Leagrave Therapy Clinic Blog

Sports Massage & Osteopathy For Upper Middle Back Pain

Tue, 21 Apr 2026 21:21:19 GMT

Understanding the Rhomboid Muscles: Small Muscles,

Big Impact on Posture and Movement & How A Sports

Deep Tissue Massage Can Help

When people think about back muscles, they often picture the large, visible groups like the lats or trapezius. But tucked between the shoulder blades are two smaller, often overlooked muscles that play a critical role in posture and upper-body function: the rhomboid minor and rhomboid major.

Despite their size, these muscles have a powerful influence on how you carry yourself, how your shoulders move, and even how your neck and upper back feel on a daily basis.

What Are The Rhomboid Muscles?

The rhomboids are a pair of muscles located in the upper back:

- Rhomboid minor: sits just above
- Rhomboid major: slightly larger, positioned below

They connect the spine to the inner border of the shoulder blades (scapulae). Their primary roles include:

- Pulling the shoulder blades together (retraction)
- Rotating the scapula downward
- Stabilising the shoulder blades against the ribcage

In simple terms, they help keep your shoulders back and your upper body aligned (3).

Posture and Scapular Positioning

The position of your shoulder blades is central to upper-body health.

When the rhomboids are functioning well:
- The scapulae sit flat against the ribcage
- The chest is open
- The shoulders are neutral

When weak or lengthened:
- Scapulae drift outward (protraction)
- Upper back rounds
- Head shifts forward

When tight:
- Scapulae may be overly retracted
- Movement becomes restricted

Experimental and EMG-based studies show that proper scapular positioning is essential for efficient shoulder mechanics and injury prevention (1).

Lifestyle Factors That Affect Rhomboid Health

Daily habits strongly influence rhomboid function.

Key contributors:
- Sedentary behaviour
- Poor workstation ergonomics
- Lack of movement variability
- Chronic stress

Studies have shown that prolonged sitting and poor posture significantly alter muscle activation patterns in the upper back and shoulder girdle (8).

Simple interventions include:
- Frequent posture changes
- Ergonomic adjustments
- Regular movement breaks

How Exercise Can Help

Exercise is essential for restoring balance in the rhomboids.

1. Strengthening (for weak rhomboids):
Targeted exercises improve scapular stability.

- Rows
- Face pulls
- Prone Y/T raises

EMG studies confirm that these exercises effectively activate scapular retractors when performed with proper technique (1).

2. Mobility and Stretching (for tight rhomboids):
Stretching and thoracic mobility work can reduce stiffness and improve function (7).

3. Postural Re-education:
Motor control and awareness are crucial. Training the coordination of the scapula with surrounding muscles improves long-term outcomes (4).

The Role of Physical Therapy

Physical therapy provides a structured approach to correcting dysfunction.

A physical therapist may:
- Assess posture and movement
- Identify muscular imbalances
- Prescribe individualized exercise programs
- Apply manual therapy techniques

Evidence-based rehabilitation programs focusing on scapular stabilization have been shown to reduce pain and improve shoulder function (4).

The rhomboid major and minor are small but essential muscles for maintaining posture and efficient movement.

Modern lifestyles often place them in a lengthened and weakened state, contributing to postural dysfunction and discomfort. However, through targeted exercise, improved daily habits, and evidence-based physical therapy, their function can be restored.

Consistency, not intensity, is the key to long-term musculoskeletal health.

References

1. Cools, A.M., Dewitte, V., Lanszweert, F., Notebaert, D., Roets, A., Soetens, B., Cagnie, B. and Witvrouw, E.E. (2007) ‘Rehabilitation of scapular muscle balance: which exercises to prescribe?’, The American Journal of Sports Medicine, 35(10), pp. 1744–1751.

2. Janda, V. (1987) ‘Muscle function testing’, in Evaluation of Muscular Imbalance. London: Butterworths, pp. 97–112.

3. Kibler, W.B. (1998) ‘The role of the scapula in athletic shoulder function’, The American Journal of Sports Medicine, 26(2), pp. 325–337.

4. Kibler, W.B., Sciascia, A. and Wilkes, T. (2013) ‘Scapular dyskinesis and its relation to shoulder injury’, Journal of the American Academy of Orthopaedic Surgeons, 21(6), pp. 364–372.

5. Kocur, P., Wilski, M., Lewandowski, J. and Łochyński, D. (2019) ‘Female office workers with moderate neck pain have increased anterior positioning of the cervical spine and stiffness of upper trapezius muscles’, Clinical Biomechanics, 67, pp. 84–89.

6. Ludewig, P.M. and Cook, T.M. (2000) ‘Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement’, Physical Therapy, 80(3), pp. 276–291.

7. Page, P., Frank, C.C. and Lardner, R. (2010) Assessment and Treatment of Muscle Imbalance: The Janda Approach. Champaign, IL: Human Kinetics.

8. Straker, L., O’Sullivan, P., Smith, A. and Perry, M. (2009) ‘Relationships between prolonged neck/shoulder pain and sitting spinal posture in male and female adolescents’, Manual Therapy, 14(3), pp. 321–329.

Sciatica - Specific Areas of Pain & Physical Therapies

Fri, 03 Apr 2026 11:08:50 GMT

Sciatica, Specific Areas of Pain, Sport

Massage & Physical Therapy

Due to its extensive anatomical course, dysfunction or irritation of the sciatic nerve can produce symptoms that radiate from the lower back and upper buttock region all the way down to the calf and foot. Pain associated with the sciatic nerve, commonly referred to as 'sciatica', often arises from compression, inflammation, or irritation of the nerve roots or the nerve itself. One of the most frequent causes is lumbar disc herniation, where protrusion of intervertebral disc material compresses adjacent nerve roots. Degenerative spinal changes such as spinal stenosis or spondylolisthesis can also contribute to nerve compression. Additionally, extra-spinal causes, such as piriformis syndrome, involve the entrapment or irritation of the sciatic nerve by the piriformis muscle in the deep gluteal region.

Sciatic Nerve Course & Anatomy

The sciatic nerve is the largest and longest nerve in the human body, originating from the lumbosacral plexus (L4–S3 nerve roots). It exits the pelvis via the greater sciatic foramen, typically passing beneath the piriformis muscle, and travels through the posterior thigh before branching into the tibial and common peroneal nerves near the popliteal fossa. These branches continue down into the lower leg and foot, providing both motor and sensory innervation.

Nature of Sciatica

The experience of sciatic pain varies widely among individuals. Patients commonly describe sharp, shooting, or burning pain that radiates from the lower back or upper buttock down the posterior aspect of the leg. This pain may extend into the lower calf and foot, sometimes accompanied by numbness, tingling (paraesthesia), or muscle weakness. The distribution of symptoms often reflects the specific nerve roots involved; for example, L5 or S1 nerve root irritation may produce symptoms in the lateral leg or sole of the foot, respectively. Activities such as prolonged sitting, bending, or lifting may exacerbate symptoms due to increased pressure on the lumbar spine or nerve pathways.

Massage Therapy

Massage therapy can play a supportive role in managing sciatic pain, particularly when muscular tension contributes to nerve irritation. Techniques targeting the gluteal muscles, piriformis, and lower back can help reduce muscle tightness, improve circulation, and decrease local inflammation. By relieving tension in surrounding soft tissues, massage may reduce compressive forces on the sciatic nerve and alleviate referred pain patterns. However, it is important that massage is applied appropriately, as excessive pressure over an already irritated nerve may worsen symptoms.

Posture Control

Posture is another critical factor in both the development and management of sciatic pain. Poor postural habits, such as prolonged sitting with a flexed lumbar spine or asymmetrical weight distribution, can increase mechanical stress on spinal structures and contribute to nerve compression. Ergonomic adjustments, including proper chair support, lumbar positioning, and movement breaks, can significantly reduce strain on the lower back and sciatic nerve. Education on posture empowers individuals to modify daily habits that may perpetuate their symptoms.

Physical examination is essential in diagnosing the source of sciatic pain and guiding treatment. Clinicians often use neurological assessments, including reflex testing, muscle strength evaluation, and sensory examination, to identify nerve involvement. Special tests, such as the straight leg raise (SLR), can help determine nerve root irritation. Palpation of the lumbar spine, gluteal region, and surrounding musculature may also reveal areas of tenderness or muscular imbalance contributing to symptoms. Accurate assessment allows for differentiation between spinal and extra-spinal causes of sciatic pain, which is crucial for effective management.

Exercise Therapy

Exercise therapy, prescribed through physical therapy, is a cornerstone of treatment for sciatic nerve-related pain. Targeted exercises aim to improve flexibility, strength, and neuromuscular control. Stretching exercises for the hamstrings, piriformis, and hip flexors can reduce tension along the nerve pathway. Strengthening exercises for the core and lumbar stabilising muscles help support the spine and reduce mechanical stress. Neural mobilisation techniques, often referred to as “nerve gliding” exercises, are specifically designed to improve the mobility of the sciatic nerve within its surrounding tissues.

Furthermore, graded activity and progressive exercise programmes encourage functional recovery and reduce fear-avoidance behaviours often associated with chronic pain. Education is an integral component of physical therapy, helping patients understand their condition and actively participate in their rehabilitation. Over time, consistent engagement in therapeutic exercise can lead to reduced pain, improved mobility, and enhanced quality of life.

In conclusion, the sciatic nerve’s extensive anatomical course makes it susceptible to a range of compressive and irritative conditions that can produce pain from the upper buttock to the lower leg and foot. The experience of sciatic pain is multifactorial, involving both structural and functional components. Interventions such as massage, postural correction, and thorough physical examination play important roles in identifying and alleviating contributing factors. Most importantly, exercise-based physical therapy provides a structured and evidence-based approach to restoring function and reducing symptoms, highlighting the importance of active rehabilitation in managing sciatic nerve-related pain.

References

Bogduk, N. (2012) Clinical Anatomy of the Lumbar Spine and Sacrum. 5th edn. Edinburgh: Elsevier.

Butler, D.S. and Moseley, G.L. (2013) Explain Pain. 2nd edn. Adelaide: NOI Group Publications.

Hall, S.J. (2015) Basic Biomechanics. 7th edn. New York: McGraw-Hill Education.

Koes, B.W., van Tulder, M.W. and Peul, W.C. (2007) ‘Diagnosis and treatment of sciatica’, BMJ, 334(7607), pp. 1313–1317.

Kendall, F.P., McCreary, E.K., Provance, P.G., Rodgers, M.M. and Romani, W.A. (2005) Muscles: Testing and Function with Posture and Pain. 5th edn. Baltimore: Lippincott Williams & Wilkins.

Magee, D.J. (2014) Orthopedic Physical Assessment. 6th edn. St. Louis: Elsevier Saunders.

Shacklock, M. (2005) Clinical Neurodynamics: A New System of Neuromusculoskeletal Treatment. Edinburgh: Elsevier Butterworth-Heinemann.

Breathing Properly for Health

Sun, 15 Feb 2026 19:01:42 GMT

Why so Many of Us Don’t Breathe the Way

We Should and Why Changing It Matters

Most people assume breathing is automatic and “good enough", however lots of us don’t habitually use the lower diaphragm and belly for slow, easy breaths. Instead we default to shallow, rapid chest-breathing (sometimes called upper-chest or clavicular breathing) or patterns that meet the moment (stress, posture, screen time) rather than the body’s long-term needs. Clinically this shows up as “dysfunctional breathing”—a recognizable pattern of irregular, often shallow or over-rapid breaths that happens even when there’s no primary lung disease. Estimates put dysfunctional breathing at roughly ~9% in the general adult population and it’s much higher among patients seen for breathing complaints or asthma.

Below I explain, with research-backed references, why diaphragmatic (lower-belly) breathing helps, what happens physiologically when we don’t breathe well and simple, evidence-based ways to practice better breathing.

What “good” breathing looks like

The diaphragm (a large dome muscle beneath the lungs) should do most of the work at rest: on inhalation it drops and the belly gently rises; on exhalation it relaxes and the belly falls.
A typical healthy adult resting respiratory rate is about 12–20 breaths per minute (many clinical sources use 12–16 or 12–20 as the normal range). Slow, deep diaphragmatic breathing practiced intentionally is often much slower (see below).

How many people are “chest breathers”?

There isn’t one widely-agreed single statistic for “percent who breathe from the chest” — researchers typically measure dysfunctional breathing instead (which often includes thoracic/chest-dominant patterns). Dysfunctional breathing affects roughly one in ten people in community samples and is more common in clinical populations and people with asthma (where studies have found rates around 25–30% in some primary-care samples). So while “chest-breather” as a lay label is imperfect, a nontrivial minority of people have breathing patterns that are suboptimal and clinically meaningful.

Why Learning to Breathe well is A Practice

Good breathing is a motor habit tied to posture, stress reactivity and awareness. Research shows that deliberate training — slow diaphragmatic or “resonance-frequency” breathing and breathing retraining programmes — reliably changes physiology (heart-rate variability, blood pressure, stress hormones) and symptoms over weeks to months. That means breathing well doesn’t always “click” once; it takes regular practice, cueing, and sometimes professional coaching.

The Physiology — Why the Lower Diaphragm Matters

1. Vagal tone & the parasympathetic system

Slow, diaphragmatic breathing increases cardiac vagal activity (measured as heart-rate variability or HRV) — a marker of parasympathetic (rest-and-digest) activation. Higher vagal tone improves the body’s ability to down-regulate stress responses and supports emotional and physiological resilience. Randomized and controlled studies show meditative or diaphragmatic breathing increases vagal markers compared with control conditions.

2. Blood pressure and autonomic balance

Breathing at or near an individual’s “resonance frequency” (often around ~5–7 breaths per minute) amplifies baroreflex function and can lower resting blood pressure and heart rate over time. Clinical trials of resonance-frequency or slow-breathing training show improvements in blood-pressure control and autonomic balance.

3. Stress hormones (cortisol) and stress symptoms

Several trials and controlled studies report that adding slow, deep breathing or breathing + mindfulness reduces cortisol and perceived stress versus control activities. Because cortisol is a major mediator of the chronic stress response, breathing practices that reduce cortisol are a direct pathway for lowering physiological stress–related symptoms (including tension and clenching).

4. Muscle tension, Jaw Clenching and Pain

Chronic stress and elevated sympathetic drive are linked to increased jaw/clenching behaviors (bruxism) and to musculoskeletal tension in the neck and upper back. Systematic reviews and clinical studies show associations between stress markers (including cortisol) and bruxism/TMD symptoms. By reducing sympathetic arousal, better breathing practice can reduce nocturnal and daytime muscle tension, which helps with jaw tension and related neck/upper-back pain.

What Goes Wrong When We Breathe Poorly (hyperventilation, shallow breathing, chest dominance)

Hyperventilation (too rapid / too deep relative to metabolic need) lowers carbon dioxide (CO₂) in the blood (hypocapnia). Hypocapnia causes cerebral vasoconstriction — less cerebral blood flow — which paradoxically can reduce oxygen delivery to the brain even though you’re “breathing more.” This state also raises sympathetic activity. The net result: anxiety, lightheadedness, brain fog, and in vulnerable people, worsening fatigue and cognitive overload.
Sustained sympathetic activation from poor breathing increases allostatic load (wear and tear), contributing to burnout when combined with psychosocial stressors.
Breathing and airway problems: behavioural or voluntary hyperventilation can precipitate bronchoconstriction in asthma and is commonly seen as a comorbidity in people with asthma and unexplained dyspnea; dysfunctional breathing patterns also complicate asthma control. There is also clinical literature describing behavioural hyperventilation’s links with sleep-disordered breathing in specific cases.

How Many Breaths per Minute Should We Take?

Normal resting adults: ~12–20 breaths per minute per clinical sources.
For training and vagal benefits: research on resonance-frequency breathing and HRV often targets ~4.5–7 breaths per minute (commonly around 6 breaths/minute) for short practice sessions; this slower rate is used intentionally in breathing training to stimulate vagal tone and baroreflex function. It is not the usual spontaneous resting rate for most people, but a therapeutic practice rate.

Practical, Evidence-Based Breathing Practices (how to start)

Gentle diaphragmatic breathing (beginner; 5–10 minutes)

Sit or lie comfortably with one hand on your chest and one on your belly.
Inhale slowly through the nose for ~4 seconds, feel the belly rise (chest should move very little).
Exhale slowly for ~6 seconds through the nose or pursed lips.
Repeat for 5–10 minutes once or twice daily. Over weeks you’ll notice calmer baseline arousal. (This pattern is a simple, safe way to start training diaphragmatic breathing; studies of slow breathing protocols show physiological benefits after repeated practice.)

Resonance-frequency practice (if you want measurable HRV/BP effects)

Many labs use guided paced breathing at ~6 breaths/min (inhale about 5–6 seconds, exhale about 5–6 seconds) for 10–20 minutes. This is often done with a coach, app, or biofeedback to find your personal resonance. Clinical trials using resonance-frequency training report improvements in HRV and blood pressure.

If you feel dizzy or lightheaded: slow down, breathe shallower, and re-introduce nasal breathing and longer exhales. If symptoms persist, stop and consult a clinician. (Hypocapnia from too-fast or overly deep breathing can cause dizziness and other symptoms.)
For chronic or complicated symptoms (asthma, chronic dyspnea, suspected dysfunctional breathing): consider referral to a respiratory physiotherapist, a clinician trained in breathing retraining (e.g., Buteyko or Papworth methods studied in respiratory clinics), or multidisciplinary care; breathing retraining has evidence of benefit for people with dysfunctional breathing and for some patients with poorly controlled asthma.

A balanced View & Safety Notes

Breathing practice is widely beneficial and low-risk for most people, but some conditions (severe COPD, unstable cardiac conditions, certain psychiatric states) need medical oversight; always check with your clinician if you have a chronic health condition.
If breathing training triggers severe dizziness, chest pain, or fainting, stop and seek medical attention. Hypocapnia from inappropriate hyperventilation techniques can be harmful; that’s why guided, paced slowing and professional programmes are safer than attempting extreme breath-holding or forced hyperventilation exercises.

Conclusion

Many people habitually breathe in ways that raise sympathetic arousal and reduce vagal tone; dysfunctional breathing affects a meaningful minority of the population and is even more common in people with asthma or unexplained breathlessness. Training slow diaphragmatic breathing regularly is a low-risk, research-backed way to improve vagal tone, lower blood pressure and cortisol, reduce muscle tension (including jaw clenching), and protect cognitive and emotional resources from chronic over-arousal, but it takes practice and, for some people, guided help.

References

1.Demeter, S.L. (1986) ‘Hyperventilation syndrome and asthma’, Chest, 89(3), pp. 388–392.

2. Deenstra, D.D., et al. (2022) ‘Prevalence of hyperventilation in patients with asthma’, ERJ Open Research, 8(1), Article 00520-2021.

3. Kaur, J., et al. (2018) ‘Regulation of regional cerebral blood flow during graded challenges: CO₂ and sympathetic interactions’, Journal of Applied Physiology, 125(2), pp. 301–310.

4. Obaya, H.E., et al. (2023) ‘Effect of aerobic exercise, slow deep breathing and mindfulness on cortisol’, Journal of Complementary and Integrative Medicine, 20(3).

5. Paccione, C.E., et al. (2022) ‘Meditation-based diaphragmatic breathing vs. vagus nerve stimulation: a randomized trial’, Applied Psychophysiology and Biofeedback, 47(4), pp. 317–329.

