Posture

This is the one subject which every patient who attends my clinic with neck or back problems will get nagged about. I find it astounding how little self awareness the majority of the population possess and although this may sound slightly harsh try and think about the last time you actually gave any thought to the position your body or body parts are in at any one time. Stop for a moment and think how you feel physically? Is there excess tension in the neck, shoulders, upper back or lower back? Are you straight on or twisted? Are your legs straight and relaxed or screwed round the chair? Is your chin poking forwards, your shoulders rounded and your lower back slumped. The answer for most people, if sat at the computer, is probably yes! Now for short periods the body can cope with being pulled out of position, however if this takes place over weeks, months and years then tissues such as ligaments, muscles and joint structures start to adapt to this twisted and tight position. They will eventually fix in shortened/tight or stretched/weak positions and then the problems really start. This is the first step on the way to spinal degeneration. A common mistake many people make is to think of posture as a fixed position when in reality "a state of equilibrium" would be a much more accurate description. There has to be a certain amount of tension in the muscles at all time otherwise we would just be a bag of bones and jelly on the floor. This equilibrium is achieved by producing equal tension in the antagonistic muscle groups (neck flexors/extensors/rotators, shoulder rotator cuff, biceps/triceps, forearm flexors/extensors/rotators, chest/upper back, abs/back extensors, quads/hamstrings, calf/shin, toe/finger flexors/extensors. In this state there should be a feeling of balance without excess tension, this is the perfect posture and in an ideal situation should be attainable through any movement. To view how the ideal posture can be used in any situation watch toddlers as they move. They are able to crouch with perfect alignment, heels on bum and not fall over (try it!) bend from the knees not the back. They have not learned bad habits and are also not strong enough to pull themselves out of shape. So in essence if you do not want poor posture and possible chronic joint conditions then you could go a long way to avoiding this by increasing your self awareness!

Osteoarthritis

There are various types of arthritis, Osteoarthritis (OA) is a degenerative condition which causes weakening and calicum leaching from the bones, also damaging cartilage in the joints. This can have multiple causes and can include joint trauma, genetic factors, prolonged drug use and repetetive strain. Joint trauma after injury, to the internal joint surfaces, will over time develop into OA and is seen most often in sports people although any joint injury can develop into OA, the speed of progress will depend on the extent of the injury, incidence of reinjury and aftercare/rehab. Genetic factors often handed down through the female line can increase likelyhood of OA development. With some drug use over long periods especially repeated steriod use for example in asthma can leach calcium from the bones and make sufferers susceptible to OA and brittle bones. All this sounds fairly depressing however there are a number of techniques which can be used to combat and slow down progress of the condition. The main factor to bear in mind with any condition, injury or disease is not to generalise. Every individual is different has a unique genetic make up, physiology, immune system and ability to heal. Thus OA can attack any joint in the body in no particular order and an individual may also have one joint affected or multiple. This means that different people will respond to different treatments in a variety of ways. The initial point is to make sure that prescribed painkillers and anti-inflammatories are correct and your GP should be consulted for this. Your physiotherapist can provide pain relief with acupuncture along with gentle mobilisation can be very beneficial for affected joints, hydrotherapy is also fantastic for getting stiff weak joints and muscles moving due to the therapeautic buoyancy qualities of warm water. Exercise in general is the key and it is essential to find the right balance between mobilisation and strengthening of OA joints and activities which will aggravate the symptoms. Cycling is excellent for leg strength and can give new lease of life to weak sore knees. Theraband can be used to give continuous resistance over range with no impact, again excellent for muscle strengthening. Some impact is needed and again this will vary from individual to individual. The bones gain strength from impact as it builds crossbridges in the calcium matrix which makes up the main bone structure. as can be seen onset of OA is not the end for an active life and if anything should spur people on to increase activity in the right way to increase quality of life. The main message is to tailor activity to your own condition and seek professional help to do this.

