This was a 10 minute presentation to a local business networking group.

 In this talk I reveiw our spinal curves and why we loose height as we age. 

 Do you want to know how to sit properly? 

What about spinal degeneration and aging? 

What about treatment? 

I also explain a little bit about the physiology of Intra Muscuar Stimulation (IMS). 

So get comfortable and enjoy the talk.

I give a presentation every year to a local running group on injury prevention and treatment related to running injuries.  The group is participating in a running program to prepare for the Victoria Times Colonist 10 Km run.

In this presentation I will address why the pelvis is important and how muscle imbalances around the pelvis contribute to common running disorders such as iliotibial band syndrom (ITBS), plantar fascitis, and achilles tendon problems. 

You will also be introduced to inner core versus the outer core.  I was introduced to this concept by Diane Lee (http://dianelee.ca/).

 You can find the presentation posted under the video section titled “Smooth Sailing: A Rendition on Running Related Injuries”.

 

Once upon a time there was a young active teenager who was having problems with her knees.  She liked to bike, play basketball, play soccer and hockey. She went to the doctor who diagnosed her with “chodromalaciapatella.”  http://www.mayoclinic.com/health/chondromalacia-patella/DS00777

The doctor told her not to bike or do jumping exercises and started her on a knee strengthening program (“VMO” or “Vastus Medialis Oblique”  muscle). 

 

 

WHY STRENGTHEN THE VMO?

http://en.wikipedia.org/wiki/Vastus_medialis

The thinking is if the VMO muscle (inner thigh) is weak or not firing properly, it creates an abnormal pull around the knee cap. 

It is true that the VMO can stop working after trauma or swelling as a protection to the knee.  It is true that sometimes it needs to be retrained.  But it is not true in all case of knee pain.

THE STORY CONTINUES

The young girl continued to have knee pain. But to be honest she never did stop being active.  Years later she discovered her thigh muscles were not weak but  tight.  What happens when the quadriceps get tight is that the knee cap (patella) gets compressed down into the thigh bone (femur).  The two cones will rub together creating compression and friction.  When you use the quadriceps during running, squatting, climbing stairs, getting into and out of a chair, or biking, the muscle tenses and creates more compression pain.

STRETCHING

The young girl was not very flexible. She has, however, been blessed with short fast twitch muscle fibers that gave her a lot of strength but not flexibility (or so she thougth). She did play sports that worked the quadriceps. She also had an injury to her left quadriceps during a soccer game (kneed right in the muscle). It did not seem to matter how much she stretched, she never got more flexible.

There is no consistent research on how best to stretch and the actual effectiveness of stretching on injury prevention and recovery.

THE BREAKDOWN

Eventually in her early 30’s while playing indoor soccer, both quadriceps went into spasm. What a sight to see her trying to continue to play soccer without being able to kick the ball (three women on the field  needed to continue to play, so she could not let the team down). The recovery took over six weeks. What she realized was that she could no longer sit on her heels and lean back to get her shoulders to the floor (stretching the quadriceps). What ever flexiblity she had was now worse.

THE TREATMENT

What I have been finding cllinically is that by releasing the tight ropy bands of muscle fibers in the quadriceps (using the Intramuscular Stimulation technique), the flexibilty of the quadriceps improves and the knee pain seems to diminish or resolve. A client with a two-year history of knee pain (patellofemoral diagnosis) who could not squat at all, and who could not walk without pain, is back to running. She is also able to fully squat.  She still does have some symptoms going up and down stairs. 

The quadriceps are not the only muscle to consider.  The hamstrings (back of the tight) are an antagonist (opposing) muscle to the quadriceps. If the hamstrings are tight, the quadriceps have to work harder to overcome the tension from the hamstring. You might even need to look at the calf muscles which cross the knee joint and can contribute to knee pain. 

MORE THAN MUSCLE IMBALANCES

It may not just be muscle imbalances around the knee that is causing the pain.  Sometimes even afer releasing the muscle tightness pain continues. What else could be going on? 

1.  Meniscal Injury: 

The meniscus is the rubber “washer” that rests between the bones of the knee (femur and tibia). There are two of them (medial or inner knee and lateral or outer knee). These are within the knee joint and are susceptible to tearing with twisting injuries to the knee. The most common finding on examination that I have noticed (and reported in literature) is tenderness and swelling at the joint line. Typically there is pain on twisting of the knee especially under load (weight bearing or compression).  There may also be a “catching”, “locking” or even a “giving way” of the knee.  These can heal without surgery (mine did), but may also require surgery. 

