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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Did you know that between 2-5 per cent of the general population will experience a “Frozen Shoulder?”

Did you know it’s more common in people with diabetes and thyroid diseases?

Did you know that it’s more common in women between the ages of 40-60?

Did you know that over 80 per cent of clients with frozen shoulder (one study) respond to conservative treatment?

What is a Frozen Shoulder?

• Evidence that there’s an “elevation serum cytokine levels”
  • Which is an over production of the cells that help with tissue repair
  • This causes ongoing inflammation and fibrosis (scar tissue formation)
• Loss of normal collagen production – new collagen is too tight and restricts the movement of the shoulder joint.
• Contracture or tightening is typically found in the “rotator cuff interval” (RCI) at the front of the shoulder.

 

How Can I tell if I Have a Frozen Shoulder?

• Painful and/or stiff shoulder with all movement directions
• Typically starts without any significant incident
• Accompanied by progressive loss of motion (freezing) in all directions
• Significant night pain
• Loss of outward rotation of more than 50 per cent
• Weakness of the internal rotations

 

What Can I Expect?

• Initial first three 3 months
  • Pain is greater than stiffness
  • Pain limiting movement in all directions of motion
  • Muscle guarding on passive movements
  • Difficulty finding comfortable sleeping position
• Stage Two (3-9 months)
  • Pain with all movements
  • Stiffness may be starting to be more of a problem than pain in the later stages
• Stage Three-Frozen (9-15 months)
  • Less pain but more stiffness
  • Still limited motion
  • Improved tolerance for exercises and physiotherapy techniques
• Stage Four-Thawing (15- 24  months)
  • Minimal pain
  • Motion improving

 

What Should I Do?

• Research supports in the early stages (more pain from hyper inflammatory) the use of a cortisone injection (results of pain reduction are best when combined with a physiotherapy-guided exercise program)
• Ultrasound and other modalities might actually aggravate the pain in the early stages
• Do range of motion exercises that don’t increase the pain in the early stages
  • Aggressive stretching in the early phases can aggravate the condition
• Physiotherapy-guided home exercise program
• Physiotherapy joint mobilizations in the frozen or thawing stages

 

What Else Could the Problem Be if Not a Frozen Shoulder?

• Rotator cuff impingement
• Rotator cuff or labral tears
• Neck problems
• Severe osteoarthritis
• Acute tendon calcification
• Tendonitis or bursitis
• Humeral fracture (proximally)

References/More Information

1. Martin J. Kelley, Phillip W. McClurr, Brian G. Leggin. Frozen shoulder: evidence and a proposed model guiding rehabilitation. February 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

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My interest in the shoulder has stemmed from having separated my shoulder playing hockey back when I was a teenager. I did not have any treatment to it until I was in my late 20s. Having to treat my own shoulder has given me personal insight into the shoulder joint and recovery from injury. 

When it comes your shoulder, you don’t have to live with the pain.

The Shoulder Joint

• ball and socket joint
• held in place by ligaments
• surrounded by a capsule

 Rotator Cuff

• group of four smaller muscles that work together to keep the ball centered in the socket                                                                                                                        

Rotator Cuff Tendonitis/Tendonopathy:

• a common problem with the rotator cuff is IMPINGEMENT
• supraspinatus and sometimes the biceps tendons get pinched as the arm is raised overhead
• may result in TENDONITIS (inflammation of the tendon) or TENDONOPATHY (thickening/changing of the tendon structure).                                                                                                                                                                                                                                                     

Common Cause of Impingement

1)     Poor Posture: Rounding of the shoulders. Slouching leaves less room under the arch.

• Stiffness and tightness in the middle back area can be contributing factors.

2)     Muscle Imbalances: Tight or weak muscles alter the movement and timing of the joint.

• Can be caused by repetitive strain or trauma injuries.

3)     Overuse: Too much, too soon, too frequently — not enough rest time.

4)     Trauma: Falls, sports (throwing, weight-lifting improperly, swimming etc.).

• The jarring of the muscle can cause a reactive muscle shortening.

5)     Shape of the Arch: Some collar bones are hooked, leaving less space for the cuff.

 Rotator Cuff Tears

• Rotator cuff tendons don’t get good blood flow and will often thin (attenuation) with age.
• Are common in middle age.
• Repetitive minor traumas accumulate, leaving the tendons weaker and more susceptible to tearing with a relatively minor injury.
• Rotator cuff tears can also occur with falling on the shoulder, or with major trauma in the younger individual.