6. Polmann, H., et al. (2019) ‘Association between sleep bruxism and stress symptoms: a systematic review’, Journal of Oral Rehabilitation, 46(6), pp. 552–563.

7. Steffen, P.R., et al. (2017) ‘The impact of resonance frequency breathing on measures of heart rate variability, blood pressure and mood’, Frontiers in Public Health, 5, Article 222. https://doi.org/10.3389/fpubh.2017.00222

8. Thomas, M., McKinley, R.K., Freeman, E. and Foy, C. (2001) ‘Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey’, BMJ, 322(7294), pp. 1098–1100. https://doi.org/10.1136/bmj.322.7294.1098

9. Tweeddale, P.M., Rowbottom, I. and McHardy, G.J.R. (1981) ‘Hyperventilation to induce bronchoconstriction in asthma’, Thorax, 36(8), pp. 580–584.

10. Vidotto, L.S., Carvalho, C.R.F., Harvey, A. and Jones, M. (2019) ‘Dysfunctional breathing: what do we know?’, Jornal Brasileiro de Pneumologia, 45(1), e20170347. https://doi.org/10.1590/1806-3713/e20170347

Consanguinity & Genetic Inheritance: Understanding The Link to Connective Tissue & Joint Related Disorders

Tue, 10 Feb 2026 16:00:50 GMT

Consanguinity and Genetic Inheritance: Understanding The Link to Connective Tissue & Joint Related Disorders

I am writing this blog not from a place of theory, but from clinical observation, having had the privilege of treating and assessing thousands of patients across Luton and Bedfordshire as a practising Osteopath and Sports Masseuse. Over that time, I have encountered a strikingly high prevalence of connective tissue disorders, chronic joint instability, unexplained musculoskeletal pain and early-onset degenerative conditions often presenting in patients far younger than would normally be expected.

For a long time, this pattern was difficult to explain. Standard lifestyle factors alone did not account for the frequency, severity, or clustering of these conditions.

However, as clinical experience accumulated alongside a growing engagement with genetic and epidemiological research, a clearer picture began to emerge. The evidence increasingly pointed toward hereditary and genetic factors, particularly those amplified within populations where consanguineous marriage is common.

This blog exists because remaining silent in the face of preventable medical harm serves no one, least of all patients. My intention is not to stigmatise communities, but to connect clinical reality with established medical evidence and to contribute honestly to a conversation that has significant implications for public health, patient education and future generations.

Medical Evidence, Religious Law, and the Public Health Crisis We Refuse to Confront

Consanguinity and consanguineous marriage between close blood relatives, most commonly first cousins is often defended as a cultural or familial tradition.

However, decades of medical research demonstrate that this practice carries significant and measurable genetic risks, particularly the increased incidence of autosomal recessive disorders, including hereditary connective tissue disorders (HCTDs). These risks are not theoretical. They are clinically observed, statistically documented, and medically devastating, with real-world consequences visible in communities across the UK, most notably in Bradford and Luton.

The Genetic Reality: Why Consanguinity Is Dangerous

From a medical standpoint, the problem is straightforward. When two people who share recent ancestry reproduce, they are far more likely to carry the same recessive genetic mutations. If both parents carry the same faulty gene, their child has a 25% chance of inheriting the condition.

The Genetic Mechanism: Recessive Genes and Health Outcomes

From a genetic perspective, the danger of consanguinity stems from the elevated likelihood that both parents carry the same recessive gene variants. When two carriers of the same recessive mutation have a child, there is a:

25% chance the child will inherit two copies of the mutation.
50% chance the child will be a carrier.
25% chance the child will inherit no copies.

IN OTHER WORDS: E ven if your child is not physically affected as a result of consanguinity, they may still be a carrier and go on to have children who then develop genetic defects and this chance is as high as 50%! I do believe that many individuals with joint and connective tissue defects, whom I have seen in the past as a physical therapist treating general public within the Luton and Bedfordshire communities, are as a result of this.

This simple Mendelian pattern explains why:

Rates of recessive genetic disorders.
Infant mortality.
Stillbirth.
Multisystem congenital conditions.

Are all statistically higher in populations with high consanguinity rates. In areas like Bradford and Luton, UK, where studies (such as the Born in Bradford project) show a high proportion of first-cousin parentage, the increased incidence of recessive disorders is not hypothetical, it is quantitatively documented.

Medical and Public Health Consequences

The cumulative effect of inherited recessive conditions is well understood in clinical genetics:

Increased rates of connective tissue disorders.
Higher incidence of neuromuscular diseases.
Greater likelihood of cardiac anomalies.
Elevated occurrence of metabolic disorders.
Increased stillbirth and neonatal mortality.

These are biological consequences of genetics and NOT religious or cultural condemnation.

Children born to first cousins face:

Twice the baseline risk of serious recessive disorders.
Elevated rates of connective tissue disorders, including conditions affecting joints, skin, blood vessels, and internal organs.
Increased likelihood of congenital heart disease, renal disorders, neuromuscular conditions and rare blood disorders.
Higher rates of stillbirth, infant mortality and lifelong disability.

Large-scale studies confirm this. The Born in Bradford longitudinal study one of the most significant population health studies in the world, found that more than one in six children in the cohort had parents who were first cousins. These children faced a 6% risk of inheriting a recessive disorder, compared with 3% in the general population. This is not conjecture, it is population-level evidence gathered over nearly two decades.

Consanguinity and incest significantly increase the risk of autosomal recessive genetic disorders due to shared ancestry. When both parents carry the same pathogenic gene variant, the probability of serious inherited disease rises sharply. These risks escalate further with repeated generations of close-relative marriage, a pattern documented in highly consanguineous populations.

1. Hereditary Connective Tissue Disorders (HCTDs)

Connective tissue disorders are particularly overrepresented in consanguineous populations because many are inherited in an autosomal recessive or complex recessive pattern.

Commonly reported disorders include:

Ehlers–Danlos syndromes (EDS) (recessive subtypes)
→ Joint hypermobility, skin fragility, chronic pain, vascular rupture
Marfan syndrome (rare recessive variants)
→ Aortic aneurysm, skeletal deformities, sudden cardiac death.
Cutis laxa
→ Loose, inelastic skin, pulmonary emphysema, arterial aneurysms.
Osteogenesis imperfecta (recessive forms)
→ Brittle bones, frequent fractures, skeletal deformity.
Stickler syndrome (recessive forms)
→ Joint degeneration, hearing loss, retinal detachment.
Loeys–Dietz syndrome (rare familial clustering)
→ Aggressive vascular disease, arterial rupture in childhood

These conditions often result in lifelong disability, reduced life expectancy and repeated surgical intervention.

2. Congenital and Structural Birth Defects

Children born from consanguineous unions show significantly higher rates of:

Congenital heart defects (septal defects, cardiomyopathy)
Neural tube defects (spina bifida, anencephaly)
Cleft lip and palate
Skeletal dysplasia
Renal agenesis and cystic kidney disease
Limb malformations
Facial dysmorphism

These defects frequently require complex neonatal care and are a leading cause of early mortality.

3. Neurological and Developmental Disorders

Consanguinity is strongly associated with:

Severe intellectual disability
Global developmental delay
Autism spectrum disorders (recessive syndromic forms)
Epileptic encephalopathies
Microcephaly and brain malformations

Many affected children require full-time care throughout life.

4. Metabolic and Blood Disorders

Autosomal recessive metabolic diseases are markedly elevated, including:

Inborn errors of metabolism
(e.g. amino acid, lipid, and carbohydrate metabolism disorders)
Sickle cell disease
Thalassaemia major
Glycogen storage disorders
Lysosomal storage diseases (e.g. Tay–Sachs–like conditions)

These conditions often lead to organ failure, repeated hospitalisation, and early death if untreated.

5. Reproductive and Perinatal Outcomes

One of the most devastating consequences of consanguinity is its impact on pregnancy outcomes:

Increased stillbirth rates
Higher rates of miscarriage
Neonatal death
Infant mortality
Premature birth
Low birth weight

Studies in Bradford and Luton demonstrate that these outcomes occur well above the national average, correlating strongly with first-cousin and closer unions. Stillbirth and neonatal death are frequently linked to previously undiagnosed recessive disorders incompatible with life.

6. Multi-Generational Harm

When consanguinity is practised repeatedly across generations, risks do not reset - they accumulate. This results in:

Clustering of rare genetic syndromes
Increased healthcare burden
Entrenched disability within families
Psychological and economic strain on caregivers
Preventable suffering transferred to children

Luton and Bradford: When Data Meets Reality

In Luton, qualitative research involving Pakistani/Kashmiri families revealed:

Higher-than-average rates of stillbirth and infant mortality.
Limited understanding of genetic risk.
Resistance to medical evidence linking consanguinity to poor outcomes.
A lack of open discussion within communities about inherited disease.

Healthcare professionals working in these areas consistently report that genetic counselling is under-utilised, often refused, or misunderstood—frequently due to social pressure rather than religious belief. The consequence is predictable: avoidable suffering repeated across generations.

Consanguinity, Genetics, and the Islamic Context

When discussing consanguinity and inbreeding, it is important to separate religious doctrine from cultural practice, and to recognise the observed health outcomes that arise from genetic inheritance patterns. According to available data on consanguineous marriage rates worldwide, the following countries rank among those with the highest proportions of marriages between close blood relatives:

Inbreeding by Country (2026) — Top 5

Pakistan — 61.2%
Kuwait — 54.3%
Qatar — 54%
United Arab Emirates — 50.5%
Sudan — 50%

These figures document relatively high rates of cousin marriage in populations where consanguineous unions are socially common. Many of these countries, including Pakistan, Kuwait, Qatar, the UAE, and Sudan have majority Muslim populations. Saudi Arabia itself, although not included in this top-5 ranking is widely recognised in genetic and public health literature as having similarly high rates of consanguineous marriage, contributing to increased genetic disease prevalence. What this suggests is not that a religion causes genetic disease, clearly it does not, but that long-term social practices within certain populations can lead to a higher probability of autosomal recessive genetic disorders when many generations involve close-relative unions.

Religion Versus Practice

It is crucial to clarify an important point that Islamic scripture itself does not promote inbreeding. The Qurʾān clearly outlines forbidden relationships in Sūrah An-Nisāʾ (4:22–23) and prohibits incest and harmful unions. Historically and theologically, Islamic scholars have consistently viewed marriage practices through ethical and moral lenses, emphasising the avoidance of harm.

Scholarly consensus is clear:

Incest is haram (forbidden).
Harm (ḍarar) is prohibited in Islamic jurisprudence.
Practices that cause predictable physical harm violate the objectives of Islamic law (Maqāṣid al-Sharīʿah), particularly the preservation of life and health.

While first-cousin marriage is technically permitted, permission does not equal endorsement, and Islamic jurisprudence strongly discourages practices that lead to harm. In other words: ongoing inbreeding is not a religious requirement.

So why do patterns of consanguinity persist in some Muslim-majority countries and within diaspora communities in the UK? The answer lies not in religion, but in culture, tradition, family structure, socioeconomics, and social norms. In many communities, cousin marriage is viewed as a way to:

Preserve family cohesion
Maintain property within extended families
Strengthen social alliances
Preserve familiarity

These social incentives can be powerful, even when the medical evidence suggests risk.

Law, Ethics, and the Limits of Cultural Defence

Both state law and religious ethics prioritise the prevention of harm and medical professionals oppose consanguinity for the main following reasons:

The genetic risks are well-established.
The burden falls disproportionately on children who cannot consent.
The healthcare system absorbs the long-term consequences.

When these facts are presented, criticism is often deflected with accusations of “Islamophobia" which is a category error. Criticising a harmful practice is not the same as attacking a faith or its followers, especially when that practice contradicts the religion’s own ethical principles. Shielding dangerous behaviour from scrutiny under the banner of cultural sensitivity does not protect communities; it traps them in cycles of preventable suffering.

Why the Practice Persists

Research consistently points to non-religious drivers:

Family pressure and inheritance concerns
Social control and insularity
Fear of community backlash
Mistrust of medical institutions
Lack of accessible, culturally competent genetic education

These are social problems, not theological ones—and they require honest discussion, not denial.

Breaking the Silence

Consanguinity is not a victimless tradition, the victims are visible in neonatal wards, disability registers, and genetic clinics across the UK. Ending the cycle requires:

Transparent public health messaging
Community-led education grounded in medical facts
Genetic counselling without stigma
The courage to distinguish religious belief from harmful custom

Silence, denial, and mislabelled criticism only ensure that the next generation pays the price.

Summary

Consanguinity remains statistically high in several countries with large Muslim populations.
Islamic law does not endorse incest or harmful marriage practices, and clearly prohibits prohibited relationships (Qurʾān 4:22–23).
The observed health outcomes, including recessive genetic disorders and higher mortality rates are a medical and genetic reality, documented by research both in the UK and internationally.
Understanding the difference between religious teaching and cultural practice is essential when discussing this sensitive intersection of health, community and belief.

References

Al-Gazali, L. et al. (2006). The profile of major congenital abnormalities in the United Arab Emirates. Journal of Medical Genetics, 43(1), pp. 52–56.
Bhopal, R. et al. (2014). The health of ethnic minority populations in the UK. BMJ, 348, g3326.
Bittles, A.H. (2001). Consanguinity and its relevance to clinical genetics. Clinical Genetics, 60(2), pp. 89–98.
Darr, A. and Modell, B. (1988). The frequency of consanguineous marriage among British Pakistanis. Journal of Medical Genetics, 25(3), pp. 186–190.
Hamamy, H. (2012). Consanguineous marriages: preconception consultation in primary health care settings. Journal of Community Genetics, 3(3), pp. 185–192.
Modell, B. and Darr, A. (2002). Genetic counselling and customary consanguineous marriage. Nature Reviews Genetics, 3(3), pp. 225–229.
Shaw, A. (2009). Negotiating risk: British Pakistani experiences of genetics. Berghahn Books, Oxford.
Sheridan, E. et al. (2013). Risk factors for congenital anomaly in a multi-ethnic birth cohort: an analysis of the Born in Bradford study. The Lancet, 382(9901), pp. 1350–1359.
Sheridan, E., Wright, J. and Small, N. (2017). Risk of congenital anomaly in children of consanguineous parents: a population-based cohort study. BMJ Open, 7(1), e014134.
Tadmouri, G.O. et al. (2009). Consanguinity and reproductive health among Arabs. Reproductive Health, 6(17).

Good Driving Posture

Sun, 25 Jan 2026 21:45:15 GMT

Driving Posture Awareness

How Poor Driving Posture Can Cause Neck,

Shoulder & Mid-Back Pain

Spending long periods driving with your head pushed forward, shoulders rounded and upper back curved eventually places extra strain on these associated muscles and joints. A forward head position means that the muscles at the back of the neck and upper back have to work much harder to support its weight. This increased load leads to muscle fatigue, tightness and discomfort in the neck and lengthening of the muscles between the shoulder blades.

Rounded shoulders also change how the shoulder blades move, placing more stress on the muscles and tendons around the shoulders which can contribute to shoulder pain and reduced related joint mobility. At the same time, a curved upper back (increased thoracic kyphosis) becomes stiff and less mobile which forces the neck and shoulders to compensate, increasing the risk of pain across the mid-back and upper spine.

Research has consistently linked forward head posture and rounded shoulders with higher rates of neck, shoulder and upper back pain, as well as altered muscle activity and reduced endurance in postural muscles. Improving posture, taking breaks from prolonged driving, strengthening postural muscles and maintaining upper back mobility can all help reduce discomfort and prevent long-term issues.

Poor Driving Posture & Whiplash Risk

The significance of poor driving posture, such as a forward head position, rounded shoulders and a slouched upper back, can increase the risk of whiplash injury during road traffic accidents. When the head sits forward in front of the body, the neck is already placed under a greater strain and thus unable to able absorb sudden forces safely.

During a collision, this misalignment leads to greater neck movement and higher stress on cervical muscles, ligaments and joints which is the main cause of whiplash injuries as a curved upper back reduces the spine’s ability to support the neck and increase the likelihood of excessive motion during impact.

Research using crash simulations have shown that poor posture and inadequate head support result in higher forces throughout the neck and more severe whiplash-type movements.

The video below highlights how maintaining an upright posture with proper headrest support can help reduce injury risk.

References

Chu, E.C.P., Lo, F.S., Bhaumik, A. (2020) Plausible Impact of Forward Head Posture on Upper Cervical Spine Stability, Journal of Family Medicine and Primary Care, 9, pp.2517–2520.
Joshi, S., Balthillaya, G., Raghava Neelapala, Y. V. (2019) Thoracic Posture and Mobility in Mechanical Neck Pain Population: a Review of the Literature., Asian Spine Journal, 13 (5), pp.849–860.
Kumar, S., Narayan, Y., Amell, T. (2003) An Electromyographic Study of Low-Velocity Rear-End Impacts , Spine, 28(10), pp.1048–1056.
Mahmoud, N.F., Hassan, K.A., Abdelmajeed, S.F., Moustafa, I.M.,Silva, A.G. (2019) The Relationship Between Forward Head Posture and Neck Pain: A Systematic Review and Meta-Analysis, Current Reviews in Musculoskeletal Medicine, 12 (4), pp.562–577.
Ono, K., Kaneoka, K., Wittek, A., Kajzer, J. (1997) Cervical injury mechanism based on the analysis of human cervical vertebral motion and head-neck kinematics during low speed rear impacts. IRCOBI Conference Proceedings, pp.349–365.
Panjabi, M.M., Pearson, A.M., Ito, S., Ivancic, P.C., Wang, J.L., Satoh, S. (2004) Mechanism of Whiplash Injury. Clinical Biomechanics, 19 (2), pp.113–121.
Siegmund, G.P., King, D.J., Lawrence, J.M. (2003) Head/Neck Kinematic Response of Human Subjects in Low-Speed Rear-End Collisions. Journal of Biomechanics , 36(8), pp.1169–1177.
Thigpen, C.A., Padua, D.A., Michener, L.A., Guskiewicz, K., Giuliani, C., Keener, J.D., Stergiou, N. (2010) Head and Shoulder Posture Affect Scapular Mechanics and Muscle Activity in Overhead Tasks , Journal of Electromyography and Kinesiology, 20 (4), pp.701–709.

Shoulder Referred Pain Caused by Pancreatic & Heart Pathology

Tue, 20 Jan 2026 15:16:21 GMT

Referred Shoulder Pain Via Underlying Diabetes

& Heart Conditions

How Pancreatic Disease Can Cause Diabetes & Frozen Shoulder

The pancreas regulates blood sugar by producing insulin. When pancreatic disease or damage disrupts this function, insulin production can fall, leading to diabetes. Long-term high blood sugar affects connective tissue by increasing inflammation and collagen stiffness and these changes can reduce joint flexibility and impair circulation, particularly around the shoulder joint (Chan et al., 2017).

Individuals with diabetes are five times more likely to develop frozen shoulder which is a condition that causes pain and stiffness in the shoulder joint (Zreik et al., 2016, Kim et al., 2023). The tissues surrounding the joint become inflamed and thickened causing them to adhere to each other which restricts movement and can be extremely painful.

Three Risk Factors For Diabetes:

1.) Firstly, high levels of sugar in the blood can lead to inflammation throughout the body, including in the tissues surrounding the shoulder joint. This inflammation can cause the tissues to become thickened and adhere to each other, leading to frozen shoulder (Kim et al., 2023).