2. Osteoarthritis:

The meniscus is often confused with the cartilage.  The cartilage is actully the shinny covering on the bone. I like to compare it to a “shelac” or “tephlon.”  It does not have any nerve fibers and offers a smooth surface to the bone. This can be damaged (Osteoarthritis) with trauma to the knee (impact injuries). I have had clients who have ongoing pain from the “arthritis” of the knee even after the muscles have been released. Some of these individuals have benefitted from acupuncture. There are also those who ask about the use of chondroitin. I have not personally read the articles and research on this, but have been told it’s been shown to be effective. It might be something you have to look up yourself. 

3. Joint stiffness:

I have occasionally found that there is full range of motion of the knee, but when I add the twist to the knee when fully bent there is a stiffness or tension. Sometimes just releasing the right muscle corrects the problems, but not always.  Then I will use my hands to mobilize (wiggle) the joint. Once the motion feels normal again, I recheck the painful activity (usually they can’t get into a full squat without the knee pain), to see if it worked. 

4.  I did have one recently where it was actually a stress fracture to the end of the thigh bone (femur). I did not pick this up but knew very quickly that I was not able to locate the problem. I thought it might have been the meniscus or tendonitis of the inner thigh muscles. 

THE REST OF THE STORY

The young girl (older now), has remained active. She still is not as flexible as she would like, but she does not have nearly the discomfort in her knees with exercise as she has in the past. In order to fully get her back to running full time, further treatment is needed for her back (history of disc pathology with sciatic pain) and pelvis (loss of dynamic muscle stability possibly from the injury to the nerve that supplies the muscles of the  pelvis, hip and leg.

Have you ever been doing an activity and felt a pain somewhere and decided that you were just going to work through it? 

How long does it take you to seek assistance after that first notion that something hurts?  A week?  A month?  Several months?

How do you know when you should keep going or should stop? 

I have some basic tips/rules for clients to follow with regards to this question.

 Pain is a signal from our body that we are doing damage to it – most of the time anyway. 

When you touch something that’s hot, you get a pain signal telling you not to touch something hot.

When you step on something sharp, you get a pain signal. 

 Do you keep touching the hot object and stepping on the sharp object? 

So why when you feel a pain in your body when you’re exercising or doing an activity, would you keep going –

especially if it was getting worse?

The pain is telling you to stop! 

 

 

 

 

What about if you have pain and when you continue to do the activity it actually starts to get better? 

 

 

Well maybe this time this is what it needs.  I had this experience when I had developed a tendonitis in my shoulder.

Doing a particular stretch in an exercise class I noticed and increase in pain. The more I stretched, the better the

 shoulder felt. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What’s going on? 

I suspect scar tissue was forming that needed to be mobilized.  After an injury where there is

inflammation, scar tissue forms. It forms in an unorganized manner and we often need to move the

injured area in a gentle manner in order for it to heal in a more organized fashion. 

Another example of this is of a friend who had a sore back and was thinking of not running that evening. My suggestion

was to do the run but if the pain got worse, then to bail. The back pain improved.  Or there was also the time after

picking up an extra bucket of strawberries, I couldn’t straighten back up. It wasn’t a pretty sight watching me getting

 in and out of the car. Instead of not going to do my swim later on, I decided to try it. By the time I finished the

kilometre swim, I was pain free. 

Picking strawberries is a bending forwards (flexion) activity that can aggravate a disc or muscles. 

Swimming is more of backwards bending activity (extension) and doesn’t have the

compressive forces from gravity.  The change in  activity direction was helpful in

counteracting the pain-causing activity. 

 

 

 

 

 

 

 

 

 

Pushing through an activity when you have experienced an injury can take it from a grade 1 injury to

a grade 2 injury (more damage) or worse. 

 

What this means is that you will have a longer time to heal and get back to your normal activities.

 

 

So why would someone not stop when it hurts? 

You want to finish the race. 

You want to finish the game. 

You don’t want to look weak in front of everyone else in the group. 

You don’t think it’s really that bad. 

Let me tell you a couple of stories about pushing through the pain.  A runner who was trying to finish a marathon after

experiencing pain in the pubic area ended up having to take a year off running due to the stress fracture in the pelvis. 

 

 

Another athlete

 

had to have surgery for pain in the front of the shins after continuing to play a running sport.  Okay, then there’s me

 who persevered through a game of hockey because I was the goalie (a whole other story…) after pulling my

hamstring.  It’s still a bit sore eights months after. 

 

 

I read an article awhile back about shoulder injuries and recovery. The longer someone waited to seek treatment, the

 longer the treatment took (more sessions equals more money).

