal sciatica symptoms due to excessive scarring in the area of injury and subsequent sciatic nerve tethering (2,3,4).

Hamstring Syndrome

A serious complication of nonoperatively treated proximal hamstring injuries is "hamstring syndrome". According to Saikku et al., ( 2010), the term "hamstrings syndrome" was first brought about by an orthopadic surgeon, Dr Puranen, who published a report on a series of six surgically treated patients who had entrapment of the proximal sciatic nerve caused by fibrotic hamstring tendons (9).

This condition usually presents as local posterior buttock pain with persistent pain at the ischial tuberosity and proximal hamstring regions. The condition is made worse by sitting and may be associated to previous hamstrings injury or tendinopathy (8, 9,11). Pain may also be made worse by fast running and stretching or exercising the posterior thigh.

Hamstrings syndrome could be perceived as a neurological related condition, as its occurrence is mainly secondary to tendinous bands of the hamstring muscles entrapping or scarring around the sciatic nerve due to fibrosis of the injured hamstring tendon (2, 9). Scarring leads to tethering of the nerve, especially with specific positions, including sitting or positions that involve stretching the hamstring muscles which may lead to sciatica related pain (2).

Proximal sciatic nerve entrapment via the hamstring fibrotic bands entrapping the sciatic nerve can irrevocably lead to the need of surgical intervention (10). Various authors have concluded that a complete neurolysis of the sciatic nerve from adherent tissue was an essential component for the need of operative treatment (2,8,9).

Orthopaedic surgeons; Puranen and Orava (1998) reported to have had successful results of surgical intervention after obtaining relief in 52 of 59 patients after the division of taught, fibrous bands of the hamstrings (9). They both developed the Puranen-Orava test to help diagnose proximal hamstring tendinopathy which involves a standing test that actively stretches the hamstring when the hip is flexed to 90 degrees with the knee fully extended and the foot is on a support 90 degrees to the standing body (3,9).

Treatment Management, How Can Physical Therapy Help?

The main purpose of any rehabilitation program following nonoperative treatment of a hamstring injury is to restore the preinjury level of function and to control the pain and inflammation ( Alzahrani et al., 2015).

Physical Therapy
Single-tendon avulsions and 2 tendon tears with retraction of less than 2 cm are treated nonoperatively (2).
Three phases of rehabilitation for acute hamstring strains are usually followed with phase 1 focusing on decreasing pain and edema and preventing of scar tissue formation (2,3).

Phase I
Initial management of hamstring strains in the acute phase includes the RICE protocol of rest, ice, compression and elevation along with NSAIDs. Athletes are encouraged to shorten their strides during whilst walking and use crutches for more moderate or severe injuries (3). Trunk stabilisation exercises can be performed, but exercises should be performed within a limited and protected range of movement and isolated resistance or excessive stretching exercises of the affected hamstring muscle should be avoided. Progression to phase II may occur when the athlete is able to walk normally without pain, jog at very low speeds without pain and perform pain-free isometric hamstring contraction exercises with prone knee flexion at 90 degrees against submaximal resistance at 50–70% effort (1,2,3).

Phase II

Involves a gentle increase in intensity of activity and exercise to improve range of motion, introduce eccentric resistant exercises, and neuromuscular training at faster speeds. Exercises involve a gradual increase in range of motion and lengthening of the hamstrings. Hamstring lengthening to end range of motion is avoided as there is still weakness within the muscle during this phase (4).

Eccentric strengthening exercises for the hamstrings are initiated as they have been demonstrated to be effective treatment for tendinopathy (3). Progression to Phase III occurs when there is full strength of the hamstring without pain when performing 1 repetition of maximum isometric contraction with prone knee flexion at 90 degrees, and the athlete can jog forward and backward at 50% maximum speed without pain.

Phase III

At this stage, rehabilitation involves more advanced neuromuscular control and eccentric strengthening exercises as well as sport/ activity-specific exercises with the goal of returning the athlete to play. Progressive ability and trunk stabilization exercises should incorporate more sport-specific drills and dynamic agility exercises. Eccentric hamstring strengthening exercises can be progressed toward end range of motion by e.g. using hamstring curl machines, reverse cable curls, weight bearing hamstring curls on exercise ball, reverse plank, kneeling Nordic leg curl, standing single or double leg dead lifts (3). Return to sport criteria include no pain with palpation over the injury site, full concentric and eccentric strength of the hamstrings without pain.

Other nonoperative physical therapy management methods may consist of medical acupuncture, electrotherapy e.g. ultrasound, electrical stimulation, rock tape and soft tissue massage along with prescribing exercises.

Steroid Injections
Ultrasound-guided corticosteroid injection can be used to provide initial relief in up to 50% of patients at 4 weeks. An alternative to corticosteroid injections includes Platelet-rich plasma (PRP) therapy performed under computed tomography or ultrasound guidance, which has similar outcomes to corticosteroid in experienced hands. These injuries may take up to 6 weeks for initial healing. In single-tendon tears, 6 weeks allows the tendon time to fibrose to the intact tendons, often allowing the initiation of limited activity.

Operative Treatment
Operative treatment is recommended for acute proximal hamstring injuries in which all three hamstring tendons are avulsed from the ischial tuberosity. Acute injuries are easier to repair, and early repair has shown excellent functional results. Operative treatment is considered in cases of high-grade two tendon injuries with more than 2 cm of retraction, especially in athletes participating in sports requiring the maintenance of a seated position under eccentric loads to the hamstrings (e.g., waterskiing, rodeo, kite surfing) (2,3,10). The goal of treatment of these injuries is to restore muscular and osseous attachments. Several techniques have been described, and most involve the use of suture anchors for approximation of the muscular rupture or avulsion to the ischial tuberosity.

Operative intervention is usually considered for chronic injuries if the patient cannot return to his or her desired activity because of persistent weakness, pain, or both and nonoperative treatment efforts have not worked (2,3). Delayed operative repair of complete proximal ruptures has found to have worse postoperative strength, with the potential for sciatic nerve involvement by surrounding scar tissue formation.

Potential treatment modalities at the clinic can be viewed in the video below.

References

1. Ahmad, C. S., Redler, L, H., Ciccotti, M. G., Maffulli, N., Longo, U. G., Bradley, J. (2013) Evaluation and Management of Hamstring Injuries , The American Journal of Sports Medicine: 1-15.

2. Alzahrani, M. M., Aldebeyan, S., Abduljabbar, F., Martineau, P. A. (2015) Hamstring Injuries in Athletes: Diagnosis and Treatment , 3; 6: 1-11.

3. Chu, S, K., Rho, M. E. (2016) Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play , Curr Sports Med Rep, 15(3): 184–190.

4. Fatima, G., Qamar, M. M., Hassan, J. Ul., Basharat, A. (2017) Extended sitting can cause hamstring tightness , Saudi Journal of Sports Medicine, 17; 2:

5. van der Made. A. D., Wieldraaijer, T., Engebretsen, L., Kerkhoffs, G. M. M. J. (2014) Hamstring Muscle Injury, Acute Muscle Injuries: 27-44.

6. Martin. H, D. Khoury. A., Schröder, R., Palmer. I. A. (2016) Ischiofemoral Impingement and Hamstrings Syndrome Distal Causes of Deep Gluteal Syndrome, Clin Sports Med; 35: 469–486 .

7. Martin, H. D., Shears, S. A., Johnson, C. J., Smathers, A. M., Palmer, I. J. (2011) The Endoscopic Treatment of Sciatic Nerve Entrapment/ Deep Gluteal Syndrome ; Arthroscopy, The Journal of Arthroscopic and Related Surgery, 27; 2: 172-181.

8. Parka, J., Chab, J., Kimb, H., Asakawa, Y. (2014) Immediate effects of a neurodynamic sciatic nerve sliding technique on hamstring flexibility and postural balance in healthy adults, Physical Therapy Rehabilitation Science, 3; 1: 38-42.

9. Puranen. J ., Orava, S . (1988) The Hamstring Syndrome. A New Diagnosis of Gluteal Sciatic Pain , 16; 5: 517-521.

10. Saikku, K., Vasenius, J., Saar, P. (2010) Entrapment of the Proximal Sciatic Nerve by the Hamstring Tendons, Acta Orthopædica Belgica; 76: 321-324.

11. Vaghef, S. H. E., Samereh Dehghani Soltani1 , Abdolreza Babaee (2017) An Uncommon Anatomical Variation of the Sciatic Nerve , 14; 2: 97-100.

12. Wilson, T. J., Spinner, R. J., Mohan, R., Gibbs, C. M., Krych, A. J. Sciatic Nerve Injury After Proximal Hamstring Avulsion and Repair , The Orthopaedic Journal of Sports Medicine, 5; 7: 1-8.

The Brachial Plexus Within the Neck; from Roots to Cords

Thu, 15 Oct 2020 00:00:00 GMT

The Brachial Plexus (C5, C6, C7, C8 & T1)

The brachial plexus transmits signals for motor and sensory innervation and supplies and controls the skin, musculature, sensations and movements for the upper extremities including the shoulder, arm, and hands. Without our brachial plexus, we would be unable to perform the various movements which we automatically perform on a daily basis with our upper limbs.

Both 'brachial' and 'plexus' are Latin words, with 'Brachial' stemming from 'brachialis', meaning 'belonging to the arm'. The term 'plexus' means a network (i.e. blood vessels or nerves) or a structure containing a complex network of parts (1).
The plexus starts in the neck and is positioned between the neck muscles of the anterior and middle scalenes before passing through the axilla (or armpit) and descending down the arm to supply and innervate muscles, joints and skin of the whole arm and hand (10).

Knowing the brachial plexus and its neural branches is important for practitioners to know, as it can help determine whether a portion of the brachial plexus has been injured which can help tell us which of the associated muscles might be affected before being tested for evidence of a nerve injury (4).

The Brachial Plexus; A Neural Network

As the nerve roots exit the cervical and thoracicintervertebral foramen, or bony openings found between adjacent vertebrae, they unite and branch in the following order: roots, trunks, divisions, cords, terminal branches (and peripheral nerves) (10, 3). A helpful mnemonic for this is; R ead T hat D eadly C adaver B ook (10). There is no difference in terms of function between each division and they are simply used as an aid to further explain or remember the brachial plexus (10).

The Roots
The first section of the brachial plexus with each spinal level having four nerve roots as there are two spinal nerve roots for the left and right side; the posterior (dorsal) and anterior (ventral) nerve roots. The anterior (ventral) nerve roots carry motor signals from the brain to the muscles and the posterior (dorsal) roots carry sensory signals from the skin to the brain (10). The anterior and posterior roots combine to form a spinal nerve at each intervertebral foramen (9).

The brachial plexus is formed by the anterior rami of cervical spinal nerves C5, C6, C7 and C8, and the first thoracic spinal nerve, T1. They unite in the neck between the anterior and middle scalene muscles, to form the trunks after the roots. The emergence of each root can be read below and followed from figure 1 and figure 2:
1st root : arises from the anterior ramus of C5 above the 5th cervical vertebra (figure 1.).
2nd root: Arises from the anterior ramus of C6 below C5.
3rd root: From the anterior ramus of C7 below C6.
4th root: From the anterior ramus of C8 emerges above the first thoracic vertebra.
5th root: Arises from the anterior ramus of T1 emerges below the first thoracic vertebra (3).

The Trunks

The three trunks of the brachial plexus originate from the roots and are located within the lower part of the posterior cervical triangle, they passes laterally over the first rib before entering the axilla (2, 3).

The Superior Trunk: The first of the three trunks is the upper (superior) trunk and is formed by the union of the anterior rami of C5 and C6. Two nerves arise from the superior trunk which are the subclavian nerve and the suprascapular nerve.

The Middle Trunk: The second trunk or the middle trunk originates directly from the anterior ramus of C7.

The Inferior Trunk: is composed of two nerves via the anterior rami of C8 and T1.