2.) Additionally, diabetes can cause nerve damage to nerves that control the muscles around the shoulder joint. When these nerves are damaged, it can lead to weakness and reduced range of motion in the shoulder joint, making it more likely for frozen shoulder to develop.

3.) Furthermore, individuals with diabetes are also more prone to developing conditions such as tendonitis and bursitis , which can contribute to the development of frozen shoulder. These conditions can cause further inflammation and damage to the tissues surrounding the shoulder joint, leading to stiffness and pain.

Management:

Managing diabetes effectively is crucial in preventing complications such as frozen shoulder. This includes maintaining a healthy diet, exercising regularly, monitoring blood sugar levels and taking prescribed medications as directed by a healthcare provider.

If frozen shoulder does develop, treatment options may include physical therapy, anti-inflammatory medications, corticosteroid injections, and in severe cases, surgery. It is important for individuals with diabetes to work closely with their healthcare team to manage their condition and prevent complications such as frozen shoulder.

In conclusion, diabetes can increase the risk of developing frozen shoulder due to the inflammation, nerve damage, and other complications associated with the condition. It is important for individuals with diabetes to take proactive steps to manage their condition and prevent complications such as frozen shoulder. By maintaining a healthy lifestyle and working closely with healthcare providers, individuals with diabetes can reduce their risk of developing frozen shoulder and other related complications.

Referred Shoulder Pain From Heart Pathology

Certain heart conditions, especially reduced blood flow (myocardial ischemia) to the heart or a heart attack (myocardial infarction) don’t always cause pain in the chest, instead pain can show up in places like the shoulder, arm, neck, or jaw which can be confusing and easy to misinterpret. This happens because the nerves that carry pain signals from the heart enter the spinal cord at the same levels as nerves from the shoulder and upper arm. Anatomically, visceral pain fibres from the heart travel alongside sympathetic nerves that enter the spinal cord at levels T1 to T5 which also receive sensory input from the shoulder and upper limb.

Since these nerve pathways overlap, the brain can struggle to pinpoint where the pain is really coming from and misinterpret cardiac pain as originating from somatic regions such as the shoulder or jaw due to this shared neural pathway, a phenomenon known as convergence-projection. As a result, it may “project” heart-related pain to the shoulder or arm even though nothing is wrong with those areas.

Because of this, shoulder pain, particularly on the left side, can sometimes be a warning sign of a heart problem even when there is no chest pain. Thus, refer red pain may be the only presenting symptom of cardiac ischemia, especially in older adults, women, and individuals with diabetes.

References

Chan, J.H.Y., Ho, B.S.Y., Alvi, H.M., Saltzman, M.D., Marra, G. (2017) The Relationship Between Diabetes Mellitus and Adhesive capsulitis of the Shoulder. Journal of Shoulder and Elbow Surgery, 26(5), pp.867–873.
Kim, Y.S., Lee, H.J., Park, I., Im, J.H., Park, K.S. (2023) Association between type 2 diabetes mellitus and adhesive capsulitis: a nationwide population-based cohort study. BMC Musculoskeletal Disorders, 24, 771.
Pal, B., Anderson, J., Dick, W.C., Griffiths, I.D. (1986) Limitation of Joint Mobility and Shoulder Capsulitis in Insulin-Dependent Diabetes Mellitus. British Journal of Rheumatology, 25(2), pp.147–151.
Zreik, N.H., Malik, R.A., Charalambous, C.P. (2016) Adhesive Capsulitis of the Shoulder and Diabetes: a Meta-Analysis of Prevalence. Muscles, Ligaments and Tendons Journal, 6(1), pp.26–34.

Text Neck

Mon, 05 Jan 2026 17:02:27 GMT

5 Ways To Manage "Text Neck"

Symptoms of Text Neck

Text neck is not a formal medical diagnosis but a phrase commonly used to describe a repetitive stress injury that occurs over a period of time from excessive use of mobile devices. One study found that on average, smartphone users maintain head flexion of 33 to 45 degrees whilst using their device [1].

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

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

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

Forces on The Neck

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

Common Symptoms

Text neck tends to cause poor upper neck and head posture which can create chronic muscular weakness particularly within the shoulders muscles including the trapezius, rhomboids and rotator cuff muscle. Headaches may also occur with sub-occipital muscle tension leading to tension type headaches.

Prolonged use with looking down at a cell phone or laptop devices each day can lead to:

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

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

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

Management

Avoid excessive mobile phone or laptop/ computer usage and take frequent breaks, setting a timer might be useful.
Avoid prolonged static postures whilst e.g. sitting or standing.
Position the mobile device higher during use.
Avoid high repetitions of movements such as prolonged typing or swiping.
Avoid holding large or heavy devices in one hand for long periods such as heavy ipads.

Acute Cases

Chin Tuck Exercises Demonstration Video:

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

Regular neck movements: rotations and side flexion.

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

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

Physical Therapy:

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

References

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

Heated Stones Massage

Fri, 19 Dec 2025 15:00:31 GMT

Six Ways Heated Stones Can Help Muscular
Tension & pain

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

Six Reasons for A Heated Stone Massage

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

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

Overall Effect

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

Demonstration of Heated Stones Massage Techniques:

References

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

Plantar Fasciitis: Pathology, Management & Treatment

Sun, 14 Dec 2025 19:20:48 GMT

Plantar Fasciitis, Pathology, Management Tips & Treatment

Pathology

Plantar fasciitis is an overuse condition involving irritation, inflammation, or degeneration of the plantar fascia, the thick band of connective tissue running along the sole of the foot from the calcaneus to the toes. It may affect one or both feet.

Symptoms typically develop gradually, with no specific history of trauma. Pain is commonly worse first thing in the morning or after periods of rest, such as when getting out of bed and may ease with initial activity. Discomfort often increases again with prolonged loading and is frequently most noticeable during the pre-swing phase of the gait cycle.

Pain is usually localised to the plantar aspect of the heel and arch, particularly at the antero-inferior surface of the calcaneus. Associated conditions such as achilles tendinopathy are commonly present due to shared loading patterns within the posterior chain.

Contributing Factors and Causes

Plantar fasciitis is most often linked to excessive or repetitive loading of the plantar fascia. Common contributing factors include:

Sudden increases in training volume or intensity.
Poor training technique or inadequate recovery.
Poor foot biomechanics.
Weakness or reduced load tolerance in the gastrocnemius and soleus muscles.
Limited ankle dorsiflexion.
Inappropriate or worn footwear.
Increased body weight.

Neural Contributions

In some cases, symptoms resembling plantar fasciitis may be influenced or exacerbated by neural involvement. The sciatic nerve, which originates in the lumbar spine and travels down the posterior aspect of the leg into the foot, can refer pain distally when irritated. Compression due to lumbar disc pathology, spinal stenosis, or piriformis tightness may produce heel or arch pain that mimics plantar fasciitis, often described as burning, sharp, or electric in nature.

Neural tension or irritation can increase sensitivity in the plantar tissues, potentially perpetuating symptoms or reducing the tissue’s ability to tolerate load.

Clinical Presentation

Localised pain at the anteromedial aspect of the calcaneus.
Tenderness on palpation of the plantar fascia and possibly the midfoot.
Palpable thickening or adhesions in chronic cases.
Pain reproduced with active or passive toe extension due to tension on the plantar fascia and intrinsic foot muscles.

Differential Diagnosis

Not all heel pain is plantar fasciitis. Other conditions that should be considered and ruled out include:

Fat pad contusion or atrophy
Calcaneal stress fracture due to repetitive loading or impact
Tarsal tunnel syndrome, involving entrapment of the posterior tibial nerve at the medial malleolus

Appropriate clinical assessment and referral are essential where indicated.

Treatment Considerations

Client positioning is important. Treating the client in prone allows effective access to compensatory structures in the lower leg. Techniques such as effleurage and petrissage may be applied to hypertonic muscles, particularly the gastrocnemius and soleus.

Muscle energy techniques may be used, including post-isometric relaxation (PIR) or reciprocal inhibition (RI), depending on presentation. In chronic cases, gentle fascial techniques or cross-fibre friction may be applied to areas of adhesion within the plantar fascia.

A global approach is essential. Assessment and treatment should extend up the kinetic chain to include the ankle, lower leg, knees, hips, gluteals, and lumbar spine—particularly in acute or recurrent presentations.

Home Care

Home management is a key component of recovery and should be tailored to the underlying cause. This may include:

Load management and training modification.
Home exercises: Stretching or strengthening programmes.
Footwear assessment or orthotic referral.
Referral for strength and conditioning support where appropriate.
Self massage.

Identifying and addressing contributing factors is critical to long-term resolution and prevention of recurrence.

Four Ways Sports Massage Can Help Sciatica

Wed, 03 Dec 2025 20:26:42 GMT

Four Ways Sports Massage Can

Help Symptoms of Sciatica

How Sports Massage Can Help With Sciatic-Related Pain

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

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

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

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

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

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

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

3. Sports Massage Can Relieve Hamstring Strain and Stiffness

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

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

Hamstring Pain and Muscle Tension

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

Why This Connection Matters

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

4. Promoting Nervous System Relaxation

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

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

Summary

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

References

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

Five Ways Sports Massage of the Abdomen Can Help Lower Back Pain

Sun, 30 Nov 2025 22:06:03 GMT

Five Ways That Sports Massage of the Abdomen Can Help Lower Back Pain

Possible Mechanisms: How Abdominal Massage Might Help With Lower Back Pain and Sciatica

Lower back pain (LBP) and sciatica (pain radiating along the sciatic nerve, often due to nerve root compression or irritation) are common, debilitating conditions. Though treatments often focus on the spine, hips, glutes, and hamstrings, there is increasing interest in approaches that include the abdominal region - especially abdominal massage and core strength workouts to help with lower back muscle stability. This post will discuss how massaging the abdomen might help, what evidence supports those ideas.

1.Reduce Muscular Tension & Improving Core Muscle strength and Function.

The core is not just the abdomen; it’s a system that includes the abdominal muscles, the diaphragm, the pelvic floor and the muscles of the lower back. If abdominal muscles are tight, weak, or poorly coordinated, the lower back may take up extra load and contribute to pain. Abdominal massage might help by loosening tense abdominals and surrounding hip flexors, encourage better muscular balance and thereby reduce stress on neighbouring lumbar structures.

2. Improve Overall Back Posture & Spinal Stability

If the abdominal wall is stiff or if there is poor abdominal control, the spine and pelvis may be held in suboptimal positions, further aggravating nerve roots or structures related to sciatica. Massaging the abdomen could help increase mobility in the abdominal fascia and connective tissues, improve alignment, and facilitate better posture - which in turn might relieve pressure on the sciatic nerve roots.

3. Loosen Fascia & Myofascial Connective Tissue System

The myofascial connective tissue spans between abdominal, pelvic, and back regions; restrictions or adhesions in fascia (from injury, posture, or surgery) can contribute to pain referral patterns. Abdominal massage might help improve fascial “gliding” or reduce adhesions, which could reduce irritative stress on nerves or reduce compensatory overuse of certain muscles. Evidence from studies using roller massage on the lower back suggests improved fascia gliding and lumbar flexibility, along with increased abdominal trunk muscle strength.

4. Reduce Bloating, Abdominal Distension & Visceral Pressure

Sometimes visceral factors (e.g. bloating, constipation) can increase intra-abdominal pressure or distension, which can alter posture (forward pelvic tilt, increased lumbar lordosis) or place indirect stress on the lower back. Massage of the abdomen helps relieve distension, improve digestion and alleviate discomfort, which may indirectly reduce lower back strain. Evidence shows that abdominal massage can reduce distension and improve bowel function in various populations (1, 2).

5. Promote Relaxation & Decreasing Nervous System Irritability

Massage (in general) promotes parasympathetic activation, reduces stress, may decrease inflammatory mediators and increases local blood flow. That helps reduce muscle guarding and nervous system hypersensitivity, which are often components of both chronic low back pain and sciatica. Though direct studies of abdominal massage for sciatica are few, general massage is known to help with low back pain in the short term.

Previous Research

A controlled trial by Zhang et al. (2014) investigated whether adding core stability exercises to Chinese massage improved outcomes in people with nonspecific lower back pain. Ninety-two participants were assigned either to massage plus core exercises or massage alone. Pain (VAS) and disability (ODI) were measured over the 8-week treatment period. The group receiving the combined approach showed significantly greater reductions in both pain and disability compared with massage alone, indicating that integrating core stability exercise training enhances the effectiveness of massage for nonspecific lower back pain (3).

Self-myofascial release (e.g. using rollers) in the lower back has been shown to improve fascia gliding, lumbar flexibility, and abdominal trunk strength. These improvements in flexibility and strength could reduce mechanical stress on the spine and contribute to reducing symptoms of back pain.

Abdominal massage shows promise as a complementary therapy for lower back pain and possibly sciatica, via mechanisms like relieving abdominal tension, improving core stability, reducing visceral distension, improving fascial mobility, and promoting relaxation. However, while there is some supportive evidence (especially in non-specific low back pain and for improving abdominal/gastrointestinal symptoms), there is as yet limited direct evidence for its use specifically for sciatica caused by nerve root compression or disc issues.

For someone with sciatica or lower back pain, abdominal massage might be useful as part of a wider program: massage (including abdominal and myofascial work), core stability exercises, posture correction, stretching, perhaps physiotherapy. If trying abdominal massage for the first time, gently, avoid pressure over sites of acute pain or inflammation, and ideally under guidance of a health professional.

Light Abdominal Massage Demonstration & Simple Core Exercises:

References:

Huang S-Y, Chiao C-Y, Chien L-Y. (2025) “Effectiveness of abdominal massage on chronic constipation in adults: A systematic review and meta-analysis.” International Journal of Nursing Studies; 161: 104936.
Lin Z, Wang D, Fei X, Han D, Liu Z. (2025) “Effect of abdominal massage on constipation: A systematic review and meta-analysis of randomized controlled studies.” Complementary Medicine Research. 2025. doi:10.1159/000548699.
Z hang, Y., Tang, S., Chen, G., & Liu, Y. (2014). Chinese massage C ombined with C ore S tability E xercises for N onspecific L ow B ack P ain: A Ra ndomi s ed C ontrolled T rial. Complementary Therapies in Medicine, 22 (3), 495–500 .

3 Effective Ways To Reduce Hyperlordosis (Increased Lumbar Spine Lordosis) & Help Lower Back Pain

Mon, 17 Nov 2025 21:25:44 GMT

3 Effective Ways To Reduce Hyperlordosis

(Increased Lumbar Spine Lordosis)

& Help Lower Back Pain

Increased lumbar lordosis, an exaggerated c-shaped curvature of the lower spine, is often associated with muscle imbalances - particularly tight hip flexors and lower-back extensors combined with weak abdominal and gluteal muscles. This imbalance tilts the pelvis forward (anterior pelvic tilt), increasing pressure on the lumbar vertebrae and intervertebral discs, which can contribute to chronic pain and reduced mobility. Research has shown that changing the position of the pelvis directly affects the degree of lumbar curvature, supporting the idea that pelvic alignment is key to managing lordosis and related pain (5).

An excessive curvature of the lower spine alters spinal alignment. This can contribute to sciatica by changing the spacing between the intervertebrae and the intervertebral discs of the spine which can then irritate or compress the sciatic nerve or its nerve roots. Increased lordosis tends to shift the body weight posteriorly causing posterior disc compression and anterior disc stretching which can make the lumbar discs more vulnerable to bulging or herniation which often directly compresses the sciatic nerve roots.

How Core and Pelvic-Tilt Exercises Help Reduce Lumbar Lordosis and Lower Back Pain

Specific Core Strengthening Exercises To Target Abdomen & Lower Back Muscles:

Targeted core-strengthening exercises, especially those that recruit the deep stabilising muscles such as the transversus abdominis and multifidus, help improve spinal stability and reduce excessive movement between vertebrae. Clinical trials and systematic reviews have demonstrated that core-stabilisation programmes significantly reduce pain and improve function in people with non-specific low-back pain compared to general exercise or minimal intervention (6, 7).

2. Pelvic Tilt Exercises

Pelvic-tilt exercises and strengthening of the posterior pelvic muscles (such as the gluteus maximus and hamstrings) can further help by correcting anterior pelvic tilt. By encouraging a more neutral pelvic position, these exercises decrease the excessive curvature of the lumbar spine and reduce pressure on spinal joints and discs. Several studies have found that combining pelvic-tilt retraining with abdominal and hip-stabilising exercises can measurably reduce anterior pelvic tilt and improve lumbar posture (2, 3).

3. Hip Flexor Stretching

Increased hyperlordosis or lumber lordosis is often linked to tight hip flexes, especially the iliopsoas muscle. This muscle attaches to the pelvis and lumbar spine. Stretching the hip flexors reduces extension loading on the facet joints of the lower back vertebrae or facets and discs. When the iliopsoas is tight it tends to indirectly drive the lumbar spine into more of an extension.

Stretching the hip flexes can improve muscle balance as the extension of the spine casuses the the hip flexors and lumbar erector spinae muscles o tighten and gluteal and abdominal muscles lengthen and become weak.

In practice, the most effective approach integrates both core and pelvic exercises rather than focusing on one area alone. Teaching deep core activation (such as the abdominal-drawing-in manoeuvre), progressing to controlled stability drills (like planks or dead bugs), and combining these with hip-flexor stretching and gluteal strengthening can restore a more neutral pelvic alignment. Evidence indicates that such integrated programmes improve motor control, reduce excessive lumbar lordosis and alleviate lower-back pain for many patients, although long-term structural reversal of degeneration may vary between individuals (1, 4).

References

Akhtar, M.W., Karimi, H., & Gilani, S.A. (2017). Effectiveness of core stabilization exercises versus routine physiotherapy in chronic low back pain. Journal of Physical Therapy Science, 29(8), 1444-1448.
Brekke, A. F., Overgaard, S., Hróbjartsson, A., & Holsgaard-Larsen, A. (2020). Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: A systematic review. EFORT Open Reviews, 5(1), 37-45. https://doi.org/10.1302/2058-5241.5.190017 .
Ghadirian Marnani L., Fatahi H., Esmaeilian M., Rostami S.” (2024/2025) — The Effect of Eight Weeks of NASM and Kinetic Chain Training on Lordosis, Pelvic Tilt, and Hip Joint ROM in Individuals with Lower Crossed Syndrome.
Lee, J.-S.; Kim, T.-H.; Kim, D.-Y.; Shim, J.-H.; Lim, J.-Y. (2015). Effects of selective exercise for the deep abdominal muscles and lumbar stabilization exercise on the thickness of the transversus abdominis and postural maintenance. Journal of Physical Therapy Science, 27(2), 367‑370.
Levine, D. & Whittle, M. W. (1996). The Effects of Pelvic Movement on Lumbar Lordosis in the Standing Position. Journal of Orthopaedic & Sports Physical Therapy, 24(3), 130–135. Available at: https://pubmed.ncbi.nlm.nih.gov/8866271/
Puntumetakul, R., Saiklang, P., Tapanya, W., Chatprem, T., Kanpittaya, J., Arayawichanon, P., & Boucaut, R. (2021). The effects of core stabilization exercise with the abdominal drawing‑in maneuver technique versus general strengthening exercise on lumbar segmental motion in patients with clinical lumbar instability: A randomized controlled trial with 12‑month follow‑up. International Journal of Environmental Research and Public Health, 18(15), 7811. https://doi.org/10.3390/ijerph18157811
Smrcina, Z., Woelfel, S., & Burcal, C. (2022). A systematic review of the effectiveness of core stability exercises in patients with non-specific low back pain. International Journal of Sports Physical Therapy, 17(5), 766–774. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9340836/

The Hidden Causes of Shoulder Pain

Wed, 08 Oct 2025 14:25:10 GMT

3 Hidden Cause of Shoulder Pain

When your shoulders ache or feel stiff, your instinct may be to stretch or massage them. Yet, in most cases, the problem isn’t surface-level muscle tension, it is likely caused by poor shoulder blade (scapular) posture with muscle and joint instability.