There’s a natural healing process that does occur and the pain in most cases will gradually improve if you are not

doing any aggravating activities. But if the injured area is not improving on a daily basis, I would recommend getting

it assessed and treated—this is within the first week of the injury.  The inflammation stage should only last 24 to 48

hours—this is when you have pain even at rest.  But remember that even though your body will heal itself, there may

be muscles that have gone into a protective pattern that need to be released or joints that may be stiff and tight, or

scar tissue that is forming.   Knowing what to do to help  your body heal the best is important.  What activities should

you do and which ones do you avoid? Getting the area assessed early can save you a lot of aggravation and money.

 

To summarize, don’t keep doing the activity after the injury if the pain is getting worse.  But if the activity is helping

improve your movement and reduces your pain then it’s okay to continue provided it is not more sore after the

activity.  We are not talking about post-exercise muscle soreness, but pain from the injury.  Remember too that the

delayed muscle onset soreness (DMOS) that arrives the day after vigorous exercise is an indication of inflammation of

the tissue and recovery time is needed. 

Get an assessment done early by a therapist who can give you advice on what you can do to manage your symptoms

and help with your recovery. 

 

 

 

 

 

 

 

 

Don’t wait until you are desperate!

This was one of the questions from someone reading one of my earlier blogs. 

It’s a great question, but unfortunately there is not a simple answer. 

Some victims claim it lasts as long as there is litigation. I know this will ruffle a few feathers and by no means am I

attempting to discredit those experiencing the pain of a neck injury following an accident. 

But there are a couple of facts that we have to talk about.

The first is that of my ten years of practicing locally, I only have two clients

who have continued to seek treatment for ongoing pain following receiving

their settlements from their insurance company. 

The second is that 99 per cent (my estimate) of the time treatment is only

sought by the person who wasn’t at fault. 

There is a ton of literature available on whiplash associated disorders and predictors surrounding recovery.  

 

 

 

 

 

WHIPLASH IS CATEGORIZED INTO FOUR GRADES

Grade I: there is soreness when touched but no loss of neck motion, range of movement (ROM)

Grade II:  there is tenderness and loss of ROM

Grade III:  there is tenderness, loss of ROM and evidence of neurological involvement

Grade IV:  there is evidence of fracture 

What is the scoop on pre-existing conditions?  

As you may already be aware (if you have read earlier blogs of mine on spinal degeneration), that our spines do wear out as we age,

some faster than others depending on how we have treated our bodies. But you can argue that you did not have this pain before the accident. 

I am not sure what research article I read this in (sorry folks but I do not have a photographic memory for research, I

only seem to remember pertainent facts, which won’t do me any good in a court of law), but people with pre-existing

problems in their necks prior to the accident tend to have a worse prognosis when it comes to recovery. What this

means in English is that if your neck is worn out (degenerated)–weak or tight prior to the whiplash injury–you’re

likely to have a longer recovery time and may not recover completely. 

I did find, however, something in one of the reviews that proves I am not just making this stuff up as I go along.

 

 

“… neck pain and severe headaches are more prevalent in subjects with a history of neck injury due to a car collision.”3

 

  

 

 

 

 

WHY IS THIS SO?

If there’s spinal degeneration, you may experience more trauma to the joints as your neck is thrown backwards

(jamming the joints). 

If your neck is weak, you are less likely able to protect the neck during the whiplash injury. 

If the muscles are tight, the muscle is not able to stretch and is more likely to experience trauma (strain). 

WHAT IS THE BEST TREATMENT

The answer from my clinical experience is that first and foremost you must be an active participant in your own

recovery. 

People who keep moving and get involved in exercises seem to recover much better. 

Manipulation (by a qualified physiotherapist or chiropractor) if you are comfortable with this technique has been shown to be effective (both clinically and in the literature) for stiff joints.  

There is a great deal of controversy around the use of neck manipulations.  There’s some research that indicates adjustments to the upper back without adjusting the neck can be just as effective in helping restore mobility.

I personally use IMS (www.istop.org) very effectively for relaxing the tight, tense and ropy muscles. 

I am very pleased to say that I have been using IMS on a number of clients who, for several years after

their car accidents, were still experiencing muscle soreness and tightness often resulting in tension headaches. 

Just like the Buckley’s saying, “it is painful but it works”. 

“A recent Cochrane review concluded that dry-needling, added to other conventional therapies such as exercise, is

more effective at relieving pain than conventional therapies alone in non-specific low back pain.