 Frozen Shoulder (Adhesive Capsulitis) 

• The formation of adhesions (scar tissue) of the shoulder capsule usually secondary to inflammation.
• As the capsule tightens, there’s pain and loss of range in all directions. 
• There are three stages:
  • Freezing: loss of movement
  • Frozen: no loss but no gain
  • Thawing: gradual regain of movement
• The process can take 1-3 years.
• If you get it in one shoulder, you’re more susceptible of getting it in the other.
• Often termed “idiopathic” because we don’t really know what causes it.
• Higher incidence in people
  • over 40 years of age
  • with diabetes (10-20 per cent of individuals affected)
  • heart conditions
  • hypothyroidism
  • hyperthyroidism
  • Parkinson’s disease
  • post-surgery
• Physiotherapy modalities can make it worse rather than better

 Treatments

 Exercises

• Proper exercise prescription requires a thorough assessment by a physiotherapist to determine the underlying nature of the problem and what stage of healing the tissue is at.
• Shown in research to improve pain scores in clients with frozen shoulders *(see references below).

 Manual Therapy

• Joint mobilizations have been shown to improve pain scores in those with frozen shoulders* (see references below).

 Modalities

• Ultrasound and iontophoresis have been shown to increase pain in those with frozen shoulders* (see references below).
• I suspect the ultrasound, which increases blood flow to the area treated, causes increased pain because of an underlying hypervascularization (increased vascularization) in those with frozen shoulders.

 Intramuscular Stimulation (IMS)

• Personally I have found IMS to be very effective in treatment for:
  • shoulder impingement
  • rotator cuff strains
  • muscle imbalances (tight ropy bands of muscles)
  • anterior glenohumeral syndromes (muscles at front or back of the shoulder are pulling and/or pushing the shoulder ball out of its central alignment (often misdiagnosed as a “frozen shoulder”)
• I have not had success with lasting improved range of motion in “true” adhesive capsulities.

 Corticosteriod Injections

• While this is beyond the scope of physiotherapy, research has indicated good short-term relief of symptoms.

 References/More Information

 1. Information from Bahram Jam, APTEI newsletter: www.aptei.com

2. Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009 May;89(5):419-29. Epub 2009 Mar 6.

 3. Martin J. Kelley, Phillip W. McClurr, Brian G. Leggin. Frozen shoulder: evidence and a proposed model guiding rehabilitation. February 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

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How do you know that traction will work for you (and you won’t hurt yourself)?

Physiotherapists have used traction as a treatment modality for decades (used medically for over 50 years). There are certain tests that we do to help determine who will benefit or not from traction.

Nowadays you don’t need to see a physiotherapist to have traction with the invention and sale of the inversion table.

Why would someone hang themselves upside down? 

The rational behind traction:

• Arthritis
  • light separation of the vertebrae (bones) in the spine
• Disc bulges or herniations
  • takes stress off of the discs

We, as upright walking humans, are subjected to the law of gravity. I have read over the course of the day we can loose up to 2 cm in height (so always measure your height in the morning). First thing in the morning we also have more fluid and height in the discs in our backs, which is why people with back pain from disc problems (herniations or bulges) often feel more pain in the morning. 

There is a list of contraindications for inversion table use. You should not use an inversion table if you have the following medical conditions:   

Glaucoma
Pregnancy
Hiatal hernia
Ventral hernia
Detached retina
Extreme obesity
Middle ear infection
Arterial hypertension
Severe vascular disease
Anti-Coagulants (use of)
Conjunctivitis (pink eye)
Bone weakness, recent fractures
History of congestive heart failure
History of space-occupying brain lesion
Vulnerable areas of stress from recent surgery

Why see a physiotherapist first?

1. Traction can aggravate the problem.

2. There may be other treatment techniques that would also be helpful.

• IMS
• Exercises
• Manual Therapy
• Education

3. There are several different causes of back pain (www.cbihealth.com).

4. May aggravate conditions in the knees and hips.

Bahram Jam reviewed Spinal Decompression in the APTEI report (www.aptei.com/report winter 2009). In this review, Bahram looks at an article published in Chiropr Osteopat. 2007 May 18; 15:7. This is more of a review based on marketing claims and scientific literature. 

The conclusion drawn is there are few studies that exist supporting spinal traction. 

There was a good study published in Spine 2007 Dec 15: 32 (26) again summarized by Bahram in the APTEI report on who might benefit from traction. 