Each trunk then divides into anterior and posterior divisions which pass beneath the clavicle where there are no nerve branches at this level as can be seen from my painting in figure 1 where the dotted golden lines represent the divisions that pass beneath the clavicle (4).

The Divisions

Overall, there are six divisions comprising of an anterior and posterior division from each of the three trunks with three anterior division fibres supplying flexor muscles and ultimately give rise to nerves associated with the anterior compartments of the upper limb (3). The posterior division fibres tend to supply extensor muscles and give rise to nerves associated with the posterior compartments of the upper limb (3).

The Cords
The cords are the fourth section of the brachial plexus, are named based on their positioning with respect to the axillary artery found distally to the clavicle and at this level are termed 'the infraclavicular brachial plexus ' (5) (Figure 6). The cords, axillary artery and vein are located deep to the pectoralis minor and major muscles in the infraclavicular fossa and is a target site for anaesthesia of the upper limb and for brachial plexus nerve blocks.

The cords are formed as follows:

The Lateral Cord (on top):
The lateral cord gives gives a branch to the lateral root (or 'head') of the median nerve and gives rise to the lateral pectoral nerve before it continues into the upper limb as the musculocutaneous nerve (figure 1 and 2).
The distal branch of the lateral cord, the lateral pectoral nerve, innervates the clavicular head of the pectoralis major and weakness indicates lateral cord injury (4).

The Posterior Cord (in the middle):
The posterior divisions of all three trunks unite to form the posterior cord which means that they receive input from all levels of the brachial plexus (C5 to TI). The posterior cord gives rise to three branches before it terminates as the axillary nerve and the radial nerve; namely, the upper subscapular nerve, the thoracodorsal nerve and the lower subscapular nerve.

The Medial Cord (at the bottom):
The medial cord is the continuation of the anterior division of the inferior trunk, and like the posterior cord, it gives off three branches before it terminates as the ulnar nerve. These branches are the medial pectoral nerve, the cutaneous nerve of the arm, and the cutaneous nerve of the forearm (figure 1 and 2).

Injuries:

Medial Cord Injury:
The union of the two anterior divisions of the superior (or upper) and middle trunks form the medial cord. The medial cord gives a branch; the medial root of the median nerve and continues as the ulnar nerve (Figure 2) (3).

Injury to Medial and Lateral Cords and How it May Affect the Pectoralis Major Muscle:
The medial pectoral nerve that arises from the medial cord and with the branches from the lateral pectoral nerve from the lateral cord innervate the sternocostal head of the pectoralis major muscle (4). Examination of the pectoral major muscle is necessary to localize a cord level injury as pectoralis major clavicular head (which creates humeral flexion) involvement implies lateral pectoral nerve injury and sternocostal head (which adducts the humerus) involvement of the pectoralis major implies injury to both the lateral and medial pectoralis nerves, i.e. both medial and lateral cords (4).

Erb-Duchenne Palsy - Upper Brachial Plexus Injury

Also known as 'waiter's tip deformity' and named after the neurologists Wilhelm Erb and Duchenne de Boulogne who first described this condition which commonly occurs during an excessive increased angle between the neck and shoulder. Anatomically, the cephalic portion of the brachial plexus C5, C6 and occasionally C7 is either stretched and or at worse torn which can happen during child birth or shoulder trauma (e.g. motor bike accidents or sports e.g. during rugby scrums) (10).

Typically, the presentation of an affected limb is to hang limply and be held in adduction with internal rotation at the shoulder jointfrom the unopposed action of the pectoralis major muscle (10). At the elbow joint, there is extension and pronation caused by atrophic muscle changes within biceps brachii and spasticity of the wrist flexors along with flexion of the fingers (10). This overall presentation has contributed towards the term "waiter's tip deformity". The typical symptom is numbness (anaesthesia) along the lateral aspect of the arm.

The most commonly involved nerves include suprascapular nerve, musculocutaneous nerve, axillary nerve and nerve to subclavius. The muscles which are affected include deltoid, supraspinatus, teres minor, subclavius, infraspinatus, biceps, supinator, coracobrachialis, and brachioradialis muscles of the upper limb (10).

In a neonate post birth, the neurological examination is characterized by the absence of Moro’s, biceps, and triceps reflexes of the affected upper limb with the presence of grasp reflexes as interossei muscles are not affected (8). Sometimes diaphragmatic paralysis is also seen if associated paralysis involves C3 and C4. At this age, treatment involves conservative management with performing physiotherapy and exercises to prevent muscle contracture which starts 7-10 days post injury and overall has excellent prognosis with good neurological outcome (8).

Klumpke's Palsy: Lower Brachial Plexus Injury

Named after the French neurologist; Augusta Dejerine-Klumpke, Klumpke's palsy is a neuropathy and rare form of paralysis involving the muscles of the forearm and hand. It is the result from a lower brachial plexus injury in which the eighth cervical (C8) and first thoracic (T1) nerves are affected. Interestingly, Merryman and Varacallo (2018) have found that approximately 50% of all brachial plexus injuries happen between the age of 19 to 34 (2).

The injury is usually caused via traction on an abducted arm in circumstances from e.g. a neonate being pulled from the birth canal by an extended arm above the head or with someone catching themselves by a branch as they fall from a tree (11).Another cause could be from a compression injury and cause similar signs and symptoms via an apex lung tumor which may press on the cervical sympathetic ganglia of C8 to T1 nerve roots and sympathetic involvement can cause a Horner's syndrome presentation (7).

The classic presentation of Klumpke's palsy is the “claw hand”, as all the intrinsic muscles of the hand are affected with a supinated forearm, the wrist becomes extended with the fingers flexed. If Horner syndrome is present, there is miosis (constriction of the pupils) in the affected eye (11). Thus, the ulnar and medain nerves are affected and a loss of sensation along the medial side of the arm is usually reported (10).

For an open related injury i.e. there is an open fracture,obvious break through the skinor severe vascular compromise, emergency surgery in this instance would required. For closed injuries, conservative treatment via physiotherapy may includes strengthening and stretching exercises the supportive and affected surrounding muscles to help maintain the range of motion and aid a full recovery (7).

If there is no improvement post 3 to 6 months of injury, surgery would be a requirement which would involve nerve grafting. In cases of injuries proximal to the dorsal root ganglion, neurotization or nerve transfer is most recommended which can be defined as 'the transfer of a healthy but less valuable nerve or its proximal stump reinnervating a more important sensory or motor territory that has lost its innervation through irreparable damage to its nerve' (6). Merryman and Varacallo (2018) note that in most cases, the nerves will eventually heal and spontaneous recovery from nerve palsy is possible, but most C8-T1 nerve palsies do not recover without intervention.

How Might Osteopathic Treatment Help?

After performing a clinical assessment, osteopathic manual therapy treatment techniques might be applied to the muscles and joints of the upper ribs, neck and mid back. Home exercise advise might be given to improve related muscular strength and posture control.

References

1. Dictionary.com, https://www.dictionary.com/browse/brachial , [online] last viewed 11/10/2020

2. Kattan, A. E., Gregory H. Borschel, G. H. (2011) Anatomy of the Brachial Plexus, Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach ; 4: 107-111.

3. Kenhub (2020) https://www.kenhub.com/en/study/the-brachial-plexus [online] last viewed 18/10/2020.

4. Kim, D. H., Murovic, J. A., Kline, D. G. (2004) Brachial Plexus Injury : Mechanisms, Surgical Treatment and Outcomes,
https://www.jkns.or.kr/upload/pdf/0042004153.pdf [online] last viewed 11/10/2020 .

5. D’amore, A., Conte, G., Viglianesi, A., Chiaramonte, R., PERO, G. Chiaramonte. (2010) Evaluation of a Patient with Klumpke’s Palsy A Case Report, The Neuroradiology Journal; 23: 325-328.

6. Narakas, A. O., Hentz, V. R. (1988) Neurotization in Brachial Plexus Injuries Indication and Results, Clinical Orthopaedics and Related Research; 237: 43-56.

7. Merryman, J., Varacallo, M. (2018) Klumpke Palsy, StatPearls, NCBI Bookshelf: 1-4.

8. Patil, D. Y. (2016) Duchenne-Erb’s palsy in newborn: Result of birth trauma, Medical Journal of Dr. D.Y. Patil University, 9; 2: 274-276.

9. Snell, R. S. (2007) Clinical Anatomy By Systems, Lippincott Williams & Wilkins.

10. Teach Me Anatomy; The Brachial Plexus, plexus https://teachmeanatomy.info/upper-limb/nerves/brachial-plexus/ [Online] Last visited 13/10/2020.

11. Wikipedia, Klumpke Paralysis, https://en.wikipedia.org/wiki/Klumpke_paralysis , [online] last viewed 18/10/2020 .

Wrist & Hand: Carpal Tunnel Syndrome (CTS)

Mon, 10 Aug 2020 05:59:59 GMT

Anatomy, Cause & Treatment Options

Carpal Tunnel Syndrome (CTS) is the most common entrapament neuropathy of the upper limb (3). The condition is a compressive neuropathy caused by a mechanical distortion by producing a compressive force and compression of the median nerve (2). The pathology is known to be more common in females than males with a 7:3 ratio and known to be more prevalent during the fourth to seventh decades, but can occur in all age groups.

Symptoms

Most individuals may complain of aching, tingling, burning or numbness within the hand localised to the first three and half digits and sensory distribution of the median nerve with intermittent aching pain in the wrist and or numbness at the tips of the thumb, index finger, middle finger, and radial half of the ring finger (3, 5, 7). Symptoms are typically worse in the morning and night and often made worse by strenuous wrist movements which becomes more persistent as the entrapment worsens (3, 5).

A progression of symptoms of CTS involve muscular weakness and atrophy can occur within the thenar eminence at the base of the thumb. Individuals can often experience an abnormally large increase in carpal tunnel pressure, especially during extreme wrist motions and whilst making a fist (3).

Risk Factors & Cause For CTS

Activities that often implicate the symptoms in individuals are those who perform and create repetitive movements of the surrounding tendons and thus cause compression of the median nerve within the carpal tunnel.
Such activities may include typing, knitting, dishwashing and house work related activities, driving, painting, gardening, lifting and DIY.

Prolonged use of computer keyboards can strain structures within the wrist and hand (5). Typing on the keyboard has proved to create a significant increase whilst typing with greater wrist extension or radial deviation (5).

Other activities that may irritate the structures are trading industries, especially within the building trade who constantly perform twisting or aggressive jarring movements with their hands or wrists whilst using hammers or drills. Therapists (in all sectors) along with those in office related jobs and regularly use laptops or the mouse. It is also common to see amongst individuals who perform heavy lifting of weights, pushing heavy weights via lifting bars at the gym or difficult objects in warehouses and building sites (3).

Medical Conditions:
Some medical conditions are associated with carpal tunnel syndrome and may include (3):

Pregnancy
Lactation
Menstrual cycles
Oral contraceptive use
Menopause
Diabetes mellitus
Pyridoxine deficiency
Toxic shock syndrome
Chronic haemodialysis
Osteoarthritis of the carpal bones
Rheumatoid arthritis
Obesity
Amyloidosis
Mucolipidosis (metabolic disorder)
Chondromalacia
Myxoedema (advanced hypothyroidism)
Acromegaly
Congenitally small carpal tunnel
Athetoid dystonic cerebral palsy; a movement disorder caused by damage to the developing brain.

Many of the above conditions are usually diagnosed before the occurrence of CTS and the aetiology (or cause) would have already been established (3, 5). Individuals with CTS tend to initially present with intermittent symptoms that may be worse at night or with repetitive upper-extremity activity. The symptoms may improve with splinting, repositioning or vigorous shaking of the hand (1).