Whether you are an office worker sitting for long hours, an athlete performing repetitive overhead movements or an older adult experiencing age-related muscle weakness, the underlying issue is often the same: weak shoulder muscles that fail to stabilise and control your shoulder blades. Strengthening these muscles is essential for healthy shoulders, good posture and a pain-free upper body.

Anatomy: The Muscles Behind Stable Shoulders

Your scapulae are flat, triangular bones that glide over the back of your rib cage. They are attached only by muscles, allowing them to move freely in six directions: upward, downward, inward (toward the spine), outward (away from the spine) and with forward or backward tilting.

Several key muscles control these movements and provide shoulder joint stability:

The serratus anterior muscle runs along the sides of the ribs beneath the armpits and help the shoulder blades glide smoothly along the rib cage, enabling the hands and arms to reach forward and overhead.
Rhomboids and middle trapezius muscles span between the spine and the inner edges of the shoulder blades. These muscles retract and stabilise the scapulae during pulling motions.
Lower trapezius extends from below the shoulder blades to the mid-back and draws the scapulae down and back, counteracting the rounded shoulder posture that is a common presentation in sedentary individuals.

When these muscles work in harmony, your shoulder blades move fluidly across your back, creating a strong, stable foundation for arm movement.

1. Muscle Weakness Around the Shoulder Joint & Scapular

Your shoulder joint has FIVE rotator cuff muscles that attach to the triangular bone called the scapula to the long bone of the arm - the humerus. When scapular stability is lost, the entire shoulder complex becomes misaligned, triggering compensations that increase pain and injury risk.

Common dysfunctions include:

Scapular winging - The shoulder blades protrude from the back like wings.
Forward tilting - The shoulders round forward, limiting smooth scapular motion.

Both positions compromise the rotator cuff muscles — forcing them to overwork and increasing the likelihood of strain or impingement. Over time, these faulty mechanics can lead to neck stiffness, upper back pain, and poor posture, as the body adjusts to compensate.

2. How Breathing Affects Shoulder Function

Breathing mechanics play a surprisingly important role in shoulder stability. During deep inhalation, the rib cage expands and the serratus anterior helps the scapulae glide naturally along the ribs. During full exhalation, the obliques draw the lower ribs inward and downward, keeping the rib cage aligned.

However, shallow, upper-chest breathing elevates the shoulders with each breath, creating chronic tension in the neck and upper traps. This not only reinforces poor posture but also disrupts scapular control.

Practicing diaphragmatic breathing while performing scapular strengthening exercises enhances rib cage alignment, reduces compensations and restores proper shoulder mechanics.

3. Building Scapular Strength and Control

You don’t need heavy weights or complex equipment to improve shoulder blade stability. Focus on controlled movements, proper breathing and awareness of scapular motion. Consistency and not intensity is the key to stronger, more resilient shoulders.

Shoulder & Mid Back Mobility Circuit To Help:

Chair Massage

Wed, 24 Sep 2025 19:38:11 GMT

Chair Massage For Back and Neck Pain

Chair Massage - What It Helps

Chair massage is a seated massage delivered on a portable support chair and was designed for busy environments like offices, clinics, and events. These sessions mainly focus on the neck, shoulders, back, forearms, and hands and evidence supports the suggestion that this form of treatment can relieve pain and stiffness in the short term, ease stress and improve of motion of associated joints. For tendon problems, it’s best viewed as an adjunct to exercise rather than a standalone fix.

Back pain

A randomised controlled trial (RCT) by Kim et al., (2020) in outpatients with chronic lower-back pain compared a massage chair program with clinic physiotherapy for three weeks. The results found that both groups improved in pain and disability; the physiotherapy group did a bit better on these outcomes, but the massage chair was more cost-effective and it was concluded that chair massage can help, especially when access or cost are barriers, but it isn’t a full replacement for rehabilitation (4).

Neck and shoulder pain

In office workers with neck/shoulder pain, an RCT adding 20 minutes on a massage chair twice weekly to basic heat therapy led to greater reductions in pain (numeric rating scale) and neck disability versus heat alone; pressure-pain thresholds also improved and no adverse events were reported.

Beyond devices, therapeutic massage more generally has RCT support for short-term relief in neck pain populations (1).

Stiff Joints and Range of Motion

A corporate chair-massage program (twice weekly for a month) in office workers reported improved neck joint range of motion (e.g., side bending and extension) and reduced self-reported neck/upper-back discomfort. While small and uncontrolled, it’s consistent with the short-term mobility gains people often feel after treatment.

In another workplace study of white-collar staff, repeated chair massage at the desk reduced musculoskeletal tension symptoms and raised pressure-pain thresholds in the neighbouring neck paraspinal muscles.

Stress, Pain Interference, and Work Functioning

Among oncology nurses, a 15-minute chair massage, twice weekly for a period of three weeks found that this form of treatment lowered stress scores and reduced the extent to which pain interfered with sleep, mood, and work versus no-treatment controls (6).

Tendinitis / Tendon Strains: Where Chair Massage Fits

For tendinopathies (e.g., rotator cuff, lateral elbow, patella), classic deep transverse friction massage has mixed evidence. A systematic review concluded benefits are uncertain when used alone, though it may help when combined with joint techniques in selected cases.

A 2024 systematic review/meta-analysis in patella tendinopathy found that adding soft-tissue techniques (including transverse friction) to therapeutic exercise improved pain and function in several trials compared with exercise alone, again pointing to massage as a supporting player, not the star.

How Chair Massage May Help

Consistent study findings have found that peripheral and spinal modulation of pain (“pain-gate-control”–like effects), reduced muscle tone with muscle guarding and short-term increases of pain thresholds. Adverse effects in the back-pain literature were minor, with no serious events reported in the Cochrane review.

Practical takeaways

Chair massage can help with tension-type neck and shoulder pain, desk-related upper-back ache, lower-back tension and stress-related muscle guarding. Best results come when you combine chair massage with brief posture/mobility breaks, progressive strengthening (especially for shoulder and trunk) and exercises to strengthen related tendons.

Thus, chair massage is a useful, low-risk tool for short-term relief of back, neck, and shoulder pain and for loosening up stiff areas, especially in desk-bound or high-stress settings. For tendon problems, it can reduce soreness but works best alongside a structured exercise program.

References

Chu H et al. (2023) Massage chair for neck/shoulder pain in office workers (RCT). Heliyon.
Furlan AD et al. (2015) Massage for low-back pain (Cochrane review).
Joseph MF et al. (2012) Deep friction massage for tendinopathy (systematic review). J Sport Rehabil.
Kim SK et al. (2020) Massage chair vs physiotherapy for low-back pain (RCT, cost-effectiveness). Medicine (Baltimore) 2020.
Ragone F et al. (2024) Soft-tissue techniques + exercise for patellar tendinopathy ( SR/MA). Healthcare.Siško PK et al. (2011) Corporate chair massage: ROM and discomfort in office workers. J Altern Complement Med.
de Souza TPB et al. (2021) Chair massage in oncology nurses: stress and pain interference (RCT). Int J Ther Massage Bodywork.
Sherman KJ et al. (2009) Therapeutic massage for chronic neck pain (RCT). Arch Intern Med.
Qaseem A et al. (2017) ACP guideline—noninvasive treatments for low-back pain; massage acceptable for acute/subacute LBP. Ann Intern Med.

Three Ways That Sports Massage Can Help Neck Pain

Tue, 09 Sep 2025 18:36:08 GMT

Three Ways That Sports Massage Can Help Neck Pain - Anatomy and Function

Neck pain is a common musculoskeletal complaint affecting people across multiple professions, especially those involving prolonged sedentary activities. Neck and back pain affect individuals across all age groups and occupations, with prevalence increasing to sedentary lifestyles, prolonged hours spent at computers and repetitive tasks (1).

Modern lifestyles have meant that workers are slouched for long hours at computers and various electronic devices which are likely contributing factors for neck and upper back pain (1). Chronic neck pain regularly occurs amongst people who engage in various careers who spend long periods of time sitting such as information technology (IT) specialists to accountants, personnel of any kind and secretaries. Non-pharmaceutical approaches have gained momentum as alternatives to prescription drugs and therapeutic massage has emerged as an effective option for managing neck pain (2).

The accumulation of muscle tension leads to restricted joint mobility and nerve related symptoms such as radiating discomfort into the shoulders, arms and hands. Sports massage may assist to alleviate these issues by applying targeted pressure and stretching techniques. Massage can reduce myofascial adhesions, improve blood flow and relieve muscular pain. Massage techniques for neck pain at the Leagrave Therapy clinic may involve Swedish massage, deep tissue massage and trigger point therapy which have received popularity due to their holistic healing process.

Anatomy

The cervical spine is made up of seven cervical vertebrae (C1-C7) and is a vital conduit for the nervous system, carrying signals between the brain, spinal cord, and the upper body. Emerging from the cervical portion of the spinal cord are eight pairs of cervical spinal nerves (C1–C8). These nerves exit through the intervertebral foramina of the cervical vertebrae and branch outward to form two important networks: the cervical plexus (C1–C4) and the brachial plexus (C5–T1). Together, these plexuses supply motor and sensory innervation to the neck, shoulders, chest and arms

C1–C4 (Cervical plexus): These nerves innervate muscles of the neck, including the sternocleidomastoid and trapezius (through the accessory nerve, cranial nerve XI, with cervical contributions) which allow turning, nodding and tilting of the head.

The cervical plexus also gives rise to the phrenic nerve (C3–C5), which descends into the thorax to control the diaphragm which is essential for breathing.

C5–T1 (Brachial plexus): This network supplies the shoulders, arms, and hands. Motor branches control movements such as lifting the arm, rotating the shoulder, bending the elbow, extending the wrist, and manipulating the fingers. Sensory branches transmit touch, temperature and pain from the skin of the upper limb back to the central nervous system.

Through these pathways, the cervical nerves allow us to perform a wide range of movements: shrugging the shoulders, rotating the arms, flexing and extending the elbows and executing fine motor tasks with our hands. At the same time, the cervical nerves enable the neck muscles to maintain posture and execute motions such as nodding and turning the head.

Three Ways A Deep Sports Massage Can Help Neck & Nerve Related Pain

1.Reduce Muscle Tension

Medical health practitioners trained in physical therapies will use a wide variety of techniques during treatment such as trigger point therapy, myofascial release, deep tissue massage, joint mobilisation and address specific areas of discomfort to reduce inflammation and releasing muscular tension.

Thus, a deep sports massage may help neck pain sufferers at it targets muscle tension and promote natural healing processes within the body (Arsoki, 2024).

2. Reduce Nerve Entrapment

Massage can alleviate nerve-related pain that arises from muscular entrapment or soft tissue tension by reducing local compression, muscular hypotonicity and improve tissue pliability. The study by Jelen et al., (2024) concluded that five 30-minute therapeutic massage sessions performed over 5 weeks lead to a significant reduction in muscle stiffness within the proximal part of the upper trapezius muscle.

3. Reduces Pain Intensity

Another study by Arsovski (2024) conducted between 2019 and 2022 and involved 127 participants across various proffesions found that regular deep tissue massage performed once or twice per month significantly reduced neck pain. Participants reported their average pain level decreasing from 7 of 10 pain being reduced to 2 out of 10 during the study period.

Howver, when massage was discontinued for around four months, pain levels increased again, highlighting the importance of continued treatment to maintain relief.

Neck & Upper Shoulders Massage: Demonstration

References

Arsovski, D. (2024) Effectiveness of Medical Massage in Reducing Neck Pain Among Multiple Occupational Groups: A Longtidunal Study, International Journal of Therapeutic Massage and Bodywork, 17; 3: 23-30.
Jelen, A., Javornik, E., Meh, S. G., Kozinc, Z. (2024) The Effect of a 5-Week Therapeutic Massage on Erector Spinae and Upper Trapezius Muscle Stiffness as Determined by Shear-Wave Elastography: a Randomized Controlled Trial, Frontiersin Sports and Active Liing: 1-11.

How Osteopathy & Sports Massage Can Help with Nerve Entrapment Symptoms

Sun, 06 Jul 2025 21:03:57 GMT

How Osteopathy & Sports Massage Can Help With Nerve Entrapment Symptoms

Difference Between Osteopathy & Sports Massage Application

Nerve entrapment syndromes such as sciatica, carpal tunnel syndrome or thoracic outlet syndrome all occur when a peripheral nerve is compressed or irritated, often by surrounding muscles, fascia, or bony structures. Common symptoms include pain, tingling, numbness and weakness along the affected nerve’s pathway. Conservative management, including manual therapies like osteopathy and sports massage, can play a significant role in alleviating these symptoms by targeting contributing musculoskeletal dysfunctions.

Osteopathy and Nerve Entrapment

Osteopathy is a form of manual therapy that focuses on diagnosing and treating dysfunctions of the body’s structure and function, especially those involving the musculoskeletal system, via postural assessment and joint range of movement testing. Osteopaths use techniques such as soft tissue manipulation, joint mobilisations, myofascial release, and nerve gliding to restore normal mobility and reduce tissue tension.

For example, in sciatica where the sciatic nerve can be compressed by the piriformis (deep buttock) muscle or lumbar spine (lower back) structures osteopathic treatment may include joint resistant techniques to release tight hip rotators, mobilisations to increase lumbar segmental mobility and postural education to prevent recurrence. A systematic review by Orrock and Myers (2013) found that osteopathic manipulative treatment (OMT) can significantly reduce pain and improve function in patients with lower back pain, which often involves sciatic nerve irritation.

Additionally, osteopaths may use neurodynamic techniques which are gentle, controlled movements that mobilise the nerve within its surrounding tissues to reduce mechanosensitivity and restore normal nerve function (Shacklock, 2005).

Sports Massage and Nerve Entrapment

Sports massage focuses on manipulating soft tissues to improve circulation, reduce muscle tension, and enhance range of motion around the joint. When nerve entrapment is caused or worsened by tight muscles or fascial adhesions, targeted massage can help release these structures.

For instance, in carpal tunnel syndrome, tight forearm flexors may contribute to compression of the median nerve. A 2015 study by Moreira et al., found that manual therapy techniques, including deep transverse friction massage, reduced pain and improved function in patients with carpal tunnel syndrome (Moreira, R. F., et al., 2015).

Sports massage can also address secondary issues such as myofascial trigger points which may mimic or worsen nerve pain. Studies indicate that releasing these trigger points can reduce referred pain and improve nerve mobility (Fernández-de-Las-Peñas, C., et al., 2009).

Complementary Effects and Individualised Care

Both osteopathy and sports massage emphasise patient-specific assessment and treatment plans. While osteopaths may address joint restrictions or postural imbalances that contribute to nerve compression, massage therapists focus on local muscular tension and soft tissue quality. Combining these approaches can be particularly effective for example, releasing tight muscles with massage and then restoring joint mobility with osteopathic techniques. Evidence supports combining manual therapies with exercise and ergonomic advice for longer-lasting improvements. A 2019 systematic review concluded that multimodal conservative care, including manual therapy and exercise is effective for various entrapment neuropathies (Fernández-de-Las-Peñas, C., et al., (2019).

Nerve entrapment syndromes can significantly impact quality of life, but manual therapies like osteopathy and sports massage offer effective, non-invasive ways to address contributing musculoskeletal factors. By reducing muscle tension, improving joint mobility and restoring normal nerve function, these therapies help alleviate pain, restore mobility and reduce the likelihood of recurrence. Further research will continue to refine best practices and optimal combinations of manual therapy and active rehabilitation.

Short Osteopathy with Massage Techniques Video

References

Orrock, P. J., & Myers, S. P. (2013). Osteopathic intervention in chronic non-specific low back pain: A systematic review. BMC Musculoskeletal Disorders, 14(1), 129. https://doi.org/10.1186/1471-2474-14-129
Shacklock, M. (2005). Clinical Neurodynamics: A New System of Musculoskeletal Treatment. Elsevier.
Moreira, R. F., et al. (2015). Effects of deep transverse friction massage on pain, pressure pain threshold, and grip strength in patients with carpal tunnel syndrome: A randomized controlled trial. Journal of Manipulative and Physiological Therapeutics, 38(9), 663–671. https://doi.org/10.1016/j.jmpt.2015.09.002
Fernández-de-Las-Peñas, C., et al. (2009). Myofascial trigger points and their relationship to referred pain and motor dysfunction. Current Pain and Headache Reports, 13(5), 365–372.
Fernández-de-Las-Peñas, C., et al. (2019). Effectiveness of manual therapy and exercise for carpal tunnel syndrome: A systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 49(12), 832–841. https://doi.org/10.2519/jospt.2019.8990

Deep Tissue Massage

Fri, 20 Jun 2025 12:33:45 GMT

What Do Therapists Mean When They Say That They Apply A Deep Tissue Massage?

How Does Deep Tissue Massage Differ to A Relaxing Massage?

Deep tissue massage is a form of therapeutic bodywork that focuses on realigning deeper layers of muscles and connective tissue. The Leagrave Therapy Clinic provides clients with a deep tissue massage which involves the use of slow, firm pressure that is often applied with the therapist's hands, forearms, knuckles or elbows to target areas of chronic tension, muscle knots and adhesions. This is unlike a relaxation massage, which uses light to moderate pressure and a soothing rhythm,

The term “deep tissue” refers not only to the depth of pressure applied, but also to the depth of the layers affected, namely the deep fascia and muscle layers that lie beneath superficial muscles. When we say “deep tissue massage,” we typically mean a manual therapy technique that incorporates sustained pressure, often applied with the therapist’s fingers, knuckles, forearms, or elbows. This pressure is deliberately deeper than what one experiences in a Swedish massage but is always adapted to remain within the client’s pain tolerance. Communication between the therapist and the client is essential throughout the session to ensure that the pressure remains therapeutic and not painful. The use of elbows and reinforced hands allows for the delivery of controlled pressure to small, tight areas without causing strain to the therapist or discomfort to the client.

When To Attend For a Deep Tissue Sports Massage?

Deep tissue massage is commonly used to treat musculoskeletal issues such as chronic tension, sports injuries, postural problems and repetitive strain. It is especially beneficial for managing muscular trigger points (or knots) which are muscular bands of painful, rigid tissue that can disrupt circulation and limit movement. By physically manipulating these tissues, massage can help restore mobility and reduce pain. The therapy is often recommended for people suffering from conditions like sciatica, fibromyalgia or tension headaches that stem from muscular imbalances.

Safety

Safety is a major concern in any form of manual therapy, and deep tissue massage is generally considered safe when performed by a trained, licensed practitioner. It should not be overly painful, though some post-session soreness is common and typically subsides within a day or two. People with certain medical conditions such as blood clotting disorders, open wounds, or recent surgery should consult a healthcare provider before undergoing deep tissue work.

Research

Research into the effectiveness of deep tissue massage has grown in recent years. Multiple studies have found that deep tissue massage can significantly reduce pain and improve function in patients with chronic musculoskeletal disorders.