People with the following symptoms are likely to benefit from traction:

1. Leg symptoms below the knee

2. Signs of nerve root compression (a pinched nerve where it exits the spinal column)

3. Peripheralization of symptoms with extension (backwards bending decreases the pain in your leg)

4. Symptoms down one leg when the other is lifted (positive crossed straight leg raise)

Conventional traction versus inversion tables

(Physiotherapy Theory and Practice (2000) 16, 151 –160 © 2000 Taylor & Francis)

• Randomized controlled – 29 clients with lower back pain and sciatic from disc herniations.
• Both groups benefited (as noted by clinical changes on CT scans) but there was no clinically significant difference between the groups.   

When making the decision to invest in the “spinal decompression” advertised in the newspapers, or on an inversion table, or physiotherapy, I would suggest doing your research and know what you’re getting for your investment. 

References/More Information

1. Bahram Jam’s reports: Chiropr Osteopat. 2007 May 18; 15:7 online: (www.aptei.com/report winter 2009) and Spine 2007 Dec 15: 32 (26)

2. (Physiotherapy Theory and Practice (2000) 16, 151 –160 © 2000 Taylor & Francis)

For more information:

1. http://www.energycenter.com/grav_f/contra.html

2. www.cbihealth.com

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Allow me to update you on who I am. I’m Wendy Bowen and I have a background in Kinesiology and 13 years of clinical experience as a physiotherapist.  I hadn’t run more than a mile until the age of 22. I struggled for years with running. Even five kilometres was a challenge due to a chronic Iliotibial Band problem.

What I discovered through my physiotherapy postgraduate studies and from what I had learned about my own issue was that the pelvis is the centre of your universe if you want to run without the pain of tissue damage or injury.   

When we run…

we are standing only on one leg at any given time. We transfer the load from the ground up through the pelvis. The pelvis is made up of the sacrum (triangle bone) and two innominants (pelvic bones). It’s held together through very tough ligaments at the front and the back (stronger at the back). It takes a lot of force to damage these ligaments (child birth, car accidents etc.). Very few people actually have hypermobility from ligament damage.

The pelvis is also controlled by muscles (dynamic system). There are a few key inner core muscles (transverses abdominus, pelvic floor muscles, multifidus at the back and the diaphragm) that all need to work in perfect timing to offer good stability. 

What else?

Other muscles attached to the pelvis (quadriceps or thigh muscles, hip muscle or gluteal muscles, hamstrings, hip adductors or inner thigh muscles) are the movers. Think of these longer muscles as springs. If there is more tension on the spring at the front of the thigh it will pull the pelvis forward and vice versa with the tension at the back of the leg (hamstrings). We can also see this tension from the muscle that runs from the pelvis up to the mid back region.

Many people are told that they have one leg that is shorter and get the leg tugged on (manipulation of the pelvis). This only corrects the problem temporarily until the next time you run. If you run with an apparent leg length discrepancy, what may happen is that you run more on the outside of your foot to have it hit the ground (more supination) but in order to get the foot in the position to push-off, you’ll need pronation, which will come from the mid foot. This pronation may contribute to plantar fasciitis or Achilles tendonitis (two other big running injuries). 

Muscle shortening (springs too tight) also contributes to muscle weakness. A common weakness is the muscles at the side of the pelvis (gluteus medius). These attach to the ITB, along with the outer (lateral) quadriceps, gluteus maximus and Tensor Fascia Lata (TFL). There is often an over dominance of the TFL over the posterior gluteus medius. This creates the abnormal pull on the ITB.

The answer!

If you’ve tried stretching or yoga and still find you have muscle imbalances, what has worked well for me (to the point where I have been able to run a half marathon distance without any ITB symptoms) has been to use Intramuscular Stimulation (IMS) to release my chronically tight muscles around my pelvis and lower back. It also worked on finding and retraining my inner core muscles while continuing to strengthen my outer core.

I continue to use core shorts as I’m still not able to continually recruit my inner core over long distance runs. 

I’m currently the only person in the Cowichan Valley trained in IMS, but as of April 1 Heidi Bovey, who is also working at Start Line Physiotherapy, will also be trained.

For more information:

1. www.istop.org

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Here’s what’s happening

Our tissues are made up of different types of fibers. Elastin is the stretchy type of fiber that is found in high amounts in skin and muscle. Collagen is the tougher fiber that is abundant in ligaments. Tendons have a mixture of both (in between muscles and ligaments).