Anatomy

The boundaries of the carpal tunnel consist of the carpal bones which form the floor (Trapezium, Trapezoid, Capitate, Hamate); and the flexor retinaculum which is situated between the transverse carpal ligament (CL) (also known as the flexor retinaculum) which is positioned superiorly along with nine flexor tendons; flexor digitorum superficialis, flexor digitorum profundus (x 5) (3, 5). The flexor pollicis longus tendons also pass through the carpal tunnel. The carpal bones; the scaphoid and trapezium are positioned inferiorly. The tendons are surrounded by synovial sheaths which is designed to reduce friction between the structures (3).

Within the tunnel, the median nerve divides into a muscular branch to supply the thenar eminence and palmer digital branch to supply sensation of the palmer aspect of the lateral three and half digits and lateral two lumbricals.

Course of the Median Nerve

The median nerve originates from the lateral and medial cords of the brachial plexus and has contributions from ventral cervical nerve roots C5 to C7 (lateral cord) and C8 and T1 (medial cord) (3, 8). Some sources report that the nerve only sometimes receives fibres from C5 and mainly originates from C6-T1 nerve fibres (4).

The median nerve is formed from the medial and lateral cords of the brachial plexus as the nerves merge within the axilla (6). The median nerve continues travelling down the arm alongside the brachial artery and supplies no innervation to any muscle here as there are no branches above the cubital / antecubital fossa (or the " elbow pit" or small triangular depression within the arm) (3, 4). The median nerve then enters the cubital fossa and passes between two heads of the pronator teres and continues to pass into the forearm between flexor digitorum profundus and flexor digitorum superficialis muscles, otherwise known as the wrist flexors.

Below shows a labelled picture for the path of the median nerve and its branches (figure 1):

Sensory Distribution of the Median Nerve

The median nerve supplies the sensation of the skin that naturally makes contact in a pinching motion between the thumb and fingers.

Sensory supply for the median nerve of the skin in the hand (6):

The skin of the palmar and distal dorsal aspects of the lateral 3 and 1/2 (three-and-the-half) digits and adjacent palm.
The skin of the palmar and distal dorsal aspects of the thumb and radial half of 2nd digit.
The skin of palmar and distal dorsal aspects of the adjacent sides of 2nd–4th digits.
The skin of the central palm.

Sufferers can commonly feel a sensation of numbness or pain in the hand which can occasionally refer into the forearm and may experience weakness and reduced active range of movement within the wrist and finger particularly the thumb (radial) side of the hand (3).

Treatment For Carpal Tunnel Syndrome

Wrist Splints: which can be worn during the day and at night. The splint can hold your wrist still whilst sleeping and can help relieve nighttime symptoms of tingling and numbness (1).
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Cortisone injection : pending on severity. Ultra sound guided cortisone injection by a qualified doctor is greatly encouraged for accuracy and efficiency.
Surgery: Decompression surgery may be appropriate if your symptoms are severe or don't respond to other treatments (1).

How Could Osteopathy & The Clinic Help?

Ultrasound Electrotherapy
Therapeutic ultrasound is provided at the clinic. This form of treatment is a modality that produces acoustical high-frequency vibrations (sound waves) via both thermal and non-thermal effects to the injured sight or area that is being treated (1). Deep, pulsed ultrasound over the carpal tunnel aims to reduce pain and paresthesia symptoms, sensory loss, and improves median nerve conduction and strength when compared with sham ultrasound (1). Ultrasound treatment can also provide a positive effect on sensation and patient-reported symptoms.

Posture Control and Educating 'Ideal' Spinal Alignment
It might not be commonly discussed amongst primary health setting or have enough clinical evidence to suggest that this approach may work. But, my clinical experience has taught me that neck, head, shoulder, upper back positioning and educating patients 'ideal' posture alignment and can play a big role to help upper limb pain. This approach does take patience and practice but successful results have been observed for elbow as well as wrist pain, amongst other complaints.

Massage and Sports Massage Treatment
This might be applied to structures around the affected sights and areas such as the neck, upper back, outer shoulder (e.g. deltoid muscles) as well as the hand.

Exercises: which may involve and be applied for the wrist, hand, neck, shoulder, elbow along with posture control.

Rocktape/ Kinesiology Tape

Medical acupuncture

Gentle Spinal and Joint Manipulations
This is only performed if the techniques are redeemed appropriate. Patient informed consent must be received for each treatment modality.

References

1.) Carlson, H., Colbert, A., Frydl, J., Arnall, E., Elliot, M., Carlson, N. (2010) Current options for nonsurgical management of carpal tunnel syndrome, National Institute of Health, 5(1): 129–142.

2.) Ibrahim, I., Khan, W. S., Goddard, N., Smitham, P. (2012) Carpal Tunnel Syndrome: A Review of the Recent Literature, The Open Orthopedics Journal; 6: 69-76.

3.) Kanaan, N., Sawaya, R. A. (2001) Carpal Tunnel Syndrome: Modern Diagnostic and Management Techniques, British Journal of General Practice, 51:311-314.

4.) McNamara, B. (2003) Clinical Anatomy of the Median Nerve , Anatomy Primer, ACNR, 2: 19 - 20.

5.) Neumann, D. A. (2010) Kinesiology of the Musculoskeletal System; Foundations for Rehabilitation 2nd Ed., Mosby Elsevier.

6.) Shahid, S. (2020) Median Nerve, Kenhub, online: https://www.kenhub.com/en/library/anatomy/the-median-nerve (last visited 09/08/2020).

7.) Singh, V., Ericson, W. B. (2016) Median Nerve Entrapments, Springer International Publishing Switzerland, 369-382.

8.) Wikepedia (2020) Median Nerve, online: https://en.wikipedia.org/wiki/Median_nerve (last visited 09/08/2020).

Lower back pain and Sciatica

Tue, 30 Jun 2020 10:44:01 GMT

Anatomy, Pathology & Management

Sciatica accompanies about 10% of lower back pain episodes and nerve root compression by disc herniation is known to be a common cause of sciatica (7). It is estimated that 90% of sciatica cases are the result of a disc herniation or disc bulge in the lumbar spine that compresses on the sciatic nerve root (5).

Symptomatic disc herniation is therefore probably a common presentation in osteopathic clinics. Three categories of disc herniation are generally recognised, consisting of disc protrusions (in which the nuclear material protrudes or bulges against the annulus), extrusions (in which the nuclear material escapes the border of the annulus), and sequestration (when the extruded nuclear material loses contact with the remaining disc nucleus) (7).

Sciatica is mainly diagnosed via case history taking and physical examination, individuals may be asked to report the distribution of their pain and whether they are experiencing radiation below the knee. Symptoms of sciatica is commonly a radiating shooting pain and/or the experience of numbness or tingling down the back of one or both legs which is also known as radiculopathy (9, 17). It may include the inability to walk depending upon where the pressure of the sciatic nerve occurs (18).

Statistically, approximately 60% of patients visiting primary healthcare with lower back pain (LBP) report back-related leg pain and it is estimated 5%-10% of patients with LBP have sciatica (9). The annual prevalence of intervertebral disc related sciatica in the general population is estimated to be 2.2% of all cases (9).

Anatomy

The sciatic nerve (SN) is formed in the pelvis by the joining the ventral rami L4-S3 SN roots (22) (figure 1). It travels inferiorly into the pelvic surface of the coccygeus muscle and enters the gluteal region. The SN leaves the pelvis through the greater sciatic foramen below the piriformis muscle and passes deep to the gluteus maximus (buttock) muscle before descending between the greater trochanter and ischial tuberosity in the gluteal region. The trunk of the sciatic nerve innervates the proximal parts of all three hamstrings muscles (semi membranosus, Semi tendonosus and Biceps Femoris) and ischial aspect of the adductor muscles (4).

The sciatic nerve then divides at the apex of the popliteal fossa into two main branches; the tibial nerve and the common fibular nerve (figure 1).
After the SN bifurcation, the tibial component innervates the semi membranosus, semi tendinosus, long head of biceps femoris muscles and adductor magnus. The short head of the biceps femoris is innervated via the common peroneal component of the SN.

Risk Factors

Age: commonly between 45 - 64 years

Height

Mental Stress

Cigarette smoking

Exposure to vibration from vehicles

Obesity / being overweight

Heavy labor / strenous physical activity

Full time desk jobs

Occupation factors

Poor posture (although not proven)

Occupational workload, such as carrying heavy items, bending, or kneeling (14, 15), and body height

Men Vs Women
Self-reported lumbar radicular pain is more prevalent among women (25), and they seem to experience slower recovery from
severe sciatica (54), while men have a higher incidence of hospitalization and surgery due to sciatica.

Obesity
Obesity may slow down the healing of a disc injury and interfere with the nutrition of the intervertebral discs, leading to an impaired healing process. Carrying excess weight may also contribute to the development of chronic, low-grade inflammation within the spine through the release of inflammatory mediators from excess adipose tissue. Obesity-related chronic inflammation may lead to the development of sciatica or the persistence of sciatica symptoms. In a 3-year follow-up study of sciatica patients, BMI was the strongest predictor of incident lumbar artery occlusion, which also suggests that impairment of nutrition can be one of the pathways of obesity’s relationship with sciatica.

Common Symptoms

Unilateral leg pain is greater than lower back pain (9).
Radiated pain below the knee into the foot or toes with either numbness or paraesthesia in the same distribution (radiculopathy symptoms).
Referred leg pain not related to a nerve root pathology (10).
Radiated pain with a dermatomal pattern.
Lower back pain.

Common Causes

Herniated Intervertebral Disc: Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space (8).
Sciatic Nerve Entrapment: May occur from the pelvis to the distal thigh. The most common site is between the greater sciatic notch and ischial tuberosity and by the piriformis muscle. Myositis ossificans (bone tissue formation inside muscle) of the biceps femoris muscle is another possible site. Biceps femoris muscle insertion on the linea aspera to the adductor magnus muscle is also another possible entrapment site to compress the sciatic nerve (14).

Piriformis Syndrome: The entrapment of sciatic nerve as it exits the greater sciatic notch is likely due to a myospasm or contracture of muscles i.e. piriformis or gemellus superior muscle (4).
Lumbar Spinal Stenosis (LSS): The anatomical narrowing of the spinal canal which can be associated with various clinical signs and symptoms including back pain and claudication (19). Patients frequently complain of numbness and pain within the lumbar region and lower limbs along with intermittent neurogenic claudication caused by compression of the nerve roots with narrowing of the spinal canal and the intervertebral foramen which can lead to gait disorders (11).

Conditions Related to An Injured Sciatic Nerve

Injury to the Deep Fibular Nerve

An isolated lesion of the deep fibular nerve can lead to muscular innervation being affected and cause the prevention of dorsiflexion resulting in foot drop and a steppage gait (4).

A steppage gait is a gait abnormality that is often adopted to counteract the effects of foot drop by exaggerating the flexion at the hip and knee during walking to allow the toes to clear the ground.

The tibial nerve then passes through the tarsal tunnel of the medial ankle and divides into two terminal branches; the medial plantar nerve and the lateral plantar nerve. These two terminal branches of the tibial nerve supply all the muscles on the plantar aspect of the foot (4).

Tarsal Tunnel Syndrome

Compression of the tibial nerve or either of its terminal branches (lateral or medial plantar nerve) in the tarsal tunnel leads to a condition known as tarsal tunnel syndrome. A patient with the syndrome may experience plantar pain and sensory disturbances and can also result in palsies of the intrinsic foot muscles (4).

Injury to the Common Fibular Nerve

The sciatic nerve is the most commonly injured nerve in the lower limb and because of its subcutaneous position around the head of the fibula, it is vulnerable to direct trauma (17, 4).

Damage to the common fibular nerve at the neck of the fibula can cause weakness or paralysis of the muscles in the anterior and lateral compartments of the lower limb. This can cause a loss of dorsiflexion which often results in foot drop.

Foot drop

Foot drop is a type of gait abnormality in which the toes cannot clear the ground during walking. If damage to the common fibular nerve occurs after it divides into its terminal branches, symptoms are dependent at which the terminal branches have been affected. For example, an isolated lesion of the superficial fibular nerve generally affects sensory innervation which can cause pain in the distal leg and the dorsum of the foot (4).