Osgood Schlatters Disease

A condition is most often seen in very active early teenagers who have just gone through a growth spurt. This may seem like a gross generalisation however those are the facts. Now this does not mean that we never see Osgood Schlatters (OS) in any other individual, just more often in this age/activity bracket. Although called a disease OS is strictly a biomechanical problem caused by the long bones in the leg (femur, tibia and fibula) growing at a very swift rate as often happens in the teens at very unpredicteable times, usually around hormone fuelled radical changes in character!! The muscles in the legs get rapidly stretched beyond the length they can comfortably work at and this places excessive strain on all the joints they control or move over. In the case of OS we are dealing with the bimechanical changes in the Patellofemoral (between kneecap and the femur) and the tibiofemoral (Femur in upperleg and Tibia in lower leg) and the tibiofiblar (tibia and fibula) joints. The changes in the way the quadriceps, hamstrings and calf muscles act on the bones places a large amount of strain on the bony muscle attachments. In the case of OS this is specifically the tibial tubercle (the bony protruberance on the front of the shin just below the knee). With time the repeated overload from the quadriceps muscle causes the surface of the bone where the patella tendon muscle attaches to become inflamed and to swell. The next stage is progressive and the body lays down new calcium to try and repair the damage resulting in an ever increasing lump below the knee. This is accompanied by pain which will gradually appear earlier in exercise so that eventually walking will be uncomfortable. This is a tricky problem to treat and the only real answer is rest and time allowing the inflammation to calm down and the muscles to adjust to the new leg length. Physiotherapy can help with advice, stretches, ice, unloading strapping and ultrasound and should be accompanied with a course of antiinflammatories prescribed by a GP. However as mentioned time and rest are the best healers for this problem. No miracles!

Neck Pain

Pain in the neck, it certainly is, second only to lower back pain in the list of complaints seen by physios. This is due to the lower back carrying much more load so exposed to much greater everyday strain. The neck however is vulnerable due to it's girth, or lack of it, and the fact that the average head weighs the same as a middle weight bowling ball. Not a small amount to support! Couple this with a huge number of nerves and blood vessels running out to the upper (thoracic)back, shoulders and arms there is plenty scope for problems to arise. By far the greatest cause of neck pain is poor posture, much more so since the majority of people lead such sedentary lives. Posture is much misunderstood and is not as most people think a static position to be held which in itself promotes increased tension. Good posture should be a free flowing state of movement where every component of the head, neck and shoulders is balanced without any excess tension. If the head is held too far forward, backwards, to the side or rotated, repeatedly over a long period of time then one set of muscle opposing this postion are going to be under constant strain. Imagine holding a bowling ball in your hand with a bent elbow for longer than 20 mins. The biceps and shoulder muscles would get tighter and sorer as time went on. If you repeated this with those tight muscles then the tension would increase and the muscles would eventually go into spasm. The same applies for the neck, however where posture is concerned this occurs over months and years, the muscles around the neck tighten to the extent that movement is restricted and actually increases pain. Postural neck pain has a snowball effect and over time starts to involve the nerves and bloodvessels in the neck possibly leading to neural and vascular symptoms such as dizzines, blurred vision, blackouts, pins/needles, numbness and tingling in the head, shoulders, arms and hands. Severe cases over time can lead to degenerative changes in the spine including spondylosis and arthritic conditions. The message here is look to your posture and see if any improvements can be made to yourself and working, home or leisure environment. Posture is controlled by habit and to break an ingrained habit can take up to a month or 6 weeks. The best result I have found are through using visual aids, specifically brightly coloured sticky dots which catch the eye and can be stuck wherever you will see them. They act as a reminder and the more you think about improved posture the more the brain sets down a new better habit. There are of course many other causes of neck pain which will be addressed in future blogs

Massage

Many physiotherapists would balk at the thought of being called masseurs, however an integral part of our treatment involves various massage techniques. A massage can be defined as any technique involving the manipulation of soft tissue through external pressure and there are many benefits to be gained through these techniques. A physiotherapist will employ massage in a number of ways, whether as reduction of muscle spasm, breaking down of scar tissue, trigger point release, increasing blood flow to an area or aiding reduction of swelling, any muscle under strain or increased tension will benefit to some degree from a form of massage. The key is to guage the depth, duration and type of massage from thorough assessment beforehand. Conversley it is possible to cause damage and further trauma due to wrong use of techniques and this is why proper assessment of the problem being treated is essential. The most important thing to bear in mind is whether your masseur is properly qualified and registered with the relevant bodies. Physiotherapy is now a name protected profession and everyone calling themselves a physiotherapist has to be fully qualified and registered with the governing bodies CSP (Chartered Society of Physiotherapy) and HPC (Health Professions Council), if in any doubt about this you can check on the CSP website as all registered physiotherapists will be logged on this site. Many Private physiotherapists are also registered with the OCPPP (Organisation of Chartered Physiotherapists in Private Practice) who also have a website. Prior to going for a massage it is an idea to have in your head an aim whether relaxation, sports massage or lymphatic drainage (swelling reduction) for example. This makes the massage technique selection much easier for the therapist. In this country massage is often seen as a luxury, however in asia and the middle east it is part of life and not unusual to find families who all perfom massage on each other as part of a daily routine. The stress relieving propereties cannot be overstated and in todays mad life stress relief is hard to come by!

