Archive for April, 2010

 

 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

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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.

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What would you think if you were informed that you had “degenerative disc disease?” It would be shocking to think of

 having a disease of the disc.

What is the disc?  

What kind of disease is it? 

Is it curable? 

Well, this condition is really not a disease. It is really one part of the spinal anatomy that is wearing out faster than the

 other parts that are wearing out from the normal aging process. 

In order to fully understand what is happening, we need to understand how the spine works and what is normal aging.

UNDERSTANDING THE ANATOMY OF YOUR SPINE

Picture taking 24 of those kids blocks (the ones with the alphabet letters on them) and stacking them one on top of the

 other. These represent our vertebral bodies. But they are not stacked perfectly, they are slightly curved one way for

the first five (your lower back or lumbar spine is a lordosis).  Then they curve the opposite way for the next 12 (your

 thoracic spine is kyphotic).  They curve again the other way (like the lumbar spine) for your neck (or cervical curve).

Now take a 10 lb bowling ball and balance it on top.  This represents your head.  Of course these curved stacked

 blocks are not resting on the ground but sitting on the pelvic (sacrum which is a small upside down triangle bone of

five fused together blocks) that sits between your two pelvic bones. This all rests on two pedestals (your legs). 

But of course these blocks are not just sitting one on top of the other. They have small water-filled balloon type

 structures between them.  These are the discs.  This does not sound like a very stable structure at all does it?

 

 

HOW DO WE STABILIZE OUR SPINES?            

In order to add stability to this stack of blocks, we add a strip of duct tape to the front and the back. This represents

 your ligaments. We will talk about the structure of muscles, ligaments, and tendons another time. You can also add

 some smaller strips of these ligaments between the blocks (running between two adjacent blocks or spanning a few

 blocks).  

HOW DO WE GET THE SPINE TO MOVE?

Now we know that the spine has to move, so the tape can’t be too tight and rigid.  To add to the stability, but allow

 some movement we add in some small elastic bands (muscles) close to the blocks. These attach to the bony parts

sticking out from the vertebra (spinous processes and transverse processes). Some of these bands run between only a

few blocks, while others span more than a few. 

In the back there are three layers of these muscles.

The deepest layer adds the stability to the vertebrae (www.dianelee.ca) for more information on the inner

 core).  The middle layer helps move the back, pelvis and neck in different directions. While the outer layer helps

move the arms and legs.  All add some stability (inner versus outer) to the spinal column. 

These elastics are controlled by electrical signals coming through wires (nerves).  

 

WHAT HAPPENS AS WE AGE?

Deconditioning 

First of all, many people in middle age get caught up in the rat race of life and stop being physically active.  So now the

 muscles don’t work as well as they should. 

 

Changes in the disc

At the disc level, there is a movement toward the disc moving into the bone. To picture this, take your hands and hold

 them slightly apart but level with each other (young disc). Now cup your hands but without moving them together.

Notice how your fingers come together. The part where your knuckles bend is the part moving into the vertebrae. As

 the fingers come closer together what happens to the duct tape that is spread between the fingers on the right and

 those on the left?  Yes the tape crinkles. It does not shorten because it, unlike the muscles, is not very elastic. 

 

Wear and tear

Now you have a muscled deconditioned back with loose ligaments. Now part of your stack of blocks

is moving too  much. This puts stress on the joints (where two bones come together) and the discs.

 The joints may start to wear under stress and soon you will be told that you have arthritis. Or the

disc starts to be placed under too much stress and you develop a bulged or herniated disc. There is also a lot of stress

 on the disc if you are doing a lot of bending and twisting, or sitting in a slouched position.

 

SPEEDING UP THE AGING PROCESS

Fractured end plates

Now you can speed up this aging process by doing a number of things.  You could have had a hard fall

 onto your back or buttocks. Just think of all those impact sports we played as children, the falls off our

 bikes and monkey bars or those tumbles because we really should not have been doing gymnastics,

but the teacher did not listen to us. These falls can create a fracture to the thin plate (end plate) on the

bottom of your vertebrae. The disc then gets exposed to foreign material causing an inflammation process and it

starts to degredate (thin). This is your “disease” process. 

 

Smoking

You can make the disc more fragile by smoking (reduced blood flow and nutrients get to the disc).There is a study out

 supporting that individuals who smoke and perform heavy lifting activities are at increased risk of lower back

injuries.  Smoking is essentially like putting your nice supple tissues into a dehydrator.  They start to become like

 dried out leather and tear more readily. (Also if you fracture a bone, it has been shown to not heal as well, and

sometimes not at all in smokers).

Tight or weak muscles (muscle imbalances)

You can have nice tight muscles in the back that will compress the disc and which can limit nutrition to the disc and

 compress the spinal joints (contributing to arthritis). Another thing that has been shown to occur after trauma to the

 back (fall or other accident, repetitive trauma from bending and twisting) is the deepest muscle (multifidus) can shut

down. Yes it just stops working. Now you can imaging what would happen if one person at work just up and quit. All

the other people would have to step in and try and do the work to keep the pole from falling over or moving too

 much.  So now the middle layer of muscles get overworked and tight. Some people even try to keep the pole stabilized

 by squeezing their buttock muscles. This just leads to a whole new set of problems. 

 

WHAT CAN YOU DO?

Don’t fret, it’s not too late. With a proper assessment to determine all your muscle imbalances (what is tight and what

is not helping out) and working on releasing the tight muscles and getting the lazy ones back to work, you can in most

cases improve the stability of your spine, reduce the compression and irritation to the spinal joints and take some of

the stress off of the disc. However, you need to be willing to do some work. You will likely be required to start a

 stretching program, and work on re-engaging your inner core (reconnecting the wires from your brain to the

muscles) and then working on overall conditioning. 

 

References/More Information

1. www.dianelee.ca

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