Treatment

The primary aim of conservative treatment for sciatica from a physical therapist is to reduce the pain and reduce the pressure on the sciatic nerve root. Initially, intervention for the treatment of patients with sciatica is a nonoperative approach which has demonstrated to be beneficial in more than 50% of patients (13).

Corticosteroid Injections
Epidural corticosteroids administered locally at the site of a lesion has a higher tendency to be effective during the first weeks of an episode of sciatica. Compared to no epidural corticosteroid administration, epidural corticosteroids may be more effective at improving limb pain at 2 weeks, but may be no more effective after more than 2 weeks in people with disc herniation (8).

Surgery

Surgical intervention is often considered for if symptoms persist for more than 8 to 12 weeks and is generally regarded as the "last resort" in many cases after a very long journey through failed medical management (13). Surgical intervention for sciatica focuses on removing the disc herniation via the removal of part of the disc or foraminal stenosis and is the choice for unilateral sciatica. The aim of the treatment modality is to ease the leg pain, but the predominantly focuses on reducing or removing lower back pain (9). Cauda equina syndrome is an indication for the need for immediate surgery.

Surgical intervention has been compared to conservative treatment for patients with sciatica. Koe et al., (2009) found that surgical intervention may provide a quicker relief of symptoms after one year and gain quicker relief of leg symptoms than patients receiving conservative treatment. But, no significant differences were found in terms of success rate in one or two years time during the patients' follow up, in some cases after 4 and 10 years follow up (9).

From a therapist's perspective, the success rate and outcome may vary from one individual to another and factors that need to be considered is the patient's severity of their present condition, lifestyle, previous exercise history and whether they have any underlying conditions which may or may not have been diagnosed whilst having consulted a practitioner. Patient preference for treatment modalities and methods will also differ.

Both standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent (8).

Conservative Management

Additional options include careful use of anti-inflammatory medications, physiotherapy, massage therapy, local injections, acupuncture and chiropractic treatment. There is no clear medical or scientific evidence as to whether particular interventions do help sciatica or lumbar disc herniation. From my clinical experiene, patient education is of paramount importance with encouraging clients to understand how to manage their injury. Recovery rates are unique and individual for everybody as lifestyle factors, exercise history, body biomechanics and posture all play pinnacle roles.

For example, a 47 year old gentleman, Bill sits working at a computer desktop for 9 hours, 5 days a week. His diet consists mainly of convenience foods high in processed fats and salts, performs less than 2 hours of weekly exercise by walking to work from his car and back at the end of a long day. His recovery rate is predicted to be slower than 29 year old Andrew who is a full time postman, has an active lifestyle, has healthy diet and has attended a gym four times a week for the past ten years and plays a sport.

Spinal Manipulation
Spinal manipulation for sciatica has been found to help improve patient outcomes, some studies have found by up to 50% (13).

References

Adibatti, M., V. S. (2014) Study on Variant Anatomy of Sciatic Nerve, Journal of Clinical and Diagnostic Research , 8; 8: 7-9.
Anbumani, T. L., Thamarai Selvi, A., Anthony Ammal S. (2015) Sciatic nerve and its variations: an anatomical study. Int J Anat Res.;3 (2): 1121–1127.
Bueno-Gracia, E., Estébanez-de-Miguel, E., López-de-Celis, C., Shacklock, M., Caudevilla-Polo, S., González-Rueda, V., Pérez-Bellmunt, A. (2020) Effect of ankle dorsiflexion on displacement and strain in the tibial nerveand biceps femoris muscle at the posterior knee during the straight leg raise:Investigation of specificity of nerve movement,
Crumbie, L. (2019) [online] Sciatic Nerve: Kenhub.com , last viewed 31/05/2020; www.kenhub.com /en/start/anatomy-sciaticnerve-branches.
Frost, L. R., Brown, S. H. M. (2016) Muscle Activation Timing and Balance Response in Chronic Lower Back Pain Patients with Associated Radiculopathy, 32; 124-130.
Gilroy, A. M., Macpherson, B. R., Ross, L. M. (2008) Atlas of Anatomy, Thieme, New York.
Green, B. N., Johnson, C. D., Snodgrass, J., Smith, M., Dunn, A. S. (2016) Association Between Smoking and Back Pain in A Cross-Section of Adult Americans, Cureus, 8; 9: 1-10.
Inman, J., Thomson, J. P. (2019) Complementing or Conflicting? A Qualitative Study of Osteopaths’ Perceptions of NICE Low Back Pain and Sciatica Guidelines in the UK, IJOM, 31: 7–148.
Jordan, J., Konstantinou, K., O'Dowd, J. (2009) Herniated Lumbar Disc, Clinical Evidence, 03; 1118: 1-33.
Koes, B. W., Tulder, M. W., Peul, W.C. (2007) Diagnosis and Treatment of Sciatica; Clinical Review , 334: 1313-1317.
Konstantinou, K., Dunn, K. M., Ogollah, R., Lewis, M., Windt, D. v. d., Hay, E. M. (2018) Prognosis of Sciatica and Back-Related Leg Pain in Primary Care: the ATLAS Cohort, The Spine Journal, 18: 1030-1040.
Kuwahara, W., Deie, M., Fujita, N., Tanaka, N., Nakanishi, K., Sunagawa, T., Asaeda, M., Nakamura, H., Kono, Y., Ochi, M. (2016) Characteristics of Thoracic and LUmbar Movements During Gait in Lumbar Spine Stenosis Patients Before and After Decompression Surgery, Clinical Biomechanics, 5: 15-19.
Lakshmi, R., Pharm, A. (2018) A Review of Etiology Pathogenesis, Treatment of Sciatica , JJSR, 7;1: 1477-1479.
Lewis, S., Jurak, J., Lee, C., Lewis, R., Gest, T. (2016) Anatomical variations of the sciatic nerve, in relation to the piriformis muscle, Translational Research in Anatomy,
McMorland, G., Suter, E., Casha, S., du Plessis, S.,Hurlbert, R. J. (2010) Manipulation or Microdiskectomy for Sciatica? A Prospective Ranomised Clinical Study, Journal of Manipulative and Physiological Therapeutics, 33; 8: 576-584.
Monteleone G, Stevanato G. Entrapment of the sciatic nerve at the linea aspera: A case report and literature review. Surg Neurol Int 19-Oct-2016;7:89. Available from: https://surgicalneurologyint.com/surgicalint-articles/entrapment-of-the-sciatic-nerve-at-the-linea-aspera-a-case-report-and-literature-review/
Netter, F. H. (2014) Atlas of Human Anatomy: 6th Ed., Elseiver Saunders, USA.
NICE guideline (2016) [ONLINE] Low back pain and sciatica in over 16s: assessment and management, https://www.nice.org.uk/guidance/ng59/ifp/chapter/What-are-low-back-pain-and-sciatica , last viewed 28/05/2020.
Palastanga, N. P., Field, D., Soames. R. (2006) Anatomy and Human Movement: Structure and Function [5th Ed.], Elsevier.
Saritha, S., Praveen Kumar, M., Supriya, G. (2012) Anatomical Variations in the Bifurcation of the Sciatic Nerve, A Cadaveric Study and its Clinical Implications , Anatomy & Physiology: Current Research, 2; 5: 1-4.
Shiri, R., Falah-Hassani, K. (2016) The Effect of Smoking on the Risk of Sciatica: A Meta-Analysis, The American Journal of Medicine, 129: 64-73.
Siebert, E., Prüss, H., Klingebiel, R., Failli, V., Einhäupl, K. M., Schwab. J. M. (2009) Lumbar Spinal Stenosis: Syndrome, Diagnostics and Treatment, Nature Reviews; Neurology, 5: 392-403.
Shiri. R., Falah-Hassani. (2016) The Effect of Smoking on the Risk of Sciatica: A Meta-analysis, The American Journal of Medicine, 129; 1: 64-73.
Toms, A. F., Rushton, L. A., Kennedy, N. R. (2017) Muscle Herniation of the Peroneus Longus Muscle Triggering Superficial Fibular Nerve Paresthesia, Sonography, 5: 1. Wiley Online Library; www.onlinelibrary.wiley.c om.
V , S., Adibatti , M. (2014) Study on Variant Anatomy of Sciatic Nerve, Journal of Clinical and Diagnostic Research, 8; 8: 7-9.

The Herniated 'Slipped' Disc and Lower Back Pain

Mon, 03 Feb 2020 00:00:00 GMT

Anatomy, Risk Factors, PAthology & Management

Fortunately for us, the notion of a herniated intervertebral disc to suddenly 'slip out of its place' is physically impossible. Discs found in between vertebrae of the spine are firmly attached to these structures, however, they can wear, split or herniate (bulge outwards).

The term herniation is a term used to describe the displacement of focalised intervertebral disc material which is beyond the limits of the disc's space (11, 16). The classification of the herniated disc depends on either the annulus fibrosus (AF), the disc's outer and tougher covering. Or, the nucleus pulposus (the jelly like center of the disc) (18).

Disc herniations can be as a result of of a sudden injury to the structure such as a trauma, progressive degenerative changes or from repetitive stress from certain activities at work or during exercise (8, 18).
Biomechanical studies have mainly found that injury to a disc rarely occurs via axial compression alone (or spinal compression which causes shortening along the spine curvature) (7, 18). Instead, spine shrinkage and the development of disc herniations are more commonly caused from the repetitive motions of forward spinal bending (flexion) and rotation (torsion) (7, 23).

Anatomy of the Intervertebral Disc

The intervertebral disc (IVD) is the largest avascular structure in the body and serves to allow movement between adjacent vertebral bodies, absorb shock and transmit loads through the vertebral column (5, 9). The IVD are mainly composed of three parts:

Annulus fibrosis
Cartilaginous vertebral endplate
Nucleus pulposus

Annulus Fibrosus (AF)
The AF is the primary load-bearing component of the IVD and is composed of collagen fibers which are tightly arranged in 10-20 sheets of lamellae (2, 3). These are arranged and positioned in onion like rings around the central nucleus pulposus and the alternating alignment of fibers within the layers account for its strength and its ability to withstand the forces applied to the disc in all directions (2, 11). The directions of the layers of the annulus fibrosus alternate which adds to the strength of the annulus fibrosus. The posterolateral aspect of the annulus fibrosus has a greater content of vertically oriented fibers which weakens the disc tissue and explains why most annular fissures occur at this particular region of a disc (17).

The AF of the lumbar spine IVDs are at their thinnest posteriorly by only having half the thickness of the anterior and lateral aspects of the annulus as there are fewer, finer and more tightly packed collagen fibers (lamellae) (2, 11). This makes the area of the AF more susceptible to injury at the lumbar intervertebral disc, especially if torsional (rotational) forces are applied.

Vertebral Endplates (EPs)
EPs are cartilaginous structures that are stongly attached to the intervertebral disc (IVD) via the annulus fibrosus but weakly attached to the vertebral bodies (2, 11). The endplates are situated superiorly and inferiorly in every disc and cover the whole length of the nucleus pulposus, but do not cover the entire extent of the anulus fibosus (2). Interestingly, the endplates are strongly bound to the intervertebral disc, but, are however weakly attached to the vertebral bodies and therefore possible for the disc to tear away from the vertebral body during spinal trauma (2).

Nucleus Pulpsoes
Is an oval shaped hydrated gelatinous material contained within a ring of collagen fibres and contains mostly type II collagen which is elastic in nature and usually found in tissues that are exposed to pressure (2, 11).