This combined approach to management has never been investigated in whiplash.” 1

“Adequate information and successive mobilization without a collar as early as 

possible supported by a physiotherapist are the best treatments for reducing

pain and increasing ROM at six months follow-up according to one study.”3

 Once muscles are relaxed and joints are moving, you must re-strengthen the muscles (see my Neck Stabilization Blog). 

 

SO HOW LONG WILL IT LAST?

“The evidence suggests that approximately 50 per cent of those with WAD will report neck pain symptoms one year after their

injuries.

Greater initial pain, more symptoms, and greater initial disability predicted slower recovery.

Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic;

however, post injury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery.

There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.”2

It is estimated that five to eight per cent of people who sustain a whiplash injury will continue to experience problems beyond six

months post accident (depending on what study you look at). 3

References

1. Michele Sterling, Stephanie Valentin, Bill Vicenzino, Tina Souvlis, and Luke B Connelly. Dry needling and exercise for chronic whiplash – a randomised controlled trial. BMC Musculoskelet Disord. 2009; 10: 160

 2. Linda J, Can-oil, PhD  et al. COURSE AND PROGNOSTIC FACTORS FOR NECK PAIN IN

WHIPLASH-ASSOCIATED DISORDERS (WAD) Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders 

3. Ylva Sterner and Bjorn Gerdle. ACUTE AND CHRONIC WHIPLASH DISORDERS – A REVIEW. J Rehabil Med 2004; 36: 193-210

 What do you think would happen if you drove your car

through a huge pot hole, never got the alignment corrected

and drove for 20 years?  

Yes the car’s parts would likely wear out faster. 

 

What do you think happens to your body when you have a

 relatively minor injury, or several, never do anything about

 them, and then drive your body hard for 20 years?

 

I have been working with a client who is in her 30s who has just taken up

 running. She has been experiencing issues in her knees and feet. We

 have been able to settle the muscle-driven pain in the legs and feet with

 IMS (www.istop.org).  We could just stop there, but I like to look at why

 the person is having issues.

So up to the pelvis, back and mid-back I go to see what I can find.

 

 

 

Why?

The muscles in the back run from the mid-back to the pelvic bones. 

Muscles from the shoulders attach to the mid-back and lower back. 

Findings:

What was discovered as stiffness in the mid-back and muscle tightness, with

the pelvic asymmetry noted (one bone more forwards than the other pelvic bone). 

On questioning why this may be tight, it was revealed that

there was a “serious car accident” a number of years ago.  

Is it related?  My answer is yes. 

 

 

 

 

 

 

 

 

 

 

Natural Healing

The body has an amazing ability to heal itself (see my previous Stages of Healing

Blog). The problems come when the injured muscle is left weak or tight

 even though the pain is no longer present. A weak muscle does not

 support the joints (where two bones come together) well. A tight muscle

 may compress the joint surfaces, eventually leading to wear of the

 cartilage part of the bone (“arthritis”).  The rest of the body will

 compensate to try and let you function, but you are now functioning in a

 less than optimal position. 

 

Now it becomes not a matter of  “IF” you will wear out or break down,  but “WHEN”. 

 

CONCLUSION

I run into this issue all the time.  A great number of my clients come to

 me for IMS treatments because they have tried other therapies but are still having

 issues.  It has been a wonderful addition to my practice, and has allowed

 me to look and treat more efficiently the other areas of the body that

 may be the source of the pain (“the driver” according to Diane Lee).  

I have seen people who are having problems now because of

ankle sprains that have happened over 20 years ago. 

The left over stiffness in the heel joint contributes to the “over

pronation” in the mid-foot. 

This can lead to plantar fasciitis, problems with the inner knee ligaments, problems with the big toe joint, iliotibial

band issues, and even hip and pelvic problems. 

 

 

RECOMMENDATION

I do recommend that if you are thinking of taking up a new activity

(running the local 10 K race perhaps), a preventative screening

assessment is a good idea.  It is amazing what you can find when people

are not in pain.  I have done these assessments for people wanting to

work with personal trainers and want to know what to focus on. 

Don’t wait until the pain gets unbearable and you’re desperate.

Have you ever wondered how people can have similar injuries but the recovery periods and level of recovery can be so different? 

Is there any truth behind the body and mind connection and our own healing? 

This is the aspect of physiotherapy and healing that really excites me. 

The mechanics of how the body works (or is supposed to work) is relatively the same between individuals.

But it is the mind that makes each person unique. 