A study published in the Scientific World Journal by Majchrzychki et al., (2014) found that deep tissue massage (DTM) was effective in reducing lower back pain and that DTM was comparable to non steroidal anti-inflammatory drugs (NSAIDs), but without the side effects.

Another study by Field et al., (2005) in the Journal of Clinical Psychiatry suggested that deep tissue massage could also reduce stress hormone levels and increase serotonin and dopamine, which can enhance overall mood and well-being.

Additionally, clinical research has shown that deep tissue massage may improve joint mobility by reducing stiffness in surrounding soft tissues. A study by Srokowska et al., (2019) found that deep tissue massage is an effective method in the treatment of pain located in the thoracic spine as it the treatment can improve spinal joint mobility, help lengthen chest muscles including the pectoralis major, especially in people who perform long hours working in a sitting position.

Deep tissue massage can be particularly helpful for individuals with arthritis or limited joint range of motion due to past injuries. A small study by Zhang et al., (2024) found that massage therapy, as a stand-alone treatment, reduces pain, improves (joint) function and reduces medial muscle co-contraction in individuals with medial knee osteoarthritis (KOA).

Deep tissue sports massage can help by promoting better circulation, flushing out metabolic waste and stimulating the parasympathetic nervous system which can promote relaxation and healing. Weerapong et al., (2012) concluded that massage can help change parasympathetic activity (measured by heart rate, blood pressure and heart rate variability) and hormonal levels (measured by cortisol levels). They found that the treatment can promote a 'relaxation response' by reducing anxiety and improve mood post massage.

Summary

Deep tissue sports massage is a targeted, evidence-supported therapy designed to address chronic muscle tension, pain, and stiffness by applying deep but tolerable pressure to the body’s soft tissues. It is a safe and effective option for many people when performed properly and its benefits are supported by growing scientific research. As awareness of bodywork and integrative health practices continues to expand, deep tissue massage remains valuable for those seeking relief from muscular pain and improved physical function.

Massage Techniques:

References

Field, T., Hernandez-Reif , M., Diego , M., Schanberg , S., Kuhn , C. (2005) Cortisol decreases and serotonin and dopamine increase following massage therapy, International Journal of Neuroscience, 15; 10.

Majchrzycki, M., Kocur, P., Kotwicki, T. (2014) Deep Tissue Massage and Nonsteroidal Anti-InflammatoryDrugs for Low Back Pain: A Prospective Randomized Trial , The Scientific World Journal; Hindawi Publishing Corporation: 1-7.

Srokowska, A., Bodek, M., Kurczewski, M., Srokowski, G., Siedlaczek, M., Lewandowski, A. (2019) Deep Tissue Massage and Mobility and Pain in the Thoracic Spine , 11 (2): 99-108.

Weerapong, P., Hume, P. A., Kolt, G. S. (2012) T he Mechanisms of Massage and Effects on Performance, Muscle Recovery and Injury Prevention , 35; 235-256.

Zhang, M., Liu, A., Pan, F., Lu, J., Zhan, H., Jones, R. K., The effectiveness of massage on pain, external knee adduction moment, and muscle Co-contraction in individuals with medial compartment knee osteoarthritis , Journal of Bodywork & Movement Therapies; 40: 1672-1678.

Dry Needling (Medical Acupuncture) for Tennis Elbow

Sun, 15 Jun 2025 11:55:59 GMT

Dry Needling can be Provided at the Leagrave Therapy Clinic

What is the Difference Between Acupuncture and Dry Needling?

Acupuncture focuses fixed acupoints, many of which lie along meridians which are associated with organ systems (e.g., Liver or Kidney) and apply affect the central nervous system, modulating pain and inflammation systemically.

Dry Needling applies acupuncture needles that focus on treating myofascial trigger points tight bands or knots in muscles that can refer pain to other areas. They are applied to muscle locations especially where trigger points or tensions are found. The technique induces a local twitch response, helping to relax the muscle and improve blood flow and works locally rather than systemically, based on muscle, fascia, and nerve anatomy.

How Medical Acupuncture Might Help with Tennis Elbow

1. Pain Reduction

Dry needling (or medical acupuncture) aims to help reduce pain by stimulating the nervous system to release endogenous opioids such as endorphins and enkephalins which act as anti-inflammatory mediators. They are naturally produced by the body and can reduce inflammation. Additionally, inserting acupuncture needles near the lateral epicondyle can modulate pain signals through the gate control mechanism and reduce the excitability of pain pathways.

2. Releasing Muscle Tension

The outer elbow muscles, especially the extensor carpi radialis brevis and longus, often develop tightness or trigger points due to repetitive strain. Dry needling directly targets these tense areas, inducing a localised twitch response that aims to improve muscle relaxation and improve blood flow. This not only relieves discomfort but also promotes better function and range of motion.

3. Improving Circulation and Healing

Dry needling helps to increase local microcirculation, help flush out inflammatory mediators, enhance oxygen and nutrient delivery to injured tissues. This process is essential in facilitating tissue repair in the tendons and surrounding musculature.

4. Neuromuscular Re-education

Chronic elbow pain can lead to changes in the way muscles are activated and controlled. By stimulating the nervous system, these therapies can help “reset” abnormal motor patterns, leading to improved coordination and reduced strain on the affected muscles.

Clinical Evidence

Numerous clinical studies support the use of dry needling/ medical acupuncture for lateral epicondylitis. Systematic reviews suggest that these interventions can significantly reduce pain and improve function when compared to standard care or placebo treatments. Furthermore, combining needling therapies with rehabilitative exercises and ergonomic adjustments offers the best long-term outcomes.

A recent study by Ma et al., (2024) looked into a total of 17 studies that involved 979 subjects and found that dry needling exhibited a significant advantage in improving pain intensity among patients with lateral epicondylitis within 1 week after treatment.

Within 1 week their study found that

Pain intensity reduced
Improved function
Increased grip strength
Improvements persisted at longer follow-ups (>1 week).
Local twitch response was key .

A typical treatment plan for medical acupuncture might involve weekly sessions for several weeks, focusing on:

Needling trigger points in the forearm extensors
Targeting distal acupuncture points to modulate systemic pain responses
Incorporating manual therapy and guided exercise for tendon loading

Video Demonstration:

Reference:

Ma, Xia., Qiao, Y., Wang, J., Xu, A., Rong, J. (2024) Therapeutic Effects of Dry Needling on Lateral Epicondylitis: An Updated Systematic Review and Meta-analysis, Archives of Physical Medicine and Rehabilitation , 105; 11: 2184-2197.

Osteoporosis

Sun, 08 Jun 2025 14:45:53 GMT

A Silent Threat To Bone Health

Osteoporosis is a chronic skeletal disorder characterized by a decrease in bone mass and deterioration in bone tissue, leading to increased bone fragility and risk to fractures. Often called the “silent disease,” osteoporosis progresses without obvious symptoms until a fracture occurs; commonly in the hip, spine, or wrist. As populations age globally, osteoporosis presents a growing public health concern, especially among postmenopausal women and the elderly.

Causes & Risk

The development of osteoporosis involves a complex interplay between genetic, hormonal, nutritional, and lifestyle factors. Bones are dynamic tissues that continuously undergo remodeling, a balance between bone resorption (breakdown) by osteoclasts and bone formation by osteoblasts. In osteoporosis, this balance tips toward greater resorption, leading to porous, brittle bones.

The primary cause of osteoporosis in women is the drop in estrogen levels after menopause, which accelerates bone loss. In men, a gradual decline in testosterone can contribute. Other risk factors include inadequate calcium and vitamin D intake, sedentary lifestyle, smoking, excessive alcohol consumption, and a family history of osteoporosis. Certain medical conditions such as rheumatoid arthritis, and the use of corticosteroids, can also increase risk.

The societal burden of osteoporosis is significant. Fractures related to osteoporosis are a major cause of morbidity and mortality, especially in older adults. Hip fractures in particular often lead to hospitalization, surgery, and long-term care needs. According to the International Osteoporosis Foundation, one in three women and one in five men over the age of 50 will experience osteoporotic fractures in their lifetime. The economic costs, both direct and indirect, are substantial and growing.

Stages of Osteoporosis:

Symptoms and Diagnosis

Osteoporosis is often asymptomatic until a fracture occurs. These fractures can lead to chronic pain, reduced mobility, and loss of independence. Vertebral fractures may result in height loss, stooped posture, and back pain. Because early detection is crucial, screening methods like bone mineral density (BMD) testing using dual-energy X-ray absorptiometry (DEXA) are essential tools for diagnosis.

How Might Osteopathy & Sports Massage Help? Prevention and Treatment

1. Postural Analysis / Postural and Alignment Improvements

Poor posture—especially kyphosis (rounded upper back)—can worsen the risk of vertebral fractures in people with osteoporosis. Osteopathy and postural analysis can help teach:

An awareness of postural defects.
Postural correction exercises
Core strengthening routines
Safe ways to sit, stand, and move without putting excess pressure on fragile bones

2. Increases Bone Density Through Weight-Bearing Exercise

Physical therapists design weight-bearing and resistance exercises tailored to each patient’s condition. These activities stimulate bone remodeling by encouraging the body to build more bone mass. Examples include:

• Walking or stair climbing

• Light weightlifting or resistance band training

• Tai chi and yoga (with modifications)

While physical therapy can’t reverse osteoporosis, it can slow its progression and help maintain current bone density.

3. Enhances Balance and Prevents Falls

Falls are a leading cause of fractures in people with osteoporosis. Physical therapists assess balance and coordination, then design exercises to:

• Improve stability and lower limb strength

• Boost reaction time and proprioception (body awareness)

• Reduce fear of falling through confidence-building movement practice

4. Provides Safe Movement Education

People with osteoporosis may unknowingly move in ways that put them at risk. Physical therapists educate patients on:

• Safe ways to lift, bend, and carry

• How to avoid twisting motions that stress the spine

• Home safety modifications (e.g., removing trip hazards)

5. Reduces Pain and Improves Quality of Life

Chronic back pain from spinal fractures or muscle strain is common in advanced osteoporosis. Physical therapists use:

• Gentle stretching and mobility exercises

• Manual therapy techniques

• Pain management strategies (heat, cold, positioning)

6. Diet

Preventing osteoporosis involves addressing modifiable risk factors early in life. A diet rich in calcium and vitamin D, regular weight-bearing exercise, and avoiding smoking and alcohol can help build and maintain strong bones. For those at high risk or already diagnosed with osteoporosis, medical treatments may be necessary.

Pharmacological treatments include bisphosphonates, which slow bone resorption, and newer options like denosumab, selective estrogen receptor modulators (SERMs) and parathyroid hormone analogs that promote bone formation. Hormone replacement therapy (HRT) may be considered for some postmenopausal women, although it comes with potential risks.

The Impact of Spinal Misalignment

Sun, 01 Jun 2025 15:21:26 GMT

How Spinal Alignment Impacts Other Joints Within the Body

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

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

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

The Spine as a Central Axis

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

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

Shoulder and Elbow Dysfunction

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

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

Impact on the Hips, Knees, and Ankles

Spinal alignment also influences the pelvis and lower limbs and misalignment may include a pelvis that may tilt anteriorly (forwards) or posteriorly (backwards), thus leading to an imbalance in leg length or altered gait mechanics. This has a direct effect on the hips and knees.

For instance, excessive lumbar lordosis (inward curvature of the lower back) can tilt the pelvis forward, tightening hip flexor muscles and put strain on the knees. Misalignment in the hips often transfers abnormal forces down the kinetic chain, affecting knee tracking and leading to conditions such as patellofemoral pain syndrome or iliotibial (IT) band syndrome.

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

The Neurological Connection

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

Postural Screen Assessment

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

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

Reference

1. Le Huec, J. C., Thompson, W., Mohsinaly, Y., Barrey, C., Faundez, A. (2019) Sagittal Balance of the Spine, European Spine Journal , Spriger, 28: 1889-1905.

2. Shiba, Y., Taneichi, H., Inami, S., Moridaira, H., Takeuchi, D., Nohara, Y. (2016) Dynamic Global Sagittal Alignment Evaluated by Three-Dimensional Gait Analysis in Patients with Degenerative Lumbar Kyphoscoliosis , Eur Spine J., Springer; 25: 2572-2579.

Dry Needling (DN) for Neck and Lower Back Pain

Sat, 10 May 2025 07:51:55 GMT

Dry needling (DN) is a standard form of treatment rapidly gaining in popularity amongst patients who seek newer options for the treatment of mechanical neck and back pain-associated symptoms (1). Dry needling is also growing to become the most common intervention used in clinical practice for the management of trigger points (TPs). The treatment method involves a thin acupuncture needle to penetrate through the skin, subcutaneous tissues, and muscles (5). The puncture technique causes local muscle tremors which relaxes the treated area and encourages the reduction of local tension and pain (5).

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

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

DN & Chronic Neck Pain

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

DN & Lower Back Pain

Hu et al., (2018) found dry needling to be more effective than acupuncture or sham needling (a procedure that mimics needling techniques but does not involve penetration of the skin). They found evidence to reveal that DN is more effective for alleviating pain intensity and functional disability at postintervention in lower back pain (3).

Another study by Rajfur et al., (2022)assessed the effectiveness of dry needling for reducing pain intensity and improving functional efficiency in patients with chronic lower back pain due to the L5-S1 discopathy. They found that dry needling effectively reduced pain and improved range of motion of local joints in patients with chronic lower back pain (5).

Demonstration

References

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

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

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

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

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

Association Between Alcohol Consumption & The Incidence of Dementia

Mon, 05 May 2025 15:27:55 GMT

Epidemiological studies suggest that excessive drinking and life-time alcohol use are associated with the risk of Alzheimer’s disease (AD) (3).

What Is Alzhemiemer's Disease?
Alzheimer’s disease (AD) is the most common form of dementia, accounting for 60 to 80% of dementia cases (1). According to Zheng et al., (2024), it is estimated that the number of people with dementia is likely to increase from 57.4 million globally in 2019 to 152.8 million by 2050.

Zhornitsky et al., (2021) found that amongst patients with possible or probable AD, a history of heavy drinking was associated with an earlier onset of AD. AD pathology is characterised by the cluster of extracellular amyloid-β (Aβ) into amyloid plaques, cognitive decline and neurodegeneration (3).

Studies have found that frequent alcohol use is associated with diminished gray matter volumes (GMV) in the posterior cingulate cortex (PCC), thalamus, hippocampus, and orbitofrontal cortex, brain regions widely implicated in the progression of AD (3). Alcohol-dependent individuals in research studies have shown smaller GMV in the medial frontal and lateral prefrontal cortex as well as posterior cortical regions, and the extent of GMV reduction predicted relapse to heavy drinking (3).

References

1. Day, S. M., Gironda, S. C., Clarke, C. W., Snipes, J. A., Nicol, N. I., Kamran, H., Vaughan, W., Weiner, J. L., Macauley, S. L. (2023) Ethanol exposure alters Alzheimer’s-related pathology, behavior, and metabolism in APP/PS1 mice , Neurobiology of Disease, 177: 1-14.

2. Zheng, L., , Liao, W., Luo, S., Li, B., Liu, D., Yun, Q., Zhao, Z., Zhao, J., Rong, J., Gong, Z., Sha, F., Tang, J. (2024) Association between alcohol consumption and incidence of dementia in current drinkers: linear and non-linear mendelian randomization analysis , OA Open Access, The Lancet, 76: 1-12.

3. Zhornitsky, S., Chaudhary, Thang, M., Chen, Y., Zhang, S., Potvin, S., Chao, H. H., van Dyck, C. H., Li, C-S. R. (2021) Cognitive dysfunction and cerebral volumetric deficits in individuals with Alzheimer’s disease, alcohol use disorder, and dual diagnosis , Psychiatry Res Neuroimaging, 30; 317: 1-25.

London Marathon Day - Intimate Details & Secret Tips From Celebs

Sun, 27 Apr 2025 18:59:33 GMT

Well Done To Every Runner on Marathon Day!

A big well done to all runners who crossed the finishing line today at the London Marathon with thousands helping to fund their charities and good causes. It was a hot, sunny day for another year's marathon with temperatures hitting 22.2C. Emotions ran high and celebrities passed on their wisdom as they ran amongst 56, 000 other runners at the city-wide event.

Vaseline!

As part of one's preparations, an intimate tip shared by Kelly Brook would be to not forget to pack one's pot of vaseline (2)! She described her agonising experience of chafing fabrics rubbing against her skin and advised to add this to the running pack to prevent frictions, burns and bleeding (2). This was an item observably not packed by another celebrity; John Terry. The famous ex Chelsea footballer admitted that he was forced to walk during his race 'as blood poured from his nipples' during his marathon ordeal (5).

Clear One's Schedule!

The comedian, Joel Dommett, completed his marathon race, but woke up in an ambulance post half way after fainting at mile 17 (4)! He explained that his 'hectic schedule' meant that he lacked sleep along with loading his body with crucial carbohydrates required as part of his pre-race preparations. He admits to have 'over done it' with the travelling prior to his big day and the 'terrible planning' may have lead to his unexpected fainting (4).

Start Preparations as Early as Possible (Life Event Pending)

The Towie star, Mark Wright, was agonisingly forced to pull out two days prior to his 26.2 mile race from a soleus muscle tear within his calf (1). He explains that his injury started off mild but gradually became worse as the weeks went on during his training regime. Despite an 'intense rehabilitation program', he was unable to recover in time and was 'heart broken' over the decision to opt out. He admits to have started his training 'late', but in fairness to Mark he has had his hands full with a new arrival of his baby daughter and so will hopefully attempt to complete the race next year (1).

Standing Calf Stretch Video Demo:

Another Marathon Day, Another Successful Adventure...

Overall, it was another successful adventure for the thousands of runners at the 45th London marathon edition (3). The event grows bigger by the year and attracted a WORLD RECORD for the number of finishers by surpassing a previous best record of 55, 646 set in the New York marathon. The race also attracted record crowd and spectator numbers with over EIGHT HUNDRED THOUSAND people cheering the runners on. Race director Hugh Brasher said that approximately 60, 000 more than usual supporters attended due to the warm weather and higher number of participants (3).

Reference

1. Chrisp, K. (26/04/2025) Mark Wright ‘truly heartbroken’ to pull out of London Marathon in emotional statement, Metro, https://metro.co.uk/2025/04/26/mark-wright-truly-heartbroken-pull-london-marathon-emotional-statemen... [Online] Last accessed 27/04/2025.

2. Evans, G. (27/04/2025) Kelly Brook shares remedy to painful London Marathon injury: ‘Nothing prepares you for the chafing’, https://www.independent.co.uk/life-style/kelly-brook-london-marathon-injuries-chafing-b2740275.html [Online], Last visited 27/04/2025.

3. Ingle, S. (27/04/2027) London Marathon Sets World Record for Number of Finishers, https://www.theguardian.com/sport/2025/apr/27/london-marathon-sets-world-record-for-number-of-finish... [Online], Last visited 27/04/2025.

4. Llewellyn, G. (27/04/2025) Joel Dommett reveals he woke up in an ambulance after FAINTING at mile 17 during London Marathon - following the exhausted star sharing glimpse of his hectic pre-race schedule, https://www.dailymail.co.uk/tvshowbiz/article-14653227/Joel-Dommett-FAINTING-mile-17-London-Marathon... [Online], Last visited 27/04/2025.