The Herniated Disc; Pathology & Risk Factors

Disc herniation can occur in any disc within the spine but the majority of disc herniations occur within the lumbar spine, particulalry L4-L5 or L5-S1 (15). Lumbar disc herniation is the most common spine disorder requiring surgical intervention and it has been estimated that approximately 5–15% of patients with lower back pain suffer from lumbar disc herniation (8). The second most common site is the cervical region (C5-C6 or C6-C7) (15). Disc herniations can occur at any age, but are mainly known to be experienced between the 4th and 5th decades of life (20).

There are various personal and occupational risk factors for sciatica and prolapse discs which include (3):

Smoking
Obesity
Age
Height
Mental Stress
Exposure to vibration from vehicles

Types of Injury To the Intervertebral Disc

Annular Disc Tear
This is when a tear or fisure occurs within one or more layers of the annulus fibrosus and most are asymptomatic. Symptomatic annular tears or fissures without disc herniation are treated with NSAIDs and physical therapy (17). Thus, even if a disc prolapse or annular tear is discovered via medical imaging (e.g. MRI), pain is NOT necessarily experienced.

Pain from an annular tear might either be acute if the tear occurs suddenly or more chronic if there is a slower development of the annular fissure. If an annular fissure or tear is symptomatic, it may cause one of two findings:

1. Localised pains that are secondary to an annular tear might might be worse during certain movements which can stress or irritate the focal annular tear. In such cases, there is no radicular nerve involvement, and the physical exam may be unrevealing.

2. Radicular symptoms secondary to irritation of the passing nerve root. In some cases, an annular tear can irritate the traversing nerve and cause radiculopathy (due to be explained in another blog post). If the annular fissure or tear is deep enough, disc material can herniate and irritate or compress neighbouring nerves or the spinal cord which can cause radicular symptoms including pain, paresthesia, and/or weakness depending on the extent of nerve irritation (17).

According to Ma (2015), the pathological classiﬁcation of lumbar disc protrusion is controversial and the study describes four different types of lumbar disc protrusion. To keep matters simple, four problems of the intervertebral disc resulting from injury have been listed and briefly explained below:

Disc Protrusion
In a protruded disc, the disc bulges posteriorly without rupture or tearing of the annulus fibrosus (13).

Prolapsed Disc
The outermost fibers of the annulus fibrosus (AF) contain the nuceleus Pulposus (13).

Disc Extrusion
The annulus fibrosus (AF) is perforated and part of the nucleus pulposus (NP) moves into the epidural space (13).

Sequestration
When a formation of discal fragments from the annulus fibrosus (AF) and nucleus pulposus (NP) is no longer connected to the disc (13).

Disc extrusion and sequestration are most likely to cause radicular symptoms. Disc sequestration does sound and appear alarming compared to the other types listed above and one might think that surgical intervention would be the only way forward for recovery. But, it has been known for patients to recover completely from this condition and be reversible after nonsurgical conservative management.

The study by Orief (2012) revised six patient case studies who had experienced and been diagnosed with a symptomatic sequestrated disc levels L4-5 in three cases, L5-S1 in two cases, and C5-6 in one case. All six patients experienced associated acute radicular pain due to sequestrated intervertebral disc herniation and refused surgery as they were worried about complications. All six patients received conservative treatment that consisted of oral anti-inflammatory drugs, analgesics, muscle relaxants and physical therapy. Their radicular pains diminished and recovered within 3 to 6 weeks and resorption of the sequestrated intervertebral disc herniation was seen in their follow-up MRI scans after 4 to 9 months (16).

Diagnosing a Herniated Disc

The diagnostic accuracy of taking a case history and performing a physical examination is still insufficient. Diagnostic imaging in patients is often used to assess nerve root compression caused by disc aviation or spinal stenosis and cauda equina syndrome. Imaging is also used to identify the affected disc level before surgery or medical intervention (6,7).

Magnetic resonance imaging (MRI), computed tomography (CT), x-ray and myelography are used as a form of diagnostic imaging.

XRay is the most commonly used form of imaging technique due to its lower cost and ready availability (6).

Magnetic resonance imaging (MRI) Scans are mostly used out of all forms of imaging for suspected lumbar spine pathologies.

Computer Tomography (CT Scan) is less costly than the MRI, its testing time is shorter and the availability of CT scanners is larger in hospital settings but has the drawback of exposure to ionising radiation (6). Myelography involves the injection of contrast medium of the lumbar spine followed by x-ray CT or MRI imaging.

Recovery & Treatment

Studies suggest that patients who have suffered a lumbar disc herniation tend to improve in 6 weeks and conservative therapy is recommended during this time if major neurological deficit is absent (4). Overall, initial management includes rest as indicated, physical therapy and appropriate use of pain medication.

Recovery

Individuals who have motor deficits within a single nerve root as a result of disc herniation which lead to symptoms such as weakness during dorsiflexion of the foot, or foot drop tend to improve over time (4). Studies have shown that 81% of patients with initial muscular paresis usually recover without surgery after a year and sensory deficits may be more persistent with a recovery rate of 50% after one year (4). MRI scans show shrinkage of herniated disks over time and up to 76% partially or completely resolve by one year (4).

Recurrence Post Herniation

Recurrences of pain are common, a study conducted Suri et al., (2012) found that the recurrence of lower extremity radicular pain after non surgical treatment of acute lumbar disc herniation was quite a common phenomenon by reoccurring in 25% of participants over a one year duration after the resolution of leg pain (19).

Spinal Manipulation
According Deyo et al., (2016), studies have shown that patients who participated in supervised exercise had greater short-term pain relief than patients who received counselling alone, however, a reduction in pain reported to be small (4).
A study for chiropractic manipulation for subacute or chronic “back-related leg pain” showed that manipulation was more effective than home exercises with respect to pain relief at 12 weeks but not at 1 year (4).

Another study found that patients with acute sciatica and diagnosed with confirmed disk protrusion via MRI scans showed that the number of patients who underwent chiropractic manipulation benefited more than other individuals who underwent sham manipulation after 6 months of receiving treatment (55% vs. 20%) (4).
It has also been observed that skilled manual therapists who utilise mobilisation and manipulation above and below the affected spinal segment(s) and address the pelvis, or restrictions in the lower extremity, may decrease the amount of mechanical stress placed on the herniated disc(s) (17).

Surgery
Clinical trials have consistently shown faster relief of pain with surgery than with conservative physical therapy treatment. Most clinical trials show, however, that there is no significant advantage of surgery over conservative treatment with respect to relief of sciatica at 1 to 4 years follow-up (4).

Lifestyle
Data from epidemiologic studies and biomechanical models suggest that lifestyle modifications such as smoking cessation, weight loss, and regular exercise may prevent sciatica or help to reduce its recurrence (4).

References References

1.) Amin, R. M., Andrade, N. S., Neuman, B. J. (2017) Lumbar Disc Herniation, Springer, CrossMark; 10: 507-516.

2.) Bogduk, N. (2005) Clinical Anatomy of the Lumbar Spine and Sacrum: 4th Ed., Elevier, Churchill Livingstone.

3.) Carragee, E.J., Han, M. Y., Suen, P. W., Kim, D. (2003) Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am; 85: 102–108.

4.) Deyo, R. A., Mirza, S. K. (2016) Herniated Lumbar Intervertebral Disk, The New England Journal of Medicine, Clinical Practice , 374; 18: 1763-1772.

5.) Fardon, D. F., Milette, P. C. (2001) Nomenclature and Classification of Lumbar Disc Pathology Recommendations of the Combined Task Forces of the North American Spine Society, Society of Spine Radiology, and American Society of Neuroradiology, SPINE, 26; 5: E93-E119 .

6.) Frost, L. R., Brown, S. H. M. (2016) Muscle Activation Timing and Balance Response in Chronic Lower Back Pain Patients with Associated Radiculopathy, Clinical Biomechanics, Science Direct; 30: 124-130.

7.) Janardhana, A. P., Rao, S., Kamath, A. (2010) Correlation Between Clinical Features and Magnetic Resonance Imaging Findings in Lumbar Disc Prolapse, Indian Journal of Orthopedics, 44; 3: 263-269.

8.) Kadow, T., Sowa, G., Kang, J. D. (2015) Molecular Basis of Intervertebral Disc Degeneration and Herniations: What Are the Important Translational Questions? Clinical Orthopaedics and Related Research, CrossMark, Springer; 473: 1903-1912.

9.) Kim, J-H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., Ostelo, R. W. G. J., van der Windt, D. A. M. W., Verhagen, A. P. (2018) Diagnostic Accuracy of Diagnostic Imaging for Lumbar Disc Herniation in Adults With Low Back Pain or Sciatica is Unknown; A Systematic Review, BMC, Chiropractic & Manual Therapies, 26: 37.

10.) Koes, B.W., van Tulder, M. W., Peul, W. C. (2007) Diagnosis and Treatment of Sciatica, BMJ,

11.) Kuwahara, W., Deie, M., Fujita, N., Tanaka, N., Nakanishi,K., Sunagawa, T., Asaeda, M., Nakamura, H., Kono, Y., Ochi, M. (2016) Characteristics of Thoracic and Lumbar Movements During Gait in Lumbar Spinal Stenosis Patients Before and After Decompression Surgery, Clinical Biomechanics, 40; 45-61.

12.) Lundon, K., Bolton, K. (2001) Structure and Function of the Lumbar Intervertebral Disk in Health, Aging, and Pathologic Conditions, Journal of Orthopaedic & Sports Physical Therapy, 31; 6: 291-306.

13.) Ma, X-L. (2015) A New Pathological Classification of Lumbar Disc Protrusion and Its Clinical Significance, Orthopedics Course, 7; 1: 1-12.

14.) Magee, D. J. (2002) Orthopedic Physical Assessment 4th Ed., Saunders, Elsevier Science.

15.) Merskey, H., Bogduk, N. (1994) Classification of Chronic Pain Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms [2nd Ed.] Seattle, IASP Press.

16.) Moore, K. L., Agur, A. M. R. (2007) Essential clinical anatomy (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins.

17.) Orief, T., O, Y., Attia, W., Almusrea, K. (2012) Spontaneous Resorption of Sequestrated Intervertebral Disc Herniation, 77; 1: 146-152.

18.) Schoenfeld, A. J., Weiner, B. K. (2010) Treatment of Lumbar Disc Herniation: Evidence-Based Practice, International Journal of General Medicine, Dove Medical Press; 3: 209-214.

19.) Suri, P., Rainville, J., Hunter, D. J., Li, L., Katz, J. N. (2012) Recurrence of Radicular Pain or Back Pain After Nonsurgical Treatment of Symptomatic Lumbar Disk Herniation. Arch Phys Med Rehabil; 93: 690-5.

20.) Tenny, S., Gillis, C. C. (2019) Annular Disc Tear, University of Nebraska Medical Center, StatPearls Publishing LLC.

21.) Vangelder, L. H., Hoogenboom, B. J., Vaughn, D. W. (2013) A Phased Rehabilitation Protocol For Athletes With Lumbar IVD Herniation, IJSPT, 8; 4: 482-516.

22.) Vialle, L. R., Vialle, E. N., Henao, J. E. S., Giraldo, G. (2010) Lumbar Disc Herniation, 45; 1: 17-22.

23.) Wankhade, U. G., Umashankar, M. K., Reddy, J. (2016) Functional Outcome of Lumbar Discectomy by Fenestration Technique in Lumbar Disc Prolapse – Retunr to Work and Relief of Pain, Journal of Clinical and Diagnosis Research, 10; 3: 09-13.

24.) Waturau, K., Deie, M., Fujita, N., Tanaka, N., Nakanishi, K., Sunagawa, T., Asaeda, M., Nakamura, H., Kono, Y., Ochi, M. (2016) Characterstics of Thoracic and Lumbar Movements During Gait In Lumbar Spinal Stenosis Patients Before and After Decompression Surgery, Clinical Biomechanics, Elseiver, 40:45-51.

25.) Wisleder, D., Smith, M. B., Mosher, T. J., Zatsiorsky, V. (2001) Lumbar spine mechanical response to axial compression load in vivo. Spine, 15, 26;18: E403-9.