 

Alternative Therapy

I was once asked by someone, “Is there anything to the energy side of healing?” My answer was that it does not work for everyone, but there are people who benefit from it. If you hurt your knee playing soccer, I would not think of doing CranioSacral Therapy (www.upledger.com) as my treatment of choice.  But if you were coming to see me for a chronic condition that was not responding to other treatments, it may be something I would consider doing. 

Why People Don’t Heal – The Emotional Chakra Connection

I watched a video several years ago by Carolyn Myss (http://www.myss.com/)  “Why People Don’t Heal and How They Can.”  

It was very insightful in terms of the connection between the body and the mind. I had a client at one time with chronic lower back pain. The client was able to live with and function with the back pain up until the client started to go through a divorce.  The back pain escalated to the point that the client was having difficulty functioning. 

In this case of back pain, it was interesting to note that chakra, which translates as “wheel” or “turning” in the Sanskrit language and relates to our energy and is also associated with the lower back, has to do with our connections with family (tribal and money). 

 

 

Where’s The Proof?

Now you might think that all of this is hog-wash. 

What is the science behind all of this? Where is the proof? 

I will refer you to a book by Candace Pert “The Molecules of Emotion.” 

Dr. Pert is a scientist who has studied neurotrasmitters.” 

 

 

The neuropeptides are the messengers between the cells in our

separate body parts.

Our cells are constantly chatting with each other by the release and binding of certain neuropeptides. When a neuropeptide binds to a cell, the cell then responds and makes certain physiological changes (i.e. increased blood flow to your muscles when you need to get away from danger quickly). Then there is a message back to the original cell (feedback loop) saying that more or less peptide is needed.

Some of the neuropeptides that people may have heard of include:

Serotonin: this is secreted by our brain cells and is the neuropeptide related to clinical depression. 

When we have lower amounts of this neuropeptide it contributes to the depression. Anti-depressants are designed to block the re-uptake of serotonin so there’s more in the system to bind to the receptors. But remember that there are receptors for serotonin in other parts of the body (gut). So anti-depressants can result in more serotonin in the gastrointestinal system with the side effect of GI upset. 

Dopamine: the uptake of this neuropeptide is blocked by our anti-psychotic drugs. But the blocking of dopamine receptors in the pituitarygland results in the release of prolactin (which is what stops ovulation in women who are breast-feeding) resulting in loss of menstruation, water retention and weight gain. Parkinson’s disease is related to problems with dopamine. 

 

Cortical Releasing Factor (CRF).  Okay, I hadn’t heard of this one either!

This neuropeptide is released by the pituitary gland. CRF stimulates the release of the ACTH (http://en.wikipedia.org/wiki/Adrenocorticotropic_hormone) which travels to the adrenal glands and binds to adrenal cells (fight or flight) and begin to make steroids (coricosterone) – which is necessary for healing and damage control when injured. People with depression have been found to have high levels of coricosterone. This is likely from a chronic ACTH activation. Individuals who are stressed or are in abusive situations have higher levels of CRF. The receptors become desensitized and reduce in number.

The Connection

Did you know that the emotional part of our brain (the limbic system) is located right beside the sensory relay part of our brain (the thalamus). 

There is a strong neurological connection between what we are sensing and the emotional connection to those sensations. The response to all of this is the release of neuropeptides that communicate with the other parts of our body. It’s like that feeling in the pit of your stomach. So neuropeptides are the scientific explanation for the body-mind connection. 

One of the interesting things that I discovered through my reading on neuropeptides was that they are in higher concentrations in the areas of our chakras. But here is another interesting fact, the chakra locations are the same points released in CranioSacral work. The highest concentration of neuropepetides according to Dr. Pert is in the area of the third ventrical of the brain (the bump area at the back of your skull). This is the location of the still point (CV4 technique) in CranioSacral Therapy. 

 

The Point

The mind is a very powerful tool.  

I am not saying that pain is all in your head. But it is in your nervous system. It has been said that when you have a thought (reliving an injury over and over), the body responds the same way as if the event was actually occurring. Think about this before you keep playing the video of the injury over and over. The repetition even through thought makes the neurochemical (release of the stress hormone cortisol perhaps) and neurological (nerve pathways) response stronger. 

Just like tracing a pattern in the sand, the pathway gets deeper and deeper ingrained.  

Break the Cycle

There are a number of methods to help you focus the mind. Meditation and relaxation techniques, yoga, and alternative therapies are some of the ones with which I am familiar.

 

 Did you know that your mother was right when she told you to sit or stand tall? 

Why? Read on.