5. Maul, P. (27/04/2025) Sun, ‘Toughest thing I’ve ever done’ – John Terry forced to walk as blood pours from NIPPLE in gruelling London Marathon,
https://www.thesun.co.uk/sport/34671424/john-terry-injury-london-marathon-chelsea/ [Online], Last visited 27/04/2025.

Supreme Court of the United Kingdom Rules That The Legal Definition of a Woman Is Based On Biological Sex

Sun, 20 Apr 2025 17:50:06 GMT

The Ruling

Wednesday 16th April 2025 marked a 'historic' day with the UK supreme court displaying common sense to the world and Great Britain. Five wise judges ruled unanimously and issued a definitive ruling for what a woman is with that 'the terms "woman" and "sex" in the Equality Act refer only to a biological woman and their biological sex' (2). Thus, the legal definition of a woman in the Equality Act 2010 does not include transgender women who hold gender recognition certificates (GRCs) or certificates to say they have changed gender (2).

The case was brought to the supreme court by the gender-critical campaign group For Women Scotland which is financially funded by the famous Harry Potter Book author, JK Rowling after two Scottish courts rejected its arguments that the Equality Act’s definition of a woman was limited to people born biologically as a female (2).

What Does This Mean For Trans Women?
This could lead to greater restrictions on the access for trans women to services and spaces reserved for women (2). The judgement means that it is lawful to exclude biological males from female only services such as medical services and single sex spaces including changing rooms and hostels (2).

With regard to sport, governing bodies are now compelled to reconsider their rules by banning transgender women from competing in women's categories (1). From now on, the Supreme Court Ruling will mean that the legal definition of a woman is likely to have implications for sport at all levels from the elite to the grassroots (1). According to Holt and Melley (2025), many businesses, sports clubs and other organisations highlight how it is too soon to know what the new ruling will mean in practice.

Despite the Supreme Court ruling, the General Medical Council (GMC)is pressing ahead with its new policy of making it voluntary for medics to record any data on their gender or sex (3). Thus, female patients will be unable to ensure whether they receive care from a doctor of the same sex, which is not a legal right but can be requested (3).

What Is a Biological Woman or Biological 'Sex'?

‘Sex’ can refer to (5):
1. A category (male or female).
2. A system (genes and hormones); with sex chromosomes XY for males and XX for females. Women primarily produce estrogen and progesterone and a small amount of testosterone. The two hormones luteinizing hormone (LH) and follicle-stimulating hormone (FSH) help regulate the menstrual cycle and ovulation in women. Men produce significantly higher levels of testosterone, with the testes being the primary site of testosterone production.
3. Phenotypic sex i.e. primary sex characteristics via external genitalia. Genital organs can be removed or modified via surgical and pharmacological interventions.

Supreme Court Ruling In Practice

Overall, the court ruling enables clarity, if a single-sex space, like a toilet or changing room is women-only, that means biological males who identify as women should not use it (4). It says instead that trans people should use their "powers of advocacy" to campaign for third spaces, such as unisex toilets (4).

Reference

1.) BBC Sport, (2025) What does the 'definition of a woman' ruling mean for sport? [Online].

2.) Carrell, S. (2025) Legal Definition of Woman is Based on Biological Sex, UK Supreme Court Rules, The Guardian [online] https://www.theguardian.com/society/2025/apr/16/critics-of-trans-rights-win-uk-supreme-court-case-ov... , last visited 20/04/2025].

3.) Croft, E. (2025) Trans doctors can hide biological sex despite Supreme Court ruling , [Online, Last visited 20/04/2024].

4.) Holt, A., Melley, J. (2025) The Supreme Court ruling gives clarity - but now comes the difficult part , BBC Indepth [Online].

5.) Joel, D., Fine, C. (2022) Who Is a Woman: Sex, Gender and Policy Making. Journal of Controversial Ideas , 2, 2; 6: 1-19. doi:10.35995/jci02020006.

Dry Fire Cupping, How It May Help With Muscle Tension, Lower Back & Neck Pain

Tue, 08 Apr 2025 12:35:12 GMT

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

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

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

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

What Does It Do?

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

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

Does It Work?

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

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

Video Demonstration:

References

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

Stress, Cortisol, Its Impact on the Body & Management

Thu, 20 Mar 2025 18:11:58 GMT

Cortisol Hormone & Stress

Living in a faster paced world and modern day pressures has meant that stress is an inevitable part of our everyday life. According to the Mental Health Foundation, an average of 37.1% of women and 29.9% of men in the UK report high levels of anxiety in 2022/23 (4). Anxiety can lead to stress and affect the sympatho-adreno-medullary (or SAM) system which is our body's coping mechanism in stressful situations. In addition, anxiety can cause mental, emotional, behavioural and health problems (8).

This post will delve into the physiological affects of chronic stress on the body, how the mind responds to stress anatomically and what can be done to help improve the wellbeing of our mind in times of perceived stressful situations.

Cortisol
Cortisol is a glucocorticoid hormone produced by the adrenal glands located at the top of the kidneys and is important for numerous physiological processes (Figure 1). It governs our circadian rhythm (or 24 hour clock), activates the complex hypothalamic–pituitary–adrenal (HPA) axis, our body's natural response to stress, and maintains the body's homeostasis (3).

Cortisol is the body’s primary stress hormone and can be linked to weight gain due to its ability to trigger metabolic changes to promote fat storage thus hinder weight loss, increase our appetite, reduce metabolism, promote muscle breakdown and alter our fat storage (3). Thus, disruptions in cortisol regulation due to chronic stress can cause chronic related disease and ageing and can have profound implications for multiple bodily systems (3).

The Role of Cortisol
Overall, cortisol is a vital catabolic hormone produced by the adrenal cortex of the kidneys. It is released in a diurnal fashion i.e. it is released throughout the day, with blood levels peaking in the morning to facilitate arousal and steadily declines thereafter. During the day, cortisol maintains blood glucose and suppresses non-vital organ systems to provide energy to actively function the brain and neuromuscular system (1). Cortisol is also a potent anti-inflammatory hormone as it prevents widespread tissue and nerve damage associated with inflammation (1).

The SAM system allows the hypothalamus in the brain to activate the sympathetic branch of the ANS which then signals the adrenal medulla to secrete adrenaline and noradrenaline (figure 2). This allows the body to get ready for either a fight or flight response, can lead to sweating, hyperventilation, increased pulse rate and blood pressure (8).

The hypothalamic–pituitary–adrenal (HPA) axis controls the body's response to stress and regulates the release of glucocorticoid (GCs) (Figure 2.) (7). The down side of the HPA axis is that it can become increasingly desensitised over a period of time as prolonged cortisol release causes chronic stress to exert ill effects on the body.

Red & Yellow Flags

Red Flags & Referral:
During consultations and prior to initiating treatment, physical therapists are trained to identify 'red flags' which warrant referral symptoms of non musculoskeletal origin and identify symptoms that cannot be treated via physical therapy (e.g., visceral pain, saddle anaesthesia or night pain) (1). Thus highlighting the importance of the case history stage as it provides therapists time to comprehend whether or not a patient is suitable for treatment.

Yellow Flags:
Identifying 'yellow flags' help warn clinicians a probability that treatment might be complicated by psychological variables such as fear, anxiety, catastrophising behaviours and that a prognosis might fair. With a UK population struggling with an increased problem of anxiety in everyday life, physical therapists are becoming increasingly proficient in the identification and treatment of yellow flags (1). According to a report focused on wellbeing by the Office National Statistics (ONS), it has been reported that one in 17 people in the UK have low life satisfaction and almost a quarter have high levels of anxiety (5).

The Sympathetic Nervous System (SNS) & Parasympathetic Nervous System (PSNS)
1. The Sympathetic Nervous System is a network of nerves that helps your body activate a “fight-or-flight” response and increases with heightened stressed, a feeling of danger or during physical activity. The SNS promotes catabolic tissue breakdown and the metabolism of fat which mobilises glucose energy for energy and promotes arousal, alertness, motivation and goal directed behaviour (1).

2. The Parasympathetic Nervous System (PSNS) - What Therapists Try To Encourage! This system helps promote HEALING, repair, immunity and the anabolic growth required for restored energy reserves. Needless to say, a delicate balance between sympathetic and parasympathetic activity is critical for long-term physical and psychological wellbeing (1).

Why Is It Important To Know & Understand Chronic Stress? Hypothalamic–pituitary–adrenal (HPA) Axis Activation & Prolonged Cortisol Release - The Link Between Alzheimers Disease (AD) and Depression

One of the proposed mechanisms is that constant Glucocorticoid (GC) release caused via chronic stress can overtime blunt the hypothalamic–pituitary–adrenal (HPA) axis response. This can lead to HPA axis dysregulation and cortisol resistance. In chronic scenarios, the release of glucocorticoids can contribute to various neurological disorders including Alzheimer's disease (AD), Parkinson's disease and depression (7).

Chronic stress triggers prolonged HPA axis activation, resulting in elevated cortisol levels, which can lead to hippocampal (responsible for learning and memory) atrophy in the brain, synaptic dysfunction, and neuroinflammation which is recognised as a key pathological feature of AD. These alterations can impair cognitive function and may exacerbate amyloid-beta plaque formation which is the pathological hallmark of AD (7). Concurrently, persistent cortisol elevation affects the prefrontal cortex and limbic structures, contributing to depressive symptoms (7). The interplay between chronic stress, HPA axis dysregulation, and neuroinflammation (tissus within the brain or spinal cord) is important for understanding the comorbidity and presence of AD and depression.

Anatomy of Thought Processing & The Chimp Paradox

According to Professor Steven Peters; the author of the 'Chimp Paradox', the mind can be divided into three parts; the Human, the Chimp, and the Computer. The Human is the logical and rational thinker; the Chimp is the emotional, impulsive being and the computer stores our beliefs and past experiences (6).

Just like the body, everybody's mind, how it thinks and copes or reacts to different situations is unique. Developing a deeper understanding of the mind, how our thought processes work and the options available to us for how to manage our thoughts can develop coping strategies that best suit us.

The Chimp Paradox is designed to try and help us to adopt a strategy that aims to slow our thought process and reactions down and think in a more calmer, logical manner. For instance, a British politician says something that triggers you to feel irritated by saying e.g. we now must pay higher taxes or bills. According to the Chimp Paradox the information processed goes like the sequence below (6):

The new (irritating) information is first processed to the amygdala - a fast acting defence mechanism that responds quickly and the chief emotional centre in the limbic system or your 'chimp'. The 'chimp' tends to overreact and makes us respond via impulse i.e. anger or outburst with irrational behaviour.
The next centre of the brain your the information to be processed is the orbito-frontal cortex which is at the outer edge of the frontal lobe and tries to control impulses and uses moral judgement e.g. to not instantly swear or shout at the politician's remark.
Next, provides us with another moral guide and a conscience of guilt - the uncinate fasciculus within the limbic system e.g. that swearing is perhaps not a good idea in this instance and try to think of a way that might resolve the problem.
A part of the frontal lobe that works analytically and logical thought is the next stage with the use of the dorso-lateral pre-frontal cortex (DLPFC) e.g. you might think another way of how to improve the economy than the politician's proposed increase of taxes or bills.
The fifth stage allows us to be more considerate and empathise for others' feelings, this happens within the ventro-medial pre-frontal cortex - i.e. one may think about whether the politician has a point (or not) but explain why in a logical and controlled way, you might then EMPATHISE for other people being told the same information as you.
Lastly, is the cingulate cortex within the limbic system which is the decision making process that is influenced via past experiences e.g. you might decide that the politician is wrong to increase taxes as past experience has taught you that this is not good for the economy.

This processing of information all happens within a split second, especially when processed to the amygdala and everyone's 'chimp' differs in strength. The stronger the 'chimp', the more work required to reason with it and prof Steve Peter's book provides different solutions with how to go about doing this.

The mind, how it processes thoughts and information should be thought as like a muscle with that it takes training, practise and patience to help develop a healthier way of thinking. The chimp paradox also explains how we all have a responsibility to manage our 'chimp' and good management can stop it from making us feel bad, do or say something that we might regret and prevent harm to others. Managing the Chimp is a skill, it takes time and practise to deal with emotions and impulses (6).

Failure & Setbacks
The Chimp Paradox explains that 'fear of failure' or setbacks need to be seen as challenges or an opportunity to further develop ourselves and improve the skill of problem-solving. When we fail at something, the chimp tends to see this as a catastrophic event and typically blows everything out of perspective which will have an impact on our self-esteem and self-worth. On the other hand, humans see failure as an opportunity to iprove skills, develop as a person and accept that sometimes we don’t win or always get everything right (6).

Ways To Look After Yourself & Calming Our Mind Down

The Mental Health Foundation provide a good list and steps for helping us to lift our mood (4):

Talk: talking to friends or peers whom you can TRUST can help the feeling of being less alone. Talking can help you feel comforted, gain a different perspective and that your thoughts can be shared and discussed.
Diet: Reduce or cut down the intake of a diet high in sugar or salt and plan meals ahead for a structured, wellbalanced diet.
Physical Activity and Boost Endorphins: Endorphins are natural hormones produced that help us to feel good. Become committed to an activity that you enjoy and CAN regularly do; regularly attending classes or an activity with others is a great way to meet new people e.g. tennis, aerobics, walking groups, book clubs, arts and crafts clubs, volunteer for a charity.
Get Out Into Nature: A GREEN environment can help reset the mind, improve our concentration, feel happier, help spiritual wellbeing and make us realise that there is a 'bigger world' outside of our own.
Avoid cigarettes and alcohol: They can feel good initially, but make make things worse in the long run, especially if in a low mood - try to avoid these things if mentally in a low mood.
Educate Yourself - You Are Your Own Best Therapist - There is a lot of help out there: Meditation, Go on YoTube and listen to hundreds upon thousands of therapists for mental health and depression including Paul McKenna or Gabor Mate for FREE! LEARN ideologies such as Reiki, chakras, yoga and pilates, reading or audio books such as the Chimp Paradox.
Write a Diary: Write down when you last felt low or irritated. How long did it last? How did you make yourself feel better? Could you think in a different way next time for if a similar trigger reoccurs? Could you have reacted differently? What could you do differently as a reaction next time? Were you tired, overworked or lacked sleep before hearing the trigger? Sometimes it is better to not react initially, collect your thoughts first and then come back with a response that is not based on an impulse?
You Are Not Alone: Everyone goes through ups and downs and has to find ways to help manage their 'chimp'/ mind or mental wellbeing in all situations. What makes one person different to another is HOW they deal or react to a situation that they are presented with. Mind management is a long term skill to be constantly trained and learned - you are very much NOT alone.
Talking Therapies/ Therapies: Talking therapy or counselling, cognitive behavioural therapy (CBT), hypnotherapy, Neuro-Linguistic Programming Therapy (NLP) - there are conferences that can be attended for free.

Stress & How Massage Could Help

Subramanium et al., (2019) found 16 studies supporting the conclusion that massage therapy can be an effective treatment to reduce anxiety. They found that massage can help relieve a person from discomfort and provide physical and psychological benefits (8).

References

1. Hannibal, K. E., Bishop, M. D. (2014) Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation, Physical Therapy, Perspective, 94;12: 1-10.

2. Knezevic, E., Nenic, K., Milanovic, V., Knezev, N. N. (2023) The Role of Cortisol in Chronic Stress, Neurodegenerative Diseases, and Psychological Disorders , MDPI, Cells, 12; 2726: 1-18.

3. Maurya, N. K. (2024) The Cortisol Connection: Weight Gain and Stress Hormones: Review Article, Archives of Pharmacy and Pharmaceutical Sciences, HSPI - the Open Access Publisher, 2639-992x: 9-13.

4.Mind, Mental Health Foundation (2023) Office of National Statistics, NHS, WHO, Children's Commissioner for England; https://www.mentalhealth.org.uk/explore-mental-health/statistics/anxiety-statistics [Online] Last visited 20/03/2025.

5. ONS (2024) Measuring progress, well-being and beyond GDP in the UK: May 2024 - Exploring quality of life in the UK, drawing on the latest economic, environmental and social statistics. This quarter we focus on the quality of life of individuals, file:///Users/joey/Downloads/Measuring%20progress,%20well-being%20and%20beyond%20GDP%20in%20the%20UK%20May%202024.pdf [Online] Last visited 15/03/2025].

6.Peters, S. (2012) The Chimp Paradox [1st Ed.], Vermilion; London.

7. Sharan, P., Vellapandian, C. (2024) Hypothalamic-Pituitary-Adrenal (HPA) Axis: Unveiling the Potential Mechanisms Involved in Stress-Induced Alzheimer’s Disease and Depression, Cureus, 16; 8: 1-11.

8. Subramaniam, S., Latip, H. F. M., Aziz, M. S. A. (2019) Massage Therapy for Anxiety Reduction: A Systematic Review, Sryahwa, Journal of Sports and Games, 1; 2:13-17.

Hip Flexor Tension Can Contribute to Lower Back Pain and Joint Related Stiffness

Tue, 11 Feb 2025 10:47:29 GMT

The hip flexor muscles significantly help contribute stability of the lower back. Muscular tensions within this area can lead to pain within the lumbar spine (lower back) and impair performance (4.). Sedentary lifestyles are a major factor for restricting hip extension flexibility and stretching can greatly overcome the associated tightness and increased range of movement (ROM) of the joint (4.).

Anatomy

The iliacus, psoas major, and psoas minor prdominantly make up the hip flexor muscles (2.). The psoas major and iliacus collectively make up the iliopsoas which helps to serve as the primary hip flexor and contributes to hip external rotation and trunk lateral flexion (2.). Due to their attachments of the lumbar spine (lower back) vertebrae and pelvis, they are considered core muscles that function to stabilise the trunk and the pelvis (2.). Juan et al., (2024) highlight how the iliopsoas plays an important anterior joint stabiliser of the hip by applying posterior compressive forces to its femoral head which reduces shear forces placed on the structurem lowering the risk of labral or capsular injury during micro-instability (2.).

Lumbar stability is associated with various muscular structures including the hip flexors, especially the Psoas Major (PM) muscle which plays an important role due to its anatomical position and function (4.). The PM provides spinal stiffness, stability and alleviation, especially during lifting activities, by acting like 'guy wires' (3.). Thus, associated muscle weakness can lead to functional disability during strenuous activity (3.). A study by Malleter et al observed that the PM plays an important role in various pathologies of the hip and lumbar spine and also concluded that it plays an important role of stabilising the hip and the lumbar spine.

A minimum amount of tightness within the hip flexors such as the iliopsoas and rectus femoris is required for lumbar spine stability, however, muscles that are too tight pose a risk for lower back pain, however, a minimum amount of tightness is required for lumbar spine stability (4.). In the physical therapy world, the modified Thomas test is used to help determine tight hip flexors and defined for if full hip extension in the end position cannot be reached (4.).

Sedentary Lifestyle
It has been estimated that the youth and elderly population spends on average more than 8 hours mean sedentary time and so it is likely that most of the sedentary population have tight hip flexors. This is underlined by the findings of a study by Hirase et al. (2023) who reported that two-thirds of the investigated population had limited hip extension flexibility, and hence tight hip flexors.

Regular Hip Flexor Stretching

The existing data provides evidence that a single bout of hip flexor stretching of up to 120 seconds (or a minute and a half) can have a positive effect on the body's balance (following dynamic stretching or PNF stretching) and jump performance (4.).