Buttock Pain & Piriformis Syndrome

Thu, 23 Jan 2020 15:42:47 GMT

Piriformis syndrome is a painful musculoskeletal condition that resembles sciatica and secondary to sciatic nerve entrapment within the piriformis muscle at the greater sciatic notch (2).

Cadaver dissections gave Beaton and Anson (1938) the hypothesis that muscle spasms of the piriformis muscle could be responsible for the irritation of the sciatic nerve.
The term 'piriformis syndrome', however, was first introduced by Robinson (1947)who described that the cardinal features (main clinical signs) of the syndrome have six criteria (1).

A history of trauma to the sacroiliac and gluteal regions.
Pain within the region of the sacrolilac joint, greater sciatic notch and piriformis muscle which may extend down the leg and cause difficulty walking.
An acute exacerbation of pain caused by stooping or lifting.
A palpable sausage shaped mass (or muscle knot) which is tender to palpate over the piriformis muscle on the affected side.
A positive Lasegue sign (viewed below).
Gluteal atrophy.

Piriformis Syndrome commonly occurs from abnormalities of the piriformis muscle such as (2):

Hypertrophy.
Inflammation.
Sciatic nerve irritation or entrapment.

In a clinical setting, piriformis syndrome may mimic other conditions such as:

Lumbar radiculopathy
Sacroilitis
Trochanteric bursitis
Intervertebral discitis

Predisposing causes may include:

Trauma
Excessive exercise
Leg length discrepency
Altered Biomechanics
Narrowed sciatic foramen
'Pocket or wallet sciatica' caused from sitting on wallets in the back pockets of trousers or jeans.

Anatomy of the Piriformis Muscle:

Origin:
The piriformis muscle originates from the anterior surface of the sacrum (S2 vertebrae to S4), upper margin of the sciatic nothch, the sacrotuberous ligament and adjoining areas of the sacroiliac joint.

Insertion:
The piriformis then inserts into the superior medial aspect of the greater trochanter of the femur and the tendon often joins with the tendons of other hip external rotators; the superior gemellus, inferior gemellus, and obturator internus muscles prior to its insertion (2).

There are overall 6 external rotator muscles of the hip which are in close proximity to one another and work as a functional unit:

Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Obturator internus
Obturator Externus
Quadratous Femoris

Diagnostic Testing:

There are several clinical tests but no single test is specific for piriformis syndrome (2).

Piriformis sign - In supine position when the patient is relaxed the ipsilateral foot is externally rotated and active efforts to bring the foot in midline results in pain which is otherwise a positive sign.
Lasegue sign (or straight leg raise (SLR) test) - In a supine position, the hip and knee is flexed to 90 degrees, then keeping the hip flexed extend the knee , if the patient reports posterior thigh pain it is a positive lasegue test.
Freiberg sign - Pain is experienced during passive internal rotation of hip joint.
Pace sign - Pace sign, revealed with the FAIR (flexion, adduction, and internal rotation) test, involves the recreation of sciatic symptoms.
The FAIR test - performed with the patient in a side lying position, with the affected side up, the hip flexed to an angle of 60 degrees, and the knee flexed to an angle of 60 degrees to 90 degrees. The hip is stabilised and the examiner internally rotates and adducts the hip by applying downward pressure to the knee. Alternatively, the FAIR test can be performed with the patient supine lying or seated with the knee and hip flexed, the hip is medially rotated. The patient resists external rotation and abduction of the hip. The FAIR test result is positive if sciatic symptoms are recreated.
Beatty test - Lying on the unaffected side, lift and hold the superior knee approximately 4 inches off the examination table. If sciatic symptoms are recreated, the test result is positive.

Other External Rotator Muscles of the Hip

The external rotator muscles of the hip are in close proximity to one another and work as a functional unit.

Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Obturator internus
Obturator Externus
Quadratous Femoris

Treatment for Piriformis Syndrome

Manipulative treatment of piriformis syndrome would mainly have the aims to restore normal range of movement and reduce pain by reducing the tightness of the piriformis muscle. Techniques used to acheive this goal may include techniques such as muscle energy techniques, joint articulation, high velocity/ low amplitude manipulative therapy treatment, massage, motion controlled and strengthening exercises, stretching techniques and exercises. Other studies suggest that additional physiotherapy modalities that may also help are heat therapy, cold therapy and sonopheresis or ultrasound (2).

References:

1.) Jawish, R. M., Assoum, H. A., Khamis, C. F. (2010) Anatomical, Clinical and Electrical Observations in Piriformis Syndrome, Journal of Orthopedic Surgery and Research, 5; 3: 1-7.

2.) Mitra, S. R., Roy. S. Dutta, A. S., Ghosh, A. Roys, R. Jha, A. K. (2014) Piriformis Syndrome: Review Article, J or Evolution of Med and Dent Sci, 3; 14: 3804-3814.

Women & Weight Training

Wed, 18 Sep 2019 15:25:17 GMT

Weight Training: Why Women Should Lift

Osteoporosis is a condition that makes bones more brittle and prone to fracture. Although osteoporosis can effect men and younger people, post-menopausal women are most at risk.

One of the best ways to help maintain healthy bones is to exercise regularly – which encourages the bones to absorb calcium and other mineral salts that keep bones strong.

Weight bearing exercises and weight resisted exercises are best for strengthening bones and muscles. They can help keep bones in good health and may also reduce the likelihood of falls as you age.

Weight bearing exercises involve the body to support its own weight, such as walking or housework or carrying groceries. Weight resisted exercise involves pushing or pulling against an additional weight, like a dumbbell or barbell or resistance equipment in a gym.

The Younger You Start, the Better!

Anyone can benefit from weight training but it has been demonstrated that younger women who trained using weights have stronger bones later in life, this essentially means that you can bank bone when you’re younger to help prevent fractures later in life – a kind of insurance scheme for your body. A life time of active living not only protects your bones but also keeps your heart healthy and may protect you from other diseases such as cancer and type two diabetes.

Starting At Any Age Will Help!

Everyone can benefit from increasing their activity levels. Studies have shown that people who have already been diagnosed with osteoporosis can improve their bone health significantly through weight bearing exercising, the key is getting good advice on how to move well and how to self-manage. BUT, start slow and build - just think, even a short 5 to 10 minute walk is better than nothing!

Some more benefits

Another reason to be picking up the extra pounds is that STRONG MUSCLES BURN MORE CALORIES, so if you want to control your body weight, lifting weights can help! It also helps with balance and can help you to regulate your sleep patterns.

Kraemer et al., (2001) found that upper-body resistance training appears to dramatically influence women’s performances in occupational tasks over the first 6 months of conditioning. The extent of enhancement to which occupational tasks women performed depended largely upon the type of resistance training program that they utilised.

Nestler et al., (2017) found that regular functional strength training benefit women who are challenged by biomechanical stresses within their profession and who have predominantly sedentary occupations.

‘I don’t want to look all 'musclely''

It takes women a lot of heavy weight lifting, and sometimes the use of controlled substances like steroids and hormones, to achieve the physique of the heavily muscled power lifter. Women don’t normally have enough testosterone in their bodies to develop bulging muscles, but can, with regular, moderate training achieve lean, toned and strong muscles.

‘I Hate Gyms!’

No problem. There are plenty of other exercises you can do that don’t involve a visit to the gym. Dancing, yoga, tennis, Pilates, walking, running, gardening and even housework count – all you are aiming to do is increase your heart rate and make yourself feel a little warmer. You can do it in several short blocks of 15 minute or more

But, you should be aiming to perform at least a total of 150 minutes per week over at least 5 days per week for the best results. If you’re not used to exercise, start slowly and build up to this target.

I Don’t Know Where to Start (?)

This is where your friendly local osteopath can help. They can screen you for any health concerns that might affect your ability to exercise, help to resolve any injuries or pain that might be holding you back and advise you on what exercises might suit your goals best. Many can teach you how to exercise correctly, avoiding injuries and how to gradually build up as your ability and fitness levels improve. As

References:

Institute of Osteopathy, https://www.iosteopathy.org/

Kraemer, W. J., Mazzetti,S.A., Nindl, B. C., Gotshalk, L. A., Volek, J. S., Bush, J. A., Marx, J. O., Dohi, K., Go’Mez, A. L., Miles, M., Flexk, S. J., Newton, R. U., Kkinen, K. (2001) Effect of Resistance Training on Women’s Strength/Power and Occupational Performances, Strength, Power and Occupational Performance In Women, Medicine Science in Sports & Exercise: 1011-1025

Iliotibial Band Syndrome

Mon, 04 Feb 2019 19:41:17 GMT

Anatomy, Prevention & Treatment

Pain in the outer part of the knee can mean several things that could be a potential cause, but it migh be worth considering iliotibial band syndrome (ITBS).

ITBS in runners is a leading cause of lateral knee pain with accounting to approximately 12% of all running related injuries (9, 4). It is the second leading cause of overall knee pain and a non-traumatic overuse injury thought to be caused by repeated flexion and extension of the knee which can irritate the structures around the joint. The constant friction of the ITB repeatedly sliding forward and backward over the lateral femoral epicondyle (figure 1) can be the cause of local inflammation of the ITB or outer knee (10, 7).

Other causes will be explained below which consider the extrinsic and intrinsic factors that can cause ITBS.

The Iliotibial Band and Anatomy

The ITB has been described as a large thick band of deep fascia and is a continuation of the fascia arising from the tensor fascia lata (TFL), gluteus maximus and gluteus medius muscles (figure 1) (1).

The connective tissue of the ITB assists stance stability and resists large varus torques at the knee and could be why this region becomes tight in individuals with a varus tibiofemoral strain (2). Iliotibial band syndrome occasionally becomes inflamed at its proximal origin and can cause referred hip pain.

The muscle is linked to the femur via strands of dense, regular fibrous connective tissue (3). After it courses between the biceps femoris and vastus lateralis, the ITB attaches to the lateral femoral condyle and sends lateral retinacular fibers to the patella (11).

The iliotibial band has two significant attachments including the lateral epicondyle, Gerdy's tubercle (at the anterolateral tibia) and the fibular head (figure 2).

The iliotibial band attachments include the distal edge of the femur at the upper edge of the lateral epicondyle which has a layer of adipose tissue underneath (2). The adipose tissue contains pacinian corpuscles which is highly vascular and may be the site of inflammation that causes pain during compression (2). Interestingly, certain movements can 'tug' at the Gerdy's tubercle attachment when the muscle is tensed, especially during internal rotation of the tibia as the knee bends during the weight-acceptance phase of gait (2).

The ITB has various other muscle and distal attachments which include the biceps femoris, vastus lateralis, lateral patellar retinaculum, patella and patella tendon (2). Collectively, these anterior and lateral attachments form a 'horseshoe pattern' or 'U shape' which support the knee (2). The site of injury is often associated with the insertion at the lateral epicondyle but interrelated with the forces created by the various attachments above and below the lateral epicondyle (Figure 2).

Figure 1

Intrinsic Contributing Factors To ITBS

Various intrinsic factors can attribute to ITBS and the following are signs that your therapist will be looking out for during a physical examination:

Femoral external rotation during stance and gait cycle.
Excessive hip adduction.
Knee internal rotation.
Leg length descrepencies.
Increased foot inversion.
Reduced Hamstring strength.
Increased knee flexion at heel strike.
Reduced hip abductor muscle strength.
Weak hip abductors which can lead to increased hip adduction during stance phase of gait (7).
Knee varus (bowlegs) or valgus (knock-knee) strain (figure 2).
Shortenend and strengthened tensor fascia lata (postural muscle) which clinically tends to create increased flexion at the hip during stance phase and tends to increase hip internal rotation.

Figure 2

Extrinsic Contributing Factors

These include:

Excessive running; greater than normal weekly mileage
Downhill running as the reduced knee flexion at foot strike increases friction between the ITB and lateral epicondyle.