THE SPINE

In an earlier blog I mentioned the spinal curves. The neck and lower back bend one way (lordosis) and the thoracic (mid-back) and tail bone (sacrum) bend another way (kyphosis).

The line of gravity is supposed to pass through the vertebrae (big bony parts).  What happens when you slouch is:

• Flattening of the lower back
• Increased roundness of the mid-back (thoracic spine)

 If you were standing with this posture, you would end up looking down at the ground all the time. It’s hard to avoid not bumping into things when you are looking down (although you won’t trip as much). So to avoid bumping into objects around you, you lift your head up.

 THE NECK

When you’re hunched over but the head is lifted, you get a kink in the lower part of your neck. Typically, this is at the C5-6 level. What would happen if you took a twig and bent it in the same spot again and again? Yes, it would wear in that spot. So, is it surprise that the C5-6 part of the neck is the most common area for “wear and tear”?  No.

When you are in the “poking chin” posture, the muscles at the back of the neck get short and tight. When this happens, you get compression of the joints and possible impingement (pinching) of the nerves. This is often a contributing factor to headaches (refer back to my April 22 blog on headaches). 

 

The muscles at the front of the neck become long and weak. When muscles at the front of the neck are long and weak, you lack stability (for more, go back to my April 15 neck stability blog). This has also been shown to contribute to headaches. 

So you can often get all the treatment that you want but if you don’t correct your posture, you’ll be back more often than you would like, or tell us that the treatment is not working. 

THE SHOULDERS

When you slouch, the shoulder blades are positioned more outwards and can often be tilted forwards. Ask a friend to look at your shoulder blades to see if the lower part is sticking out. It shouldn’t be. It is possible that the Pectoralis Minor muscle is tight. So why is this a problem? Not only do you look like you’re not confident, but there can also be compression nerves and blood vessels that travel in front of the shoulder. When you compress these, you will often experience symptoms (tingling, numbness, aching) in to the elbow, wrist or hand. This can be part of the problem with diagnoses of Thoracic Outlet Syndrome or Carpal Tunnel Syndrome. 

The other problem with having the shoulder blades resting in the wrong position is that the muscles that stabilize and those that move the shoulder muscles are not in an optimal length—meaning they won’t work properly. When you raise your arm overhead, the shoulder blade needs to rotate up about 60 degrees so that the rotator cuff and biceps tendons don’t get pinched under the arch at the side of the shoulder (for more on that too, see my March 26 frozen shoulder blog or should fix one dated March 19). So muscle imbalances from poor posture contribute to rotator cuff attenuation (thinning) which makes it easier to tear. Poor posture also contributes to rotator cuff or biceps tendon tendonitis. 

THE BACK

When you slouch, the long muscles of the back are stretching (long and often weak). They will tire faster. You get more compression of the disc with the pushing of the inner part of the disc more to the back and more strain to the back of the disc contributing to disc protrusions or herniations (check out my April 1 blog on the spine). 

Standing when there’s an increase in the lower lumbar curve or in the neck curve (rather than a decrease) means the line of gravity is no longer through the large bones (vertebral bodies) but is now through the smaller joints at the back.  The joints are not designed to take this kind of stress and will wear out.  This is what is often referred to as Osteo (bone) arthr (joint) itis (inflammation). 

 

CORRECT POSTURE

So if you don’t want to contribute to nerve compression, headaches, joint irritation, arthritis, disc injury, carpal tunnel and thoracic outlet syndromes, and muscle imbalances, correct posture is important. 

How should you sit?

One of the best cues that I picked up from Diane Lee on getting people to sit properly was to have the back of the thighs touch the chair first (rather than the buttocks). The hips should stay slightly higher than the knees. The using of a roll behind the lower part of the back is good too (if you use a back rest). The downside to not using a backrest is that the muscles at the front of the hips have to stay turned on to keep you from falling backwards. You may feel more muscle fatigue if you have to sit for longer periods of time. 

How should you stand?

First of all, you should not be standing with your buttocks sticking way out to the back. This puts the pelvis into what we call an anterior pelvic tilt (front part of the pelvis is lower than the back).

The head should be centred over the shoulders. When looking from the side of the ear, it should line up with the shoulder. The shoulder should line up with the hip. The hip should line up with the ankle. 

I never suggest that someone stand with their shoulders pulled back like they were in the military. This posture can also create problems. But lifting the chest (standing tall) is a more ideal posture (than slouching).

So that’s what was behind your mother’s orders to not slouch!

Do you get it now?

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   Have you ever wondered why you have a headache that can be in different parts of your head at different times?   