Elastin vs. collagen

When you stress a tissue, there is a certain amount of give, depending on the amount of elastin vs. collagen. The stress creates a strain and the tissue needs time to recover after each stress (collagen tissues need longer as they are not as elastic).  If you apply several small amounts of stress over a short period of time, you have what is called repetitive strain syndrome.

The little stresses build up on top of each other until your tissue reaches its breaking point. If you apply a small amount of stress over a prolonged period of time (like what happens when you have to sit on a long flight and don’t get to change position very often) you again build up the strain on the tissue (and start to squirm around because of the discomfort).

These little muscle aches are telling you this: (“GET MOVING” or “TAKE A BREAK”). This is the hurt, but not the harm. The harm comes when you don’t listen and keep stressing the tissue until it breaks (tears). RECOVERY is an essential part of all activities. This is called taking a break, or changing the stress on your tissues. A physician once put it like this: 

The difference between working out to make your tissues stronger and injury, is that working out is controlled injury. You are only stressing the tissue enough, and then providing it with recovery, so that the body knows it needs to make the tissue stronger. When you overstress the tissue, whether it is gradually, repetitively or with a fast trauma, you get injury.

Our bodies are very smart!

They know that when we stress the tissues, that it needs to strengthen them. This is called Wolfe’s Law.

What to do to train, work, or play without injury? 

1.  Start small and gradually build mileage, resistance, repetitions.

2.  With mileage (running, swimming, biking etc.) keep track of your weekly mileage and build no more than 10 per cent/week.  Every fourth week should be a recovery week.

3. If you miss a week, don’t increase the 10 per cent the following week, only repeat what you did the week prior.

4. If you miss more than a couple of weeks, start over.

 Having a preventative screening assessment performed by a physiotherapist is also a beneficial way to minimize the risk of injury. This assessment would help determine areas of specific muscle tightness or weakness which will allow you to develop a program to address any issue before the injury occurs.

Start Line Physiotherapy (250) 746-7463

wendy@wendybowen.com

  

Let’s find out

You’ve  just come into the physiotherapy clinic with a script stating that you have Achilles tendonitis. You know it must be this because it hurts at the back of the heel area (maybe a little bit above the heel).  It really hurts after a run and sometimes even into the next day if your run is more than a certain distance. It often feels a bit tight and sore at the start of your run, but it seems to get better as the run progresses. And boy is it sore when you press on the area or it touches something.

This is the story that you tell the physiotherapist. You may be asked a few more questions regarding how far you typically run or how long you have been running.

As a physiotherapist I could ultrasound the sore area over several visits or give you some eccentric exercises and teach you some stretching. But what I really want to know as a therapist is why? Why is it just happening on one side of your body? What is happening at your pelvis?; your foot?; and even into your back that might be contributing to this problem.  

A common pattern 

I’ve  noticed with Achilles tendon pathologies is that there is often one hip (pelvic bone) that is higher when the person is standing. There is more muscle tension in the muscles running up one side of the spine that may be pulling the pelvis up. The foot then has to supinate (roll outwards) to achieve heel strike. The outer calf muscle (gastrocnemeus) often has a ropy band in it (indicative of a shortened muscle).  This can also create a loss of movement/mobility at the calcaneus (heel) joints. Other times the heel joints are stiff because of past ankle sprains (even up to 20 years prior) where there was no treatment administered.

Treatment

How I might treat this is by releasing the tight ropy muscle bands (using my preferred method – IMS or intramuscular stimulation). Go to www.istop.org for more informaiton on IMS. Then I would use my manual therapy skills to restore joint mobility where needed (this may include the ankle and foot as well as the sacroiliac joint or SIJ). Friction massage to the tendon can be helpful if there is a bump. Clinically, what I have noticed is that if the tenderness seems to get less as the area is rubbed, it is likely a tenodonopathy (no inflammation but rather a change in the quality of the tendon collagen).  Eccentric exercises have been reported in the literature to be effective in the treatment of tendon problems.  These are when exercising the muscle you lengthen it rather than shortening it. Proper stretching (watching the heel position as many people turn the heel in at the back when stretching) of the calf muscles can also be beneficial.

For more information:

1.www.istop.org

2. If you are a physiotherapist, there are a couple of upcoming video/teleconferences on the use of electrophysical agents and the Achilles tendon issues.  Go to the PABC website for more information at: http://www.bcphysio.org/app/index.cfm?fuseaction=pabc.ubc

Start Line Physiotherapy (250) 746-7463

wendy@wendybowen.com