Abnormal Walking Biomechanics

Biomechanical studies in runners with ITBS show that the posterior edge of the ITB can impinge against the lateral femoral epicondyle of the femur just after foot strike in the gait cycle (6). This can produce irritation and a subsequent inflammatory reaction, especially in the region beneath the posterior fibers of the ITB which are felt to be tighter against the lateral femoral condyle than the anterior fibers.

The symptoms usually occur after a reproducible time or distance and consist of a sharp pain or burning on the lateral aspect of the knee. Occasionally, there will be swelling and thickening of the tissue where the band moves over the lateral femoral condyle (6).

Assessment

The Ober Test

The Ober test is the most commonly used to assess tightness of the iliotibial band which is performed via:

The examiner stands behind a side lying patient and stabilises the pelvis with one hand. The superior thigh is then moved into maximal abduction which is maintained in this position whilst moving the thigh into extension. The examiner lowers the limb into adduction until end range, or until the pelvis starts to tilt. The angle of hip joint adduction is considered to be a measurement of ITB length (7).

Angle of Knee Flexion During Stance Phase

Knee flexion at about 20-30 degrees is the usual knee range of motion at which the ITB is most likely to 'rub' against or compress underlying structures within the lateral femoral condylar region and create pain (7).

Treating ITBS

Stretching

Wilhelm et al., (2017) investigate the iliotibial band tensor fascia lata complex (ITBTFLC) elongation response to a simulated clinical stretch (in-vitro) and whether a “stretch” to the region translates into a clinically meaningful tissue elongation. The study found that greater lengthening occurred in the proximal region of the ITBTFLC, suggesting that the proximal region (containing the TFL) is more likely to undergo elongation in response to a clinical stretch force when compared to the middle or distal regions (11).

However, the increased lengthening response in the proximal region of the ITB may be due to the presence of the TFL, which suggests that the ITB is incapable of elongating when applying a passive stretch (11).

Massage

A study by Chaudhry et al., (2008) found that large forces, outside the normal physiologic range of manual therapy, are required to produce even 1% compression and 1% shear in the tensor fascia lata (with 9075N or 925 kg)and in the plantar fascia (4515N, 460 kg). This indicates that it is virtually impossible to physically elongate the length of the tensor fascia or ITB (3). For this reason, I have learnt that it is more effective to apply massage and physical therapy to the quadratus lateralis and gluteal muscles which surround the ITB attachments and are often tight.

Correcting Biomechanics

Manual therapy might consist of correcting contributing intrinsic factors listed above and handing strengthening exercises to address weakness within gluteus medius and excessive hip adduction and knee internal rotation or excessive knee varus or valgus strain.

More information and exercises can be read in the attached here.

References

1.) AiKhaund, R., Flynn, S. H. (2005) Iliotibial Band Syndrome: A Common Source of Knee Pain, 71; 9: 1545-1550.

2.) Baker, R. L., Souza, R. B., Fredericson, M. (2011) Iliotibial Band Syndrome: Soft Tissue and Biomechanical Factors in Evaluation and Treatment, Clinical Review: Current Concepts, the American Academy of Physical Medicine and Rehabilitation; 3: 550-561.

3.) Chaudhry, H., Schleip, R., Ji, Z., B, B., M, M., F, T. (2008) Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy, JAOA; 108: 8.

4.)Fredericson, M., Cookingham, C. L., Chaudhari, A. M., Dowdell, B. C., Oestreicher, N., Shirley A. Sahrmann, S. A. (2000)Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome, ClinJ Sport Med; 3 (10): 169-175.

5.) Fredericson M., Guillet M., DeBenedictis L. (2000) Quick solutions for Movement Patterns. Iliotibial Band Syndrome. Phys Sportsmed, 28, 52-68.

6.) Fredericson, M., Wolf, C. (2005) Iliotibial Band Syndrome in Runners: Innovations in Treatment, Injury Clinic, Sports Med; 35 (5): 451-459.

7.) Lavine, R. (2010) Iliotibial Band Friction Syndrome, Humana Press; 3: 18-22.

8.) Miller, R. H., Lowry, J. L., Meardon, S. A., Gillette, J. C. (2007) Lower extremity Mechanics of Iliotibial Band Syndrome During An Exhaustive Run, Science Direct, Gait and Posture; 26: 407-413.

9.) Noehren, B., Schmitz, A., Hempwl, R., Westlake, C., Black, W. (2014) Assessment of Strength, Flexibility, and Running Mechanics in Men with Iliotibial Band Syndrome, JOSPT, 44; 3: 217-222.

10.) van der Worp, M. P ., van der Horst, N ., de Wije, A ., Backx, F. J ., Nijhuis-van der Sanden, M. W . (2012) Iliotibial Bnd Syndrome in Runners: A Systematic Review, Sports Med, 1 42; 11: 969-92.

11.) Wilhelm , M., Matthijs , O., Browne , K., S eeber , G., Matthijs , A., Sizer , P.S., Brismée , J. M., James , R., Gilbert , K. K. (2017) Deformation Response of the ITB -Tensor Fascia Lata Complex To Clinic- Grade Longitudinal Tension Loading In-Vitro, Int J Sports Phys Ther ., 12(1): 16–24.

Shoulder Pain & Subacromial Impingement Syndrome

Thu, 10 Jan 2019 00:00:00 GMT

Suffer With Shoulder Pain?

How Common Is Subacromial Shoulder Impingement (SAIS)? How Common Is SAIS?

Do you struggle to lift your arm above your head or find yourself feeling a 'pinch' inside the shoulder joint during certain activities? If so, this post might prove useful. Shoulder complaints are the third common musculoskeletal presentation after back and neck disorders in primary care (8).

Shoulder impingement syndrome is a commonly diagnosed shoulder pathology and often presents in dominant than non dominant shoulders which tends to accumulate over a period of weeks to months (4, 5). The incidence of (SAIS) of all shoulder pain complaints account for approximately 44-65% and can cause a functional loss within the joint, making normal daily activities such as brushing hair or reaching up to objects or items painful (Michner et al., 2003) .

SAIS is Commonly found in people in individuals over the age of 40, their pain reports to be persistent and their cause can idiopathic without any known specific trauma.

The most common clinical diagnoses amongst shoulder complaints are rotator cuff muscle defects i.e. tears (85%) and/ or shoulder impingement syndrome (74%) (2). Changes in scapular kinematics (mechanics) that cause subjects to accumulate SAIS generally have decreased scapular posterior tilting, reduced upward rotation and increased internal rotation of the GHJ (5). Weak scapular musculature, fatigued infraspinatus and teres minor muscles are also associated along with changes of thoracic and cervical spine posture (8).

Rotator cuff muscle defects tend to increase with age as our joints reduce elasticity and flexibility and a considerable proportion of individuals produce shoulder complaints over the age of sixty years old (3). Statistically, 30% of individuals over the age of 70 have a total defect within the joint but 75% of cases are asymptomatic (with reporting no symptoms) (3). People at this age group who do have subacromial impingement syndrome diagnosed tend to not receive international surgery.

Anatomy of the Subacromial Space

The subacromial space is defined by the Humeral head inferiorly, the under surface of the anterior third of the acromion, the coracoacromial ligament and the acromioclavicular joint superiorly (figure 1).

The anatomical tissues within the subacromical space are the supraspinatus tendon, the subacromial bursa, the long head of biceps brachii tendon and the capsule of shoulder joint. Any one of the structures above can be affected and cause SAIS (4).

Figure 1

Primary and Secondary Impingement

Primary Impingement:

Primary impingement has been described by Neer as ‘impingement of the rotator cuff beneath the coracoacromial arch’ and is caused from structural changes within the joint which causes the subacromial space to narrow . This can be brought about from bony narrowing of the shoulder joint or increased volume (inflammation) of the subacromial soft tissues from e.g. subacromial bursitis or calcific tendonitis (3).

Primary impingement may result from subacromial crowding, posterior capsular tightness or excessive superior migration of the humeral head due to weakness of the humeral head muscle depressors.

Secondary Impingement:

Secondary impingement is a reduction of the subacromial space from scapulothoracic instability or a functional disturbance of the glenohumeral joint causing the centering of the humeral head with relation to the glenoid fossa to not be in the ideal position (3). It can be caused by a muscular imbalance leading to soft tissue entrapment or triggered by weakness of the rotator cuff muscle mechanism along with the biceps tendon (4). The end result of both syndromes is rotator cuff tendon inflammation and potential rupture if the same activities are performed repetitively.

Other Anatomical Factors

Anatomical factors that can narrow the subacromial space and cause 'pinching' of the rotator cuff (RC) tendons include:
1. Variations in shape of the acromion and its orientation of slope/ angulation which can be classified as flat (type I), curved (type II) or hooked (type III) (Figure 2) (8). There is uncertainty as to whether acromial shape is congenital or acquired with age (8).
2. Thickening of the coracoacromial ligament (figure 1) (8).
3. Reduced force output and muscle performance of the trapezius and serratus anterior muscles (8).
4. Weakness of rotator cuff musculature (8).

Figure 2

What Activities Commonly Make SAIS Worse?

SAIS is typically made worse by elevating the arm between 70 and 120 degrees, known as “painful arc” (Figure 3). Forced movement above the head and lying on the affected side.

What Can Be Done To Help?

Studies show that specifically designed exercise regimes prove to be the most successful method for helping patients with the condition (2, 7). Bjornsson Hallgren et al., (2017) discovered that specific exercises reduced the need for surgery in subacromial pain patients after a 1 and 5-year follow-up.

Steuri et al., (2017) investigated the effectiveness of various different interventions including corticosteroids, nonsteroidal into anti-inflammatory drugs (NSAIDs), exercise manual therapy ultrasound laser shockwave therapy kinesiology tape myofacial trigger point therapy acupuncture and nerve block. They concluded that shoulder specific exercises proved to be most effective for patients with shoulder impingement. They also found that additional interventions such as manual therapy, tape, shockwave therapy and laser treatment might also benefit individuals rather than doing nothing to help improve symptoms (7).

1. Abdulazeem, K., Irrgang, J. J., Whitney, S. L. (1993) Nonoperative Management of Secondary Shoulder Impingement Syndrome, Cinical Commentary, JOSPT,17; 5: 212-224.

2. Bjornsson Hallgren, H. C., Adolfsson, L. E., Johannon, K., Oberg, B. Peterson, A., Homgren, T. M. (2017) Specific Exercises for Subacromial Pain Good Results Maintained for 5 years, Acta Orthopaedica, 88 ;6: 600–605.

3. Garving, C., Jakob, S., Bauer, I., Nadjar, R., Brunner, U. H. (2017) Impingement Syndrome of the Shoulder, Deutches Arztebl Int., Medicine, 114: pp. 765-76.

4. Kamkar, A., Irrgang, J. J., Whitney, S. L. (1993) Nonoperative Management of Secondary Shoulder Impingement Syndrome, Cinical Commentary, JOSPT,17; 5: 212-224.

5. McKenzie, T. A., Herrington, L., Horsley, I., Cools, A. (2015) An Evidence-Based Review of Current Perceptions with Regard to the Subacromial Space in Shoulder Impingement Syndromes: is it Important and What Influences it? Clin Biomech, 30; (7): 641-8.

6. Michener, L. A., McClure, P. W., Karduna, A. R. (2003) Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clinical Biomechanics; 18(5): 369–379.

7. Steuri, R., Sattelmayer, M, Elsig, S., Kolly, Tal, A., Taeymans, J., Hilfiker, R. (2017) Effectiveness of Conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of our RCTS, Br J Sports Med, 51: 1340-1347.

8. Umer, Masood., Qadir, Irfan, Azam, M. (2012) Subacromial Impingement Syndrome, Orthopedic Reviews, 4; 18: 79 - 82.

9. Yamaguchi, K., Ditsios, K., Middleton, W. D., Hildebolt, C. F., Galatz. (2006) The Demographic and Morphological Features of Rotator Cuff Disease: A Comparison of Asymptomatic and Symptomatic Shoulders., J Bone Joint Surg Am, 88; (80): 1699-704.