  Why is it sometimes at the front of my head?  Why at other times is it only in the back of my head? 

   What can I do to keep the headaches from starting?

   How do I get rid of them once they’ve started?         

  

  

 

 

There are three basis classes of headaches

Primary Headaches

1.   Tension
2.   Migraine
3.   Cluster

Some of the secondary headaches triggers include:

1. Alcohol
2. Hunger
3. Over medication
4. Sinus problems
5. Dehydration

CERVICOGENIC HEADACHE

The Cervicogenic Headache is one of the most common types of headaches seen by physiotherapists (at least in my experience). The prevalence (occurrence) has been reported to be approximated 18 per cent of all headache types. 

What you might typically see with this type of headache is:

1. Signs of neck involvement (typically the upper neck C1-2-3 levels).
   1. pain and tenderness in the neck area
   2. reduced range of motion in the neck
2. Brought on by neck movement or positioning.
3. Typically one-sided pain in the neck, head and shoulder.
4. Possible history of neck trauma (whiplash).
5. Moderate to severe, non-throbbing pain typically starting in the neck.
6. Accompanied by dizziness, light sensitivity, nausea and blurred vision.

What is the Trigeminal nerve and why is it so important?

The trigeminal nerve is the fifth cranial nerve (comes out of the head). It supplies feeling to the face and also has a motor supply to the muscle of the jaw area.

In the upper part of the neck, the nerves from the neck and the trigeminal nerve converge. When there’s dysfunction in the upper part of the neck, the trigeminal nerve can get facilitated (gets improper input and over active).This can create tension in the jaw muscles and the headache sensation that’s often felt on one side of the face. Treating the jaw often is needed when treating neck problems and headaches.

TENSION HEADACHES AND TRIGGER POINTS

Tension in the muscles is thought to be the contributing factor to what are called tension headaches. One of the key muscles involved seems to be the upper part of the trapezius (traps). The other key muscles that I have noted clinically are the longissimus cervicus and the intercostalis cervicus. If you have ever experienced tightness in the upper back part of the shoulder and just slightly between the shoulder blades, this is the area where these muscles start.   

Trigger points are the area of the muscle that when pressed on reproduces the symptom that you are having. Trigger points have been shown to be areas of peripheral sensitization (have release of alogenic substances). Peripheral (spinal part of the nervous system) sensitization has been connected with central sensitization (central is the brain part of the nervous system). It is thought that the release of the trigger point will affect the pattern of the headache in the brain and thereby reduce the headaches. 

Weak neck muscles and chronic headaches

There is research that has shown a correlation between weakness or dysfunction of the deeper neck muscles at the front of the neck (look back to the April 15 blog on neck stabilization). Headache sufferers may also have a smaller bulk of muscles at the upper part of the neck at the back. 

Treating the headache

So we already discussed reducing headaches by releasing the trigger points. The other way to reduce headaches is through exercise. This occurs by activating the parts of our spinal cord that come down from the brain (descending pathways). This helps to block the pain signal. Cardiovascular-type exercise releases endorphins which are a neuropeptid that acts like a morphine.

Manipulation:  Spinal manipulation has been shown to be effective in reducing headache symptoms. In recent years there has been a lot of controversy about manipulation of the neck area. Some research has indicated that manipulation of the thoracic spine (mid-back) can be effective for management of neck pain and headaches. A recent study by GA Jull indicated that we cannot yet predict who will or won’t benefit from this treatment. Although, if the pain starts in the neck before the headache and you don’t have associated light-headedness, there is a good chance you will benefit. 

Exercise:  For people who have associated light-headedness with their headaches, there are some specific exercises that target the proprioceptors in the upper neck. (Proprioception is the awareness of where our body is positioned through receptors in our joints and ligaments. There is a high concentration of these in the upper neck). 

The benefit of cardiovascular exercise was mentioned previously. 

Manual Therapy: I consider manual therapy to include acupressure, massage, joint mobilizations (moving the joints but not doing a high velocity manipulation  thrust). 

Craniosacral Therapy: This is considered an alternative therapy technique, but I have seen it employed clinically to help with reducing headache tension. 

IMS (intramuscular stimulation):  IMS works on the principle of peripheral sensitization caused by pressure to the nerves that exit from the spinal canal. When there is pressure on the nerve, the muscle becomes overly sensitive and overactive to environmental stimuli. The muscles that are tense and ropy along with the spinal segment area are released using an acupuncture needle. I personally have been using IMS quite successfully for management of tension headaches.  For more information on IMS, go to www.istop.org

Summary

So where you feel your headache, may actually have to do with the type of headache that it is. When there’s tension just at the upper back of the neck, you might start to eventually experience the headache at the front of the face on one side (trigeminal nerve involvement).