Standing Hip Flexor Stretch:

Overall, a change in muscular imbalances in terms of length and strength around the hip joint has been observed in patients with lower back pain and regular stretching to the hip muscles can improve lower back instability (3.). Findings by the study of Juan et al., (2) suggest that exercises in increased hip flexion (e.g. active supine lying leg raise) provide greater activation of the iliopsoas muscle group compared to exercises where the trunk is moving on the lower extremity (i.e. that of flexing the trunk e.g. sit ups).

Reference

Hirase, T., Mallett, J., Barter, L.E., Dong, D., McCulloc, P.C., Harris, J. D. (2020) Is the iliopsoas a femoral head stabiliser? A systematic review. Arthrosc Sports Med Rehabil; 2: e847-53.
Juan, J., Leff, G., Kevorken, K., Jeanfavre, M. (2024) Hip Flexor Muscle Activation During Common Rehabilitation and Strength Exercises, J. Clin. Med., 12; 6617: 1-35.
Khan, A., Malik, A, N. (2023) Association between hip flexor tightness and lumbar instability in Adults, J Pak Med Assoc., 73; 11: 2239-2241.
Konrad, A., Mocnik, R., Titze, S., Nakamura, M., Tilp, M. (2021) The Influence of Stretching the Hip Flexor Muscles on Performance Parameters. A Systematic Review with Meta-Analysis, International Journal of Environmental Research and Public Health, MDOI, 18; 1936: 1-20.
Mettler, J.H.; Shapiro, R.; Pohl, M.B. (2019) Effects of a Hip Flexor Stretching Program on Running Kinematics in Individuals With Limited Passive Hip Extension. J. Strength Cond. Res. 33, 3338–3344.

Back Pain and The Bridge Exercise

Sun, 19 Jan 2025 23:34:06 GMT

What the Studies Say and Exercise Video

Introduction

Slumped half way down one's armed chair listening to a respected consultant during a six hour talk at a lower back pain conference, a question needed to be further explored after a splendid South London accent asked; 'Is it best practice to teach clients to lift their bottoms off the ground and hope that they might understand the benefits of such exercise...?'. A half slump changed to a sat upright posture and a temporary pause for teaching the bridge exercise. A modification of the exercise technique and experience has taught the author, here, that the bridge exercise still has a place within the physical therapy world provided that it is taught in a way that helps teach spinal positioning and alignment. When performed correctly, the bridge exercise helps to improve muscular efficiency of the core and gluteal muscles and most importantly of all - it needs to be performed pain free.

The following post will explore the benefits for the bridge exercise, its relevance and question the adequacy of the regularly prescribed exercise throughout the rehabilitation world across the country and indeed the globe.

Chronic Lower Back Pain

Chronic lower back pain (CLBP) is often associated with muscular weakness, pain and local structural damage such as disc height reduction, as these individuals experience a decline in physical activity (1). The condition tends to cause long-term physical inactivity leading to muscle atrophy or wasting, as muscles are unused. Studies show that the activation of transverse abdominis (TrA) and multifidus (deep back) muscles (MM) are more delayed in those with CLBP (1). Muscles showed a slower response and worsened atrophy in CLBP patients compared to those without CLBP (1).

An unstable spine reduces endurance, flexibility and range of motion of the lower back in addition to causing pain. Should one’s lower back pain intensify, patients are limited with what type of physical activity they may perform and their symptoms can lead to physical dysfunction including muscular weakness and imbalance, poor posture, weakened deep abdominal (core) muscles, inadequate trunk stabilisation and neuromuscular disorders (1). Thus, the strengthening of muscles within the lumbar spine is essential for treating lower back pain, improving one’s proprioception or joint positioning of the lumbar spine (1).

Appropriate exercise programs are an essential component of physical therapy for back pain patients after their symptoms have been evaluated (1). In particular, lumbar stabilisation exercises (LSE) can help prevent repetitive injuries to the intervertebral discs, small joints, surrounding tissues and minimise compressive stress in the spine during activities by strengthening core muscles (1).

Regular LSE in patients with low back pain strengthens ligaments, bones, tendons, and muscles and supplies sufficient nutrition to several joints and cartilages, including the spinal disc, thereby improving motor control (1). In addition, it restores muscle strength, functional mobility, balance, improves muscle activity of the lower trunk and core, enhances health and makes LSE effective not only for patients with low back pain but also for athletes (1).

The Bridge Exercise

Due to their strengthening effects on the gluteal muscle and lower limbs, bridge exercises are widely prescribed in clinical practices to improve torso stability and strengthening muscles, joints and ligaments within the legs and spine (1). Clinically the exercise has found to be a form of low- intensity training of trunk muscles and effective for achieving trunk stability (1).

Kong et al., (2016) compared different variations of the bridge exercise and found that the prone bridge exercise (PBE) was more effective than the conventional bridge exercise in increasing the muscle activity of the trunk.

A study by Ynag and Uhm (2020) found a significant improvements within individuals in their step width and length in stroke patients after performing the general bridge exercise, bridge exercise on an unstable support surface and bridge exercise combined with whole body vibrations. It is interesting to read that the bridge exercise combined with whole body vibrations (by using a power-plate machine) group showed a statistically significant improvement compared to the other two groups. The study found that bridge exercises can be used as an effective program for not just patients with central nervous system damage but also to normal people and athletes (2).

In conclusion, the bridge exercise has proven to be an effective, appropriate and powerful exercise to regularly perform by all individuals with or without neurological defects to help improve muscular and joint strength, co-ordination, sensory feedback and stability.

Bridge Exercise Video

Below shows a bridge exercise technique that is taught at the clinic. Individuals are encouraged to fully contract their core and gluteal muscles by slowly lifting the lower back off the floor from a flat position. Here, clients are taught to imagine lifting the vertebrae one-by-one individually before placing the upper back first to the ground and finally flatten the spine.

The clinic's YouTube Channel can be viewed the vie the link here.

References

1. Kong, Y-S., Park, S., Kweon. M-G., Park, J-W. (2016) Change in Trunk Muscle Activities with Prone Bridge Exercise in Patients with Chronic Low Back Pain , J. Phys., 28: 264-268.

2. Ynang, D-J., Uhm, Y-H. (2020) Effects of Various Types of Bridge Exercise on the Walking Ability of Stroke Patients , J Kor Physical Therapy, The Korean Society of Physical Therapy, 32; 3: 137-145.

Three Phases of Muscle Healing

Wed, 02 Oct 2024 13:14:29 GMT

Destruction/ Repair/ Remodelling Phases

Skeletal muscle ranges from 40 to 50% in men of total body weight and 25 to 35% in women and can reach to 65% in weightlifters.

Muscle fibres can be divided into two types with 50% composed of slow twitch/ contraction fibres (type I) and 50% of fast twitch contraction fibres (type II). Postural muscles have a larger quantity of type I fibres with presenting to be a slow contraction speed but a greater resistance to fatigue.

Type II fibers fast contraction fibres) can be subdivided into types IIA and IIB. Type IIA fibres are known as intermediate layers that have larger quantities of mitochondria and myoglobin than seen in type IIB fibres and are thus more resistant to fatigue. Type II fibers (fast twitch fibres) can be transformed into type I fibers (slow twitch fibres) through training.

According Barroso and Thiele (2015), the largest portion of muscle injuries occur during sports activities and correspond to 10 to 55% of all sporting injuries.

The Physiology of Injuries and The Three Stages of Muscle Repair Post Injury

1. Destruction/ Inflammation Phase

1. Destruction/ inflammation Phase: Muscle degeneration and inflammation occurs throughout the first few days post injury and is characterised via the rupture and necrosis of muscle fibres. Many pro-inflammatory molecules such as cytokines, chemokine and growth factors are secreted by neutrophils.

Macrophages are a type of immune cell that are involved during the inflammation stage that are defined as pro-inflammatory macrophages. These cells act during the first few days post injury and contribute towards cell lysis or the 'eat' and 'clean away' the removal of cellular debris and stimulate myoblast proliferation. M2 macrophages, defined as anti-inflammatory macrophages, act two to four days post injury and help with muscle repair by promoting myotubule formation (2).

Treatment Implications: During this phase, immobilisation with braces, splints, crutches or taping technique application might be appropriate. Brief immobilisation for 3-7 days can assist with minimising the pain and swelling within the injured tissue. Application of RICE (Rest, ice, compression, elevation) can help reduce the inflammation and promote wound healing.

2. Repair/ Regeneration Phase

2. Repair/ Regeneration/ Remodelling Phase: During this stage, damages muscle undergoes repair and reorganisation to restore the muscle's structure and function.

Macrophage is introduced into the injured site. A macrophage “eats” and will “cleans away” dead tissue and dry blood caused by injury. Once this is complete, another cell called a satellite cell is released into the injured area. Satellite cells transform into myoblast cells, which group together to create new muscle fibres. Fibroblasts also produce connective tissue at the injured site and it is a combination of connective tissue and muscle fibres that repair the injured muscle. In addition, new blood vessels (angiogenesis) and nerves generate during this phase. This repair phase commonly peaks about two weeks after injury (2).

Treatment Implications: Moving and mobilising muscles can encourage faster regrowth of blood vessels and muscle fibres which will reduce scarring formation and increase tensile strength of muscle fibres. The expertise of physical therapists is important at this phase, as they can help select appropriate rehabilitation exercises. Initially, gentle exercises called isometrics exercises might be prescribed whereby the muscle contracts but there is no movement of a joint or limb. Next, progression to isotonic exercises would be prescribed to strengthen the muscle through its full range of motion. This, in combination with gentle stretching, is standard during the repair phase.

A few soft tissue massage techniques can be viewed below:

3. Remodelling Phase

This stage can overlap with the repair phase, the regenerating of muscle fibers and connective tissue continue to mature and are being oriented into the final scar tissue. This stage is important for the manner in which the scar tissue is being orientated. Typically, muscle tissue is orientated in straight lines. When the tissue repairs itself, the mixture of new muscle fibres and connective tissue is randomly orientated. Hands-on physical therapy treatment during this phase can assist the new tissue to regenerate into parallel lines, like a pile of straws, instead of a big knotted lumps, like a piece of cord or muscle 'knot', which is sensitive and painful.

Treatment implications: Instrument assisted soft tissue massage techniques and specialised massage tools may be used by physical therapists along with medical acupuncture to help reduce the tension within muscles and muscular knots. This is important for reducing the likelihood of reinjuring the tissue. Returning to regular functional activity by normalising joint mechanics, regaining full strength through isokinetic exercises and sports-specific training can occur during this time.

References

1. Barroso, G. C., Thiele, E. S. (2011) Muscle Injuries in Athletes, Rev Bras Ortop., 46; 4: 354-58.

2. Koh, T. J., Dipietro, L. A. (2011) Inflammation and Wound Healing: The Role of the Macrophage, NIH, 13, e23: 1-14.

Blood Pressure & Body Aches

Wed, 04 Sep 2024 17:31:15 GMT

According to the Office of National Statistics (ONS), a Health Survey for England in 2015 to 2019 estimated that 32% of adults living in private households in England have high blood pressure (hypertension). 'Three in ten adults (29%) were undiagnosed which equates to approximately 4.2 million adults with undiagnosed hypertension (in England)' (5).

NHS Dr Kearney highlights that having high blood pressure is associated with half of all strokes and heart attacks (3). But, the good news is that hypertension is easily treated and for every 10mmHg reduced within blood pressure, the risk of a life changing heart attack or stroke is also reduced by 20% (3)!

Hypertension and Osteoarthritis
A study by Alenazi and Alkhathami (2023) demonstrated that hypertension is prevalent in patients with osteoarthritis and has a significantly positive association with pain severity among patients (1). Thus, it is known that individuals with hypertension (high blood pressure) have higher osteoarthritic associated pain severity and intolerance than those without hypertension (1).

Interestingly, cardiovascular disease risk factors such as obesity, smoking, and serum lipid levels have been implicated to cause lower back pain (LBP) and osteoarthritis (2). In individuals with obesity & elevated inflammatory markers, low-grade systemic inflammation is present in individuals with obesity. Most obese people display elevated inflammatory markers including C-reactive protein and triggers inflammation, and causes joint pain, swelling, and stiffness (2).

Smoking & Osteoporosis: Smoking reduces bone mineral content which can potentially lead to osteoporosis and a higher susceptibility to microfractures in the trabecular bone of the vertebral bodies. There are also reports that high serum cholesterol and triglyceride levels result in higher LBP occurrence (2).

Did you know?

The charity’s High Blood Pressure: How Can We Do Better? report, found that for every ten people diagnosed with high Blood Pressure in the UK, seven more remain undiagnosed and untreated (3).

What Blood Pressure Readings Mean:

Blood pressure readings have two numbers, for example 140/90 and measured in millimeters of mercury (mmHg).

Blood pressure that is too low is called hypotension , and pressure that is consistently high is hypertension .

The top number of the reading is systolic blood pressure and is period of contraction of the heart muscle. This measures the force of blood against the arterial walls whilst the heart ventricles (the lower two chambers of the heart) squeeze and contract, pushing blood out to the rest of the body.

The diastolic number (the second number or bottom number) is the pressure when the heart relaxes and fills with blood. It is the period of relaxation of the heart muscle and measures the force of blood against the arterial walls as the heart relaxes and ventricles refill with blood. The heart relaxes between beats and the coronary artery is able to supply oxygen and blood to the heart (3).

Blood Pressure Readings:

90 over 60 (90/60 mmHg) or less: indicates low blood pressure.
More than 90 over 60 (90/60 mmHg) and less than 120 over 80 (120/80 mmHg): This blood pressure reading is ideal and healthy .
More than 120 over 80 and less than 140 over 90 (120/80-140/90 mmHg): You have a normal blood pressure reading but it is a little higher than it should be, and you should try to lower it. Health changes are required for a healthier lifestyle.
140 over 90 (140/90 mmHg) or higher (over a number of weeks): Indicates high blood pressure (hypertension). Change in lifestyle likely needed. See the doctor or nurse.

What Is The Average Resting Heart Rate?
The normal resting heart rate for adults over the age of 10 years, including older adults, is between 60 and 100 beats per minute (bpm). Highly trained athletes may have a resting heart rate below 60 bpm, sometimes reaching 40 bpm (3).

Hypertension and Oedema

Oedema (swelling) caused by cardiac related diseases (4):

Venous insufficiency can cause oedema in the feet, lower legs and ankles as the veins are unable to transport sufficient blood all the way down into the feet and back up to the heart. As a result, blood builds up in the legs, and fluid is forced out of the blood vessels into the surrounding tissue. Edema can also be caused by varicose veins (4).

Heart failure (cardiac insufficiency) can cause oedema in the arms and legs (peripheral oedema) and the abdomen (ascites) as the heart is too weak to pump blood around the body properly and so blood gathers within the anterior region of the heart (4). Due to the increased blood pressure within the veins, fluid can flow out into the surrounding tissues which may cause swelling within the legs or build-up fluid within the abdomen. If a person spends a lot of time laying down then oedema can occur within the lower back (also known as sacral oedema) (4).

Heart failure can also cause oedema within the lungs (pulmonary oedema); this is not common and life-threatening. Here, the lungs fill with fluid as the heart is too weak to pump out the blood. Blood gathers in the blood vessels of the lungs and fluid flows into the lung tissue. Signs of pulmonary oedema include shortness of breath and rapid, shallow breathing or coughing (4).

Other Causes of Oedema (4):

Kidney disease: can cause oedema within the legs and around the eyes as pressure within the blood vessels starts to build up. If the kidneys are unable to remove enough sodium and water from the body, this can lead to oedema (4).

Low protein levels in the blood (albumin): If there is a lack of the protein albumin in the blood, fluid can leak out of the blood vessels more easily. This lack of protein can be caused by extreme malnutrition or via kidney and liver diseases where the body loses too much protein or produces too little protein (4). A blood test is needed for this confirmation.

Liver diseases: Scarring of liver tissue or liver cirrhosis from long-term alcohol abuse or liver inflammation can cause oedema in the abdomen (known as ascites). Cirrhosis can lead to a lack of protein formation, a build-up of blood within the liver can increase the pressure within the blood vessels and fluid flows out into the abdomen (4). Again, a blood test is required to determine this.

Severe lung diseases like emphysema can cause oedema within the legs and feet as pressure within the lungs increases and blood builds up within the heart and veins (4).

Treatment:

A light lymphatic drainage massage is offered at the Leagrave Therapy Clinic and has been applied for related conditions listed above. If you are unsure whether you can accept such treatment due to your current health condition, please ask your doctor or medical health practitioner first.

References

1. Alenazi, A. M., Alkhathami, K. M. (2023) Hypertension Is Associated with Joint Pain Severity Among Individuals with Osteoarthritis, 24; 5 : e97-e101.

2. Bae , Y-H., Shin , J-S., Lee , J., Kim , M-R., Park , K. B., Cho , J-H., Ha ., I-H. (2015) Association between Hypertension and the Prevalence of Low Back Pain and Osteoarthritis in Koreans: A Cross-Sectional Study, Plos One, 10; 9: 1-13.

3. Blood Pressure UK (2008) http://www.bloodpressureuk.org/BloodPressureandyou/Thebasics/Bloodpressurechart [online]

4. Brandes, R., Lang, F., Schmidt, R. (2019) Physiologie des Menschen: mit Pathophysiologie., Berlin: Springer.

5. NHS (2016) Blood Pressure: How Can We Do Better? https://www.england.nhs.uk/blog/matt-kearney-7/ [online]

Ouch! What to do When You Sustain An Injury

Sat, 06 Jul 2024 18:34:13 GMT

Muscle Sprains & Strains

Sprains and strains to muscles and joints happen to all of us and for most they are a painful, but temporary reminder to be a little more careful. Prompt action can help your body to heal faster and may prevent further injury or prolonged pain.

What is The Difference Between A Strain & Sprain?

A sprain is an injury to the ligaments and capsule within the joint of the body.
A strain is an injury to muscles or tendons .

Strained or ‘pulled’ muscles often happens when we over exert untrained muscles, train without properly warming up or try to go beyond a joint’s natural flexibility. Sometimes we feel the pain straight away, however some injuries might not cause pain until later on.

Muscle strains can be classified into three categories according to their severity (2):

Mild (first degree) strain: a tear of a few muscle fibers; minor swelling and discomfort with no or only minimal loss of strength and restriction of the movements.
Moderate (second degree) strain: T here is greater damage of muscle with a loss of strength.
Severe (third degree) strain: Tearing of muscle is extended across the muscle belly which results to a total loss of muscle function (2).

Muscle strain often results in a large hematoma, because the intramuscular blood vessels are torn.

What can you do?

RICE

Remember RICE (Relative rest, Ice, Compression and Elevation), using these can help to relieve the pain and start the healing process.

Relative rest : The first thing to do if you feel pain is to reduce the offending activity – pain is usually your body’s way of telling you that there is something wrong that needs your attention. It can be normal to feel a little sore after exercises for a day or two, but if it is more than this, pushing through the pain is rarely beneficial.

However, movement stimulates the healing process so stay as mobile as you comfortably can. Try to keep the joint moving through a comfortable range of motion, without forcing it to the point of pain. This will help to encourage blood flow and keep your joint flexible whilst it heals. This is particularly relevant for back pain as gentle exercise, such as walking, can help. You should slowly build your activity levels up as soon as your symptoms begin to resolve and you are able.