Manipulation

There is much misunderstanding regarding manipulation especially among patients. As physiotherapists we massage, mobilise and manipulate on a graded scale of intensity. Massage, for the purposes of this blog, refers purely to soft tissue techniques, whereas mobilisation and manipulation refer to joint techniques. Mobilisation is graded I-IV concerning depth of movement and amount of force used, this is a general description and there are finer details to each grade. A grade V technique is still a type of mobilisation but is refered to as a manipulation due to the fact that the therapist is taking the joint to the end of range and slightly beyond to act as a release or realigning tool. Now obviously prior to any therapist carrying out this technique a full assessment will have taken place not only physically but also close questioning to ascertain if there are any possible risk factors the present condition, in medical and drug/medication history. The physical exam will show any relative stiffness/excess movement between adjacent joints and highlight any which would be candidates for manipulation relative to the symptoms being suffered. Prior to any manipulation informed consent has to be gained from the patient involved. From my point of view informed means that the patient has had the technique about to take place fully explained including the reason for it and the actual process. This has to include explaining possible risks in a common sense manner. The patient is then placed in the appropriate position to isolate the joint involved and this can include any joint although will most often concern the spine whether cervical, thoracic or lumbar. After the manipulation has taken place all movements and subjective markers are revisited to establish any change in symptoms or movement. Following manipulation if any muscle imbalance remains then it is very likely that with patients habitual patterns of movement will cause the manipulated joint to start to cause future problems, therefore appropriate ongoing progressive exercises to address these imbalances are vital to stop a recurrence of symptoms. The important part of this is to give the patient knowledge to minimise the problem happening again. http://rannoch-physiotherapy.blogspot.com/2009/03/knowledge.html

Muscle

Muscle is the powerhouse which allows us to move in the way we direct with our brains. Without muscle we would just be a bag of bones and jelly slopping on the floor. We need to create a certain tension in muscle and control it even to stand still. Movement is an incredibly complicated process, to control my fingers as I type this, a multitude if connections have to be made in the brain and transmitted down the nerves to the muscles in the neck, back, shoulders, elbows, wrists and fingers to allow me to move all these joints in a certain way and type accurately with speed, precision and correct spelling (hopefully). So muscle provides power for movement, what then happens when a muscle is strained or torn? A complex process is initiated we know as healing and this is broken into specific stages which have overlapping timescales depending on the severity of the injury, the immediate aftercare and the body type of the person involved. Initially the trauma causes release of chemicals which tell the brain that damage has been caused and we feel pain! Next blood rushes to the area to fill any break in tissue and a clot forms as a barrier to infection. At this stage if swelling is not reduced then further damage occurs from excess pressure on already damaged tissues and those adjacent. Immediately after trauma is the time to apply R.I.C.E (Rest, Ice, Compression, Elevation). Of all these Compression is the most relevant at inital stages in relation to swelling and can reduce secondary tissue trauma immensely. Ice can be applied during this and after as an ongoing treatment. Due to the fact that muscle is pumped full of blood healing times are much shorter than for most other tissues because plenty of nutrition is available to fuel the healing process. The further stages of healing are specialising of tissue type to muscle then scar formation. If the correct directional stresses are placed on the scar while it is healing then the new tissue will be much stronger and able to withstand stretching without damage. A final point to make would be that muscle is predominantly made of protein and if the diet can tend towards this during healing with products which contain plenty of amino acids (the building blocks of protein) such as oily fish, cottage cheese, eggs, lean meat ,quinoa,(a cous cous like grain), then this will aid the production of good quality healing muscle tissue. These should also be eaten as part of a balanced diet!