When you get the headache at the base of the skull area and the back of the head, it is most likely from tension in the muscles in that area located there, and pinching of the occipital nerve, which supplies that area. 

A throbbing headache may be vascular (true migraine), which I did not talk about. Basically what I know about vascular-type headaches is that the blood vessels dilate allowing more blood into the brain area. 

Keeping the headaches from starting involves knowing what triggers them. Working on proper posture when sitting (especially working on the computer) and standing (slouching puts more pressure on the areas where the nerves come out and creates muscle imbalances). I do know that once the headache moves from the back of the neck to the front, it is much more difficult to get rid of. The best time to take your medication is at the first sign of tension. Heat is also often effective for muscle relaxation as is regular stretching.

If you are plagued with chronic headaches that have not responded to other treatments (manual therapy, massage, manipulation) I would recommend reading up on IMS to see if it is something you would like to try. 

References/More Information

K Aaseth, RB Grande, KJ Kværner, P Gulbrandsen, C Lundqvist & MB Russell.   Prevalence of secondary chronic headaches in a population-based sample of 30–44-year-old persons. The Akershus study of chronic headache. Blackwell Publishing Ltd Cephalalgia, 2008, 28, 705–713

C Fernández-de-las-Peñas1. Physical therapy and exercise in headache. Blackwell Publishing Ltd Cephalalgia, 2008, 28 (Suppl. 1), 36–38

S Evers. Comparison of cervicogenic headache with migraine. Blackwell Publishing Ltd Cephalalgia, 2008, 28 (Suppl. 1), 16–17

GA Jull & WR Stanton. Predictors of responsiveness to physiotherapy management of cervicogenic headache. Blackwell Publishing Ltd Cephalalgia,2004, 25, 101–108

Start Line Physiotherapy (250) 746-7463

wendy@wendybowen.com

STABILIZATION FOR THE NECK

All the rage these days is doing stabilization exercises for the lower back.

Did you know that you can reduce headaches by strengthening the correct neck muscles? 

 The muscles at the front of the neck include: 

• Rectus Capitus Anterior  
• Lateralis Capitus
• Longus Cervicus

 

These muscles at the front of your neck lie deep along the spinal vertebrae. 

These are like your deep abdominal muscles. 

When you have poor posture (forwards head where your chin is poking forwards) the muscles at the back of the neck

get short and tight, compressing the back joints of the neck bones, while the muscles at the front of the neck get long

 and stretched. Both short and long muscles can be weak as they are not in the optimum position for working. 

Whiplash injuries may contribute to the improper use of the deep neck muscles.

The more superficial muscles, Sternocleidomastoid (SCM) and Scalenes will compensate for the weak, deeper

muscles. These muscles are the movers of the neck and are not great stabilizers.   

Over time, because of poor stabilization the neck joints can wear (often considered as arthritis).

 

 

Nerve impingements at the neck, either where the nerve comes out between the bones, or as the nerves pass

through the scalene muscles, under the collar bone and over the ribs, can cause symptoms into the shoulder, elbow

and wrist/hand. 

The neck often has a roll in conditions such as “tennis elbow,” “carpal tunnel syndrome,” and

“thoracic outlet syndrome.” 

 

Testing of the deep neck muscles is done by a physiotherapis with you lying on your back and the head

and neck in a neutral spinal position. A chin nod is performed. A Pressure Feedback Cuff (PBU) can be used to help

measure the force of the contraction (superficially). The therapist will monitor the more superficial muscles (SCM,

 Scalenes and Suprahyoid) to determine if you are using these more superficial muscles through 2/3^rds of the motion

 versus just the deep muscles. The ultimate goal is to be able to sustain the proper contraction during the chin nod

exercise 10 seconds for 10 repetitions before fatiguing. 

Research has shown people who suffer from headaches have weakness of the deep neck muscles. 

Supervision by a physiotherapist is required initially to determine if you are recruiting the correct muscles.  

There is no sense in doing the exercise incorrectly, as it will then only serve to reinforce the incorrect movement pattern

and may contribute to more discomfort.

More Information

Carol Kennedy of Treloar Physiotherapy (www.treloarphysio.com) is leading the way in the area of neck pain and

 exercises. It was Carol who instructed myself through my manual therapy levels and introduced me to the concept of

Deep Neck Flexion exercises.

Start Line Physiotherapy (250) 746-7463

wendy@wendybowen.com