Ice

Ice : Cooling the area using an ice pack can help to reduce swelling and pain. Wrap a thin tea towel around the area so as to avoid direct skin contact and then apply the pack to the injured area for 10 – 15 minutes. You should repeat this several times per day for the first 72 hours. This will help to control inflammation, making it easier for your body to get blood and nutrients to the area and resolve the injured tissues.

Recommendations in review articles range from applying ice (1):

Option 1: 10 to 20 minutes 2 to 4 times per day.

Option 2: Up to 20 to 30 minutes every 2 hours.

Most clinicians will recommend Option 1 and suggest applying ice for 2 to 5 minutes only to peripheries i.e. fingers and toes to avoid burns.

Compression : Gently applying a compression dressing (e.g. tubey-grip for arms or legs) may help to temporarily support the injured joint and reduce swelling, though remove this immediately if there are signs that this is reducing the circulation to the area (numbness, pins and needles, the skin turning white or blue etc).

Elevation : If the injury is in the lower limb (knee or ankle), elevating the area a little can make it easier for your body drain fluids that might accumulate around the area, causing swelling. For example, if you’ve hurt your knee, sitting down with the knee raised on a low foot stool may ease your pain.

Seek medical attention . If you have pain that can not be controlled with over the counter painkillers, you cannot put weight on the injured (upper or lower) limb, experience paralysis or loss of sensation or the swelling is very bad seek help from your local A&E department, urgent care centre or telephone 111 for advice.

If the pain or swelling fails to improve within a week, a visit to a physical therapist, osteopath, sports massage therapist may be beneficial. They will be able to assess the injury, advise you on the correct treatment and can provide some manual therapy which may help it get better faster.

References:

Bleakley, C., McDonough, S., MacAuley, D. (2004) The Use of Ice in the Treatment of Acute Soft-Tissue Injury; A Systematic Review of Randomized Controlled Trials, The American Journal of Sports Medicine, 32; 1: 251-261.
Järvinen, T. A. H., Kääriäinen, M., Järvinen, M. Kalimo, H. (2000) Muscle Strain Injuries, Lippincott Williams & Wilkins, 12: 155-161.

The Tilted Pelvis & Injury Prevention

Mon, 10 Jun 2024 08:25:42 GMT

The Significance of a Pelvic Tilt

"Now, please flatten your lower back against the floor, as if to stop yourself from passing water and try to raise your belly button up towards your head".

Whilst various clients may look blankly with total confusion at their therapists after such a request, the pelvic tilt is a common exercise to be taught by physical therapists around the world to their patients and for good reason. Years of practise by the author here has established the conclusion that men in particular require the teachings of this technique to prevent injury.

Pelvic tilt exercises can stretch and strengthen the abdominal muscles and help to relieve sciatica and lower back (lumbar) pain . Chun and Jean (2019) highlight how an increased anteriorised pelvic title increases one's lumbar lordosis which leads to a higher risk of falls due to impaired balance and dynamic movements.

Suits (2021) define a pelvic tilt as the spatial position or motion of the pelvis about a frontal horizontal axis on the rest of the body within the sagittal plane (5). It is relevant for several musculoskeletal conditions commonly seen in physical therapy practices, particularly conditions affecting the hip and groin.

Hamstring Strains & the Pelvic Tilt

It has been suggested that shortened hip flexors i.e. illiopsoas or rectus femoris can pull the pelvis anteriorly (2). Kellis et al., (2024) highlight how an increased anterior pelvic tilt can cause the hamstrings muscles to lengthen. This study found that an anteriorised pelvic tilt increased the torque of hip extension movement only (2).

Mendiguchia et al., (2024) agree with that an increased anterior pelvic tilt produces a significant increase in muscular tissue elongation in all the three hamstring muscles i.e. semitendinosis (SMD), semimembranosus (SMB)and long head of biceps femoris. Their conclusion revealed that pelvic positioning plays a fundamental role as a strain regulator of the hamstring muscles and impact injury rehabilitation. Appreciating and understanding the maintenance of neutral pelvic positioning can highly impact injury rehabilitation and prevent hamstring injuries.

Pregnancy

The pelvis tends to tilt forward as pregnancy progresses which increases the risk for lower back pain and pelvic girdle pain. According to Morino et al., (2019), the anterior width of the pelvis is not recovered until one month postpartum and it is still wider than that at 12 weeks of pregnancy. The anterior pelvic tilt increases especially from 12 weeks to 36 weeks of pregnancy and then reduces one month postpartum (3). They found pelvic asymmetry to be present throughout pregnancy and after childbirth.

Sports Hernias and the Anteriorised Pelvis

Waryasz (2010) supported the conclusion that biomechanical alterations associated with an increased anterior pelvic tilt may increase the likelihood of sports hernias and osteitis. They encouraged the method of providing a strength and conditioning program that focuses on the prevention or correction of biomechanical imbalances of the anteriorised pelvis to reduce the risk of sports hernias and osteitis pubis.

Training programs should focus on abdominal strength and hip flexibility, while still incorporating power, strength, and dynamic flexibility in the lower extremities (6). Interestingly, Waryasz (2010) highlight the requirement of preventing unwanted lumbar spine lordosis and the reduction of an anteriorised tilted pelvis to ensure the activation of the gluteus maximus and hamstrings and prevent overloading the erector spinae muscles.

According to Waryasz (2010), sports hernias are the result of damage to the fascial structure of the inguinal region which leads to abdominal wall laxity combined with adductor/hip flexor dysfunction. Osteitis pubis is a lytic bone response to forceful adductor movements. Both sports hernias and osteitis pubis have been proposed to occur because of some degree of adductor dysfunction due to lack of flexibility (6).

How To Perform A Pelvic Tilt

To do a basic pelvic tilt:

Lie on your back on the floor (or on a mat on the floor) with the knees bent and feet flat on the floor. Allow your back to maintain a natural curve, leaving space between your low back and the mat. You should be able to slide your hand into this space.
Inhale. Then as you exhale, engage your abdominal muscles and pull your belly button up towards your head, the pubis of the pevlis should also rotate towards the head. The buttocks will slide down towards the feet.
This is should close the space between your low back and the mat or floor. You'll feel a gentle stretch of your low back.
Inhale, allowing your spine and pelvis to return to the original position.
Do 5 to 10 reps.

1. Chun, S., Jeon, K. (2019) Effects of Muscle-Strengthening Intervention Exercise on Pain Alleviation and Postural Control in Patients with Chronic Low Back Pain, Iran J Public Health, 48; 1: 171-172.

2. Kellis, E., Konstantopoulos, A., Salonikios, G., Ellinoudis, A. (2024) Does Pelvic Tilt Angle Influence the Isokinetic Strength of the Hip and Knee Flexors and Extensors?, J. Funct. Morphology. Kinesiol., 9; 2: 73.

3. Morino, S., Ishihara, M., Umezaki, F., Hatanaka, H., Yamashita, M., Aoyama, T. (2019) Pelvic Alignment Changes During Perinatal Period, PLoS One, 14; 10.

4. Mendiguchia, J., Garrues, M. A., Schilders, E., Myer, G. D., Dalmau-Pastor, M. (2024) Anterior Pelvic Tilt Increases Hamstring Strain and is a Key Factor to Target for Injury Prevention and Rehabilitation, 32;3: 573-582.

5. Suits, W. S. (2021) Clinical Measures of Pelvic Tilt in Physical Therapy , International Journal of Sports Physical Therapy, 16; 5: 1366–1375.

6. Waryasz., G. (2010) Exercise Strategies to Prevent the Development of the Anterior Pelvic Tilt: Implications for Possible Prevention of Sports Hernias and Osteitis Pubis, National Strength and Conditioning Association, 32; 4: 56-65.

Spinal Stenosis, Sciatica and Lower Back Pain

Mon, 27 May 2024 10:25:19 GMT

According to the Evening Standard, Queen Elizabeth II was a long term sufferer of sciatica. The Palace said that 'the Queen's chronic back problem was 'a private medical matter', but it is understood that she suffered from sciatica since a 2003 operation on damaged cartilage within a knee' (3).

As the Standard noted, sciatica within the elderly is often caused from osteoarthritis within the spine which may cause limited walking distance and cause one's leg to seize after having walked 30 to 40 yards (3).

But, what if sciatica is caused via spinal stenosis? What is the difference between stenosis and osteoarthritis? How can one tell the difference between the two?

Spinal Stenosis

Osteoarthritis is the most common form of arthritis and occurs when cartilage breaks down to create a lack of cushioning between joint surfaces. This may force bones to rub together and can cause pain, stiffness, and swelling. As osteoarthritis symptoms worsen, spinal stenosis can develop.

Spinal stenosis is a condition that can cause narrowing of the neural canal and foramina which can result to the compression of the nerve roots and lead to symptoms such as pain, weakness, and numbness (5). The upper neck (cervical) and lower back (lumbar) areas are most frequently affected, although the thoracic spine also can be compressed most frequently by a disc herniation (5). The condition can cause symptoms such as pain, numbness, and weakness (5).

Three different anatomical sites within the vertebral canal can be affected by spinal stenosis (5):

The central canal, which houses the spinal cord, can be narrowed and lead to compression of neural elements and reduction of blood supply to the spinal cord in the cervical area of the neck and the cauda equina in the lumbar area.
Secondly, the neural foramen, which are openings through which the nerve roots exit the spinal cord, can be compressed as a result of disk herniation, hypertrophy of the facet joints and ligaments, or unstable slippage of one vertebral body relative to the level below.
Lastly, the lateral recess, which is seen in the lumbar spine only and is defined as the area long the pedicle that a nerve root enters just before its exit through the neural foramen, can be compressed from a facet joint hypertrophy. Depending on the level of the spine affected, each type of compression can lead to different symptoms that warrant a particular treatment modality.

Most patients will experience some type of pain associated with the spine but luckily, even without surgery, the majority will have an uneventful recovery (6). Only 1 to 3% will have a herniated disc and less than 2% will have compression of a nerve root (6).

Spinal stenosis is common with ageing but predicting which individual will develop symptoms is not possible. In most cases, the degenerative process can be controlled by changes in lifestyle (6).

Lumbar Spinal Stenosis

LSS is a significant cause of disability in older individuals and a common indicator for spinal surgery in patients older than 65 years. Typical, symptoms of lumbar spinal stenosis include (6):

Pain at the gluteal muscles and/or lower extremities which may or may not be associated with the lower back.
Neurogenic claudication is a 'hallmark' symptom and characterised by pain in the lower limbs and the presence of neurological symptoms exacerbated by walking.
In addition, these symptoms are exacerbated by standing and lumbar extension.

Anterior flexion of the trunk and maintaining a sitting and supine position tends to alleviate symptoms.

Central stenosis arises from anterior ligamentum flavum hypertrophy compounded by posterior disk bulging (4). This condition is more prevalent at the L4 to L5 level than other spinal segments. Meanwhile, lateral recess stenosis can results from facet osteoarthritis (arthropathy) and osteophyte formation that can compress the nerve before it passes the intervertebral foramen.

Foraminal stenosis can result from:

Disc height loss.
Foraminal disc protrusion.
Osteophyte formation.

With such changes, impingement on the nerve root inside the intervertebral foramen can be caused. Extraforaminal stenosis is usually due to lateral disc herniation which causes compression on the nerve root after exiting the intervertebral foramen laterally (6).

Physical Therapy For Spinal Stenosis

Simple Lower Back Mobility & Stretch Exercises:

Physical therapy tends to be recommended for patients with mild to moderate LSS (4). Patients with severe LSS typically undergo a trial of conservative treatment before surgery is proposed (4).

Most literature supports the notion that exercise therapy should be considered before surgery. Surgery leads to better longer-term (2 years) outcomes for pain and disability (4).

There is very low-quality evidence to suggest that the two interventions (of surgery and physical therapy) are similar in relation to walking capacity or to pain and disability for the short and long term (4).

Acupuncture For Spinal Stenosis

The therapeutic modality of acupuncture for conservative management of spinal stenosis has historically been met with trepidation, particularly in the Western world (2).

However, clinical trials are beginning to emerge with the majority demonstrating the benefit of acupuncture techniques, particularly electroacupuncture, in providing pain relief in spinal stenosis patients (2).

Acupuncture appears to be a very safe treatment option with several studies demonstrating pain relief at least on par with surgical intervention for patients who do not meet criteria for urgent surgical intervention (2). Clark et al., (2022) concluded that acupuncture appears to be viable and effective as an adjunct conservative treatment option in these patients.

References

1. Ciardi, G., Lamberti, G., Casati, V., Paris, E. (2023) Rehabilitation Outcome Measures in Patients with Spinal Stenosis: A Literary Review , Phsysiologia, MDPI; 3: 421-432.

2. Clark, A., Lucke-Wold, B. P. (2022) Acupuncture and Spinal Stenosis: Considerations for Treatment , HHS Public Access, 1; 1: 23-31.

3. Evening Standard, The Queen is in great pain but insists she will open Parliament, https://www.standard.co.uk/hp/front/the-queen-is-in-great-pain-but-insists-she-will-open-parliament-... [Online].

4.Macedo, L. G., Hum, A., Kuleba, L., Mo, J., Truong, L., Yeung, M., Battie, M. C. (2016) Physical Therapy Interventions for Degenerative Lumbar Spinal Stenosis: A Systematic Review, 93; 12: 1646-1660.

5. Raja, A., Hoang, S., Patel, P., Mesfin, F. B. (2023) Spinal Stenosis, StatPearls Publishing LLC, https://www.ncbi.nlm.nih.gov/books/NBK441989/#:~:text=Most%20patients%20will%20experience%20some,com... . [Online].

6. Wu, L., Munakomi, S., Cruz, R. (2024) Lumbar Spinal Stenosis, https://www.ncbi.nlm.nih.gov/books/NBK531493/ [Online].

Breathing Patterns & Their Impact on Health

Tue, 30 Apr 2024 00:00:00 GMT

Breathing Pattern Disorders, Understanding the Need for Calmer Breathing

"Constant pains within the neck and upper shoulder muscles, unable to sleep or relax, headaches around the front and back of the head, a busy mind that 'won't switch off', constant mid back pains - especially around the shoulder blades, can sometimes feel as though not enough breath is 'drawn in or out' and it can be even painful whilst taking a deep breath in!"

Above is a couple of respiratory related symptoms that might be described by individuals to their practitioner. It is interesting to sometimes observe a client's resting breathing rate which can sometimes be seen as... well, fast! This particular discovery was made after having taken countless blood pressure readings from individuals. Interestingly, a blood pressure reading can sometimes be lowered after asking individuals to slow their breathing rate down. Slower breathing can help slow down the cardiovascular system, slow down the activity of the mind and help stimulate the parasympathetic autonomic nervous system (7).

Normal or 'Optimal' Breathing

Normal breathing, also known as diaphragmatic breathing requires adequate functional use and active control of the diaphragm muscle (1, 5). Here, muscles function with synchronised motion of the upper rib cage, lower rib cage and abdomen (1). During slow inspiration, the lower ribs stay low and only expand laterally, the abdomen expands instead of the chest (5).

Abnormal Breathing

Abnormal breathing is known as thoracic breathing and can be observed in individuals who tend to breathe from the upper chest (1). Here, one can observe that there is greater movement and use of the upper rib cage compared to the lower rib cage whilst breathing (1).

Breathing Pattern Disorders (BPD)

Breathing pattern disorders (BPD) can be defined as 'inappropriate breathing that is persistent to cause symptoms with no apparent organic cause and is present in a variety of individuals with musculoskeletal dysfunction' (1). According to Bradley and Esformes (2014), individuals who show signs of faulty breathing mechanics tend to have poor posture, scapular dyskinesis, lower back pain, neck and temporomandibular joint (TMJ) pain.

Chest Breathing

A type of breathing that is commonly observed amongst individuals and one that practitioners look out for is 'chest or thoracic breathing' which is produced by the over involvement of accessory muscles of respiration including; the sternocleidomastoid, upper trapezius, and scalene muscles within the neck (1). These muscles dominate the lower rib cage and abdominal motion and over‐activity of these accessory muscles have been linked to neck pain, scapular dyskinesis and trigger point formation of these associated muscles (1).

Poor diaphragm movement and action whilst one breathes is often confirmed via reduced abdominal motion with relation to the upper thoracic motion (1). The diaphragm acts as a respiratory pump that attaches to the the lower six ribs, the xiphoid process of the sternum and the lumbar vertebral column (L1‐3). The diaphragm muscle is important for the functioning of posture and breathing and the disruption of one function (i.e. the posture) can negatively affect the other (i.e. the quality of one's breathing pattern) (1).

Consequences of BPD

Altered breathing pattern tends to reduced lung volumes, hypoxia (lower levels of oxygen in the body tissues), respiratory alkalosis and can increase the excitability of the nervous system both centrally and peripherally (6). Additionally, chest breathing patterns can cause excessive activity and fatigue of superficial neck flexor muscles such as the sternocleidomastoid (6).

There are several different terms to describe irregular respiratory rates by health professionals (3):

Bradypnoea : Abnormally slow breathing.
Tachyphoea : Rapid breathing.
Dyspnoea : Shortness of breath with a elevated, normal or reduced respiratory rate.
Hyperpnoea : Deep and laboured breathing.
Apnoea : Absence of breathing.

Neck Pain and Breathing Disorders

A recent study by Yousefiyan et al., (2023) explored whether neck pain, in particular individuals with unilateral cervical radiculopathy (or nerve root entrapment/ irritation), had a correlation with respiratory dysfunction. They concluded that there was a moderate to large clinical significance in individuals with a dysfunctional breathing pattern and a unilateral reduction of diaphragmatic excursion on the side of their cervical radiculopathy (6). One of the main factors to have cause diaphragmatic dysfunction in patients with cervical radiculopathy (CR) is motion restriction of the diaphragm and irritated nerve roots of the phrenic nerve (6).

The study noted that prolonged compression of the ipsilateral phrenic nerve roots can eventually lead to trophic changes and disturbance in nutrition and function of the phrenic nerve, and consequently diaphragmatic weakness and altered breathing patterns (6).

Breathing Exercises For Blood Pressure and Heart Rate

A very recent study by Garg et al., (2024) discovered that breathing exercises can 'have a modest but significant effect on reducing systolic and diastolic blood pressure (mmHg).' They also observed that breathing exercises can significantly reduce heart rate (beats/ minute).

Research has shown that a slow breathing rate towards 6 breaths per minute can result to an increased venous return (5). Russo et al., (2014) note that this can be further enhanced with diaphragmatic breathing due to the anatomical fact that the diaphragm is connected to and supports the heart and provides passage for the aorta and the inferior vena cava (5).

Studies have found that individuals who breathe at 6 breaths per minute reportedly have a tendency for heartbeats to cluster during the inspiratory phase (5). The relationship between heart rate, blood pressure and respiration are known as cardiorespiratory coupling (5).

There are approximately over one billion people who suffer from hypertension (HTN) and this has been estimated to increase to 1.5 billion in 2025 according to the American Heart Association (AHA) (2). HTN is defined as systolic blood pressure (SBP) over 140 mmHg and diastolic blood pressure (DBP) over 90 mmHg. Uncontrolled HTN may lead to various cardiovascular complications including stroke, aneurysm, myocardial infarction and heart failure.

It is a good idea that practitioners try to take every new client's blood pressure and/or retest it on clients throughout their course of treatment as there is a strong correlation between blood pressure (BP) and adverse cardiovascular outcomes. It is reported that even a small reduction of blood pressure by 5 mmHg BP in hypertensive patients can lead to