Nocturnal Leg Cramps (NLC)

Wed, 15 Aug 2018 00:00:00 GMT

Why Do They Occur & What Can Be Done to Help Them?

Nocturnal Leg Cramps (NLC)

Nocturnal leg cramps (NLC) are sudden, episodic, painful and involuntary muscle contractions of either the calf, hamstrings (back of thigh) or foot and mainly occur at night (5). Up to 33% of the general population over the age of 50 have complaints related to NLC but they can occur at any age group (5, 6).

Twenty percent people who experience NLC also experience muscle cramps during the day (5). NLC are usually benign with that they do not progress to motor neuron disease (MND) or cause daytime disability (Miller and Layzer, 2005).

Medical Conditions or Pathologies Associated with NLC Include:

Chronic liver disease
Renal (kidney) failure (haemodialysis)
Vascular disease
Magnesium (Mg) or calcium (Ca2+) deficiency
Dehydration
Varicose veins
Uraemia
Diabetes
Thyroid disease
Hypomagnesaemia
Hypocalcaemia (low calcium levels)
Hypokalaemia (low potassium levels)

Investigations:

With regards to investigations, it is suggested to check electrolyte count in the urea, creatinine, potassium, magnesium and calcium concentrations, random blood glucose, and thyroid function tests. It is best to see your GP and attend to have a blood test if the problem keeps happening (1).

Medications Reported to Cause Leg Cramps Include:

Diuretics (hypertension, liver cirrhosis, heart failure)
Nifedepine (blood pressure and angina)
β-agonists (asthma and heart failure)
Steroids
Morphine
Cimetidine (histamine H2-receptor antagonist, stomach acid inhibitor)
Penicillamine (anti rheumatic drug)
Statins (lower LDL cholesterol)
Lithium (mood stabiliser)

(Hallegraeff et al., 2017)

Cause
Muscle NLC cause is idiopathic (unknown), however, there are various hypothesis for their cause such as:

Abnormal excitability of motor nerves
Electrolyte imbalances.
Dehydration.
Accumulation of metabolites in exercised muscle.
Use of prescriptive drugs: e.g. diuretics, steroids and morphine, quinine.
Repetitive movements during sport or physical activity.
Physical inactivity.
Lack of muscle stretching leading to muscle reduced muscle and tendon length.
Medical Conditions and pathologies; varicose veins, arthritis, hypertension, genetic disorders, endocrine and metabolic disease

(Hallegraeff et al., (2012), Miller and Layzer (2005), Qiu and Kan, (2017)).

What Can YOU Do To Help NLC?

Stretch & Night Time Stretching

A study by Hallegraeff et al., (2012) found that six weeks of nightly stretching of the calf and hamstring (back of the thigh) muscles reduced the frequency and intensity of nocturnal leg cramps in 80 adult participants who were over the age of 55. They concluded that stretching exercises before going to bed prevented the occurrence of nocturnal leg cramps (NLC).

Coppin et al., (2005), however, found no difference when comparing subjects who stretched at night and took quinine to manage the symptoms.

What Can WE Do To Help NLC?

Soft Tissue Massage and Instrument Assisted Soft Tissue Massage (IASTM)

Instrumental soft tissue mobilisation is the use of specific massage tools which uses deep friction massage and may benefit adhesive and contracted muscles and help heal soft tissues (7).

Deep friction massage with instrument-assisted soft tissue mobilisation (IASTM) along with other related interventions such as the Graston Technique®, ASTYM®, ASTM (Augmented Soft Tissue Mobilisation) or guasha techniques are specifically designed solid instruments that are popular in physical therapy practice, particularly for tendonitis (7).

IASTM reportedly provides strong afferent stimulation of muscles and help realign and reorganise collagen fibres in muscle, aid an increase in microcirculation and facilitate the activation of fibroblasts which is important in tendon healing (3). This technique has also been shown to disrupt rebound and cramp prone conditions (7).

References

1. Butler, J. V., Mulkerrin, E. C., O’Keefe, S. T. (2002) Nocturnal Leg Cramps In Older People, Postgrad Med J, 78: pp. 596-598.

2. Coppin, R. J., Wicke, D, M., Little, P. S. (2005) Managing Nocturnal Leg Cramps, Calf-Stretching Exercises and Cessation of Quinine Treatment: a Factorial Randomised Controlled Trial. British Journal of General Practice: pp. 186-191.

3. Davidson, C. J., Ganion, L, R., Gehleson, G, M., Verhoestra, B., Roepke, J. E., Sevier, T. L. (1997) Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exerc. 9: 313–319 [PubMed]

4. Hallegraeff, J., de Greef, M., Krijnen, W., van der Schans, C. (2017) Criteria in Diagnosing Nocturnal Leg Cramps: a Systematic Review, BMC, 18:29; pp. 1-9.

5. Hallegraeff, J. H., van der Schans, C. P., de Ruiter, R and Mathieu, H. G., and de Greef , M. (2012) Stretching before sleep reduces the frequency and severity of nocturnal leg cramps in older adults: a randomised trial , Stretching for nocturnal leg cramps, Journal of Physiotherapy, Australian Physiotherapy Association, 58: pp. 17-22.

6. Miller and Layzer (2005) Muscle Cramps, Muscle and Nerve, 32; 431-442.

7. Renzulli, J. F., Lombardo, R., Jack, Payne. (2017) Nocturnal Cramps and Introduction of a Novel Topical Therapy Review of Pathophysiology, Etiology, and Therapeutic Approaches to Nocturnal Cramps, Internal Medicine Review; 3: 8.

8. Qiu and Kan (2017) Exercise Associated Muscle Cramps - A Current Perspective, Arch Sports Med 1(1): 3-14 .

Knee Pain & Patellofemoral Pain Syndrome (PFPS)

Wed, 11 Jul 2018 00:00:00 GMT

5 Common Factors Affecting Patella Alignment

One of the most common knee problems that presents itself to various clinicians is patellofemoral pain syndrome, also known as 'runner's knee' or “anterior knee pain”.

PFPS mainly affects physically active individuals aged between 15-30 years old (4). Statistically, the prevalence ranges from 21% to 45% in active adolescents, 15% to 33% in adults and is higher in females than males especially in the younger age group (4).

The most reported symptoms related to PFPS are:

Retropatellar pain (behind the patella/ knee cap) especially during activities.
Crepitation (clicking)
Giving way.
Pain whilst running, ascending or descending stairs, squatting and sitting with flexed knees for long periods

The Mechanics of Patellofemoral Joint During Activity are Worth Noting.

Patellofemoral Joint Reaction Force (PFJRF)

It has been proposed that patellofemoral pain (PFP) can be caused by elevated Patellofemoral Joint Reaction Force (PFJRF). This is the compression force acting on the patellofemoral joint (PFJ) whilst we are active on our knees and increases during knee flexion. The compression force is influenced by knee joint angle and force generated by the quadriceps ( muscle tension) .

The stress placed on the PFJ is calculated via PFJRF divided by the PFJ joint contact area and measured as force per unit area. Interestingly, during stance phase of walking, when the peak knee flexion is 20 degrees, the PFJ compression force is approximately 25% - 50% of body weight (BW) (1).

With greater knee flexion and quadriceps activity such as running and ascending and descending stairs PF compressive forces have been estimated to reach between five and six times our body weight. Deep knee flexion exercises such squatting which require large magnitudes of quadriceps activity can increase compressive forces seven to eight times one’s body weight (7) .

The greater the contact area between the patella surface and femur, the less stress is placed on the articular tissues. A smaller contact area results in high PFJ stress and may harm the joint meniscus (cartilage) and is made worse for if the patella positioning is poor (1).

Thus, if the patellofemoral joint structure is malaligned or out of “normal” range during these movements, one must consider the impact that it will have on the surrounding soft tissue structures.

One of the most recent studies that supports the hypothesis of PFJRF is Atkins et al., (2018) who concluded to support the notion that patellofemoral joint loading contributes to changes in patellofemoral pain after subjects performed repetitive single limb landings.

Infographic on PFPS:

5 Main Factors Affecting Patella Alignment:

1.) Increased Q Angle

2.) Muscle Tightness

3.) Excessive Pronation

4.) Patella Alta

5.) Vastus Medialis Obliquus (VMO) Insufficiency

1.) Increased Q Angle

The Q angle is measured by the encounter of two lines; one from the anterior superior iliac spine (ASIS) to the centre of the patella and the other is measured from the tibial tuberosity to the centre of the patella (9). A normal angle is between 10-13 degrees for males and 15-17 degrees for females.

It has been observed that there is a slight Q-Angle difference amongst men and women by only 2.3 degrees which appears to be related to individuals' height rather than pelvic dimensions. Shorter individuals in stature tend to have a larger Q angle which indicates that the difference between genders may be attributed to men being taller than women.

There appears to be controversy over whether increased Q angle is associated with PFPS, as a study has concluded that runners who had a Q-angle greater than 20 degrees were prone to developing PFPS whilst others conclude there to not be a strong correlation (8).

However, there does seem to be an association with increased Q-Angle and increased lateral patellofemoral contact pressures and patella dislocation (12).

2.) Muscle Tightness

Rectus Femoris; if tight, affects patella movement during knee flexion.

Iliotibial band ; if tight pulls the patella laterally during knee flexion.

Hamstrings (biceps femoris, semitendinosis and semimembranosus); if tight will cause increased knee flexion which increases the patellofemoral joint reaction force (PFJRF)* during stance. This can cause an increase in ankle dorsiflexion, which can lead to pronation at the subtalar joint as dorsiflexion at the talocrural joint is more likely to occur.

Gastrocnemius; if tight will result in compensatory pronation.

(McConnell , 1985)

Tight hamstrings can be a causing factor to PFPS and their anatomy can be viewed below:

Tight quadriceps can also play a role:

3.) Excessive Pronation

Excessive pronation of the subtalar (ankle) joint during gait is frequently linked to PFPS development especially when there is a combination of increased foot pronation with increased tibial and femoral internal rotation causing the quadriceps to pull the patella laterally (3, 6). Excessive STJ pronation can also increase the stresses on the medial supporting structures of the knee and create symptoms within the knee joint (11).

Other factors that may influence kinematics at the knee are limited dorsiflexion and excessive midfoot mobility (6).

Below shows the subtalar joint highlighted in green, found at the back part of the lower ankle joint and is the articulation between the talus and calcaneus:

4.) Patella Alta

Patella Alta or 'high riding patella' is considered a predisposing factor for the development of patellofemoral pain and is associated with recurrent dislocation of the patella (1). Syed et al., 2009 Report that individuals with patella alta have altered knee extensor mechanics which may predispose them to increased PFJRF.

A high riding patella that is positioned superiorly in height by as much as 8mm can increase the magnitude of the contact force (PFJRF) by 25% and have a reduced contact area by an average of 19% (1). The combined increase of joint force and reduced contact area results in increased joint stress (force per unit area) and thus lead to PFP and chondral injuries in these patients (1).

Patella Baja: If the patella is positioned more inferiorly and sits more lower than ‘normal’, it is termed ‘patella baja’ and might caused from a shortened patella tendon (5).

5.) Vastus Medialis Obliquus (VMO) Insufficiency

Weakness of the VMO has been thought to cause an imbalance of medial or lateral forces acting on the patella and pull the patella laterally in the femoral groove during movement (9). This can lead to overloading the lateral aspect of the patellofemoral joint resulting in joint pain and possibly presenting a predisposition for osteoarthritis (9). It is interesting to note that VMO activity is greater with the hip in external rotation.

Single Leg Squat Test : Hip external rotators have been noted to be weaker in PFPS patients whilst performing the single leg squat test. Loading in external rotation whilst performing the actions is known to being beneficial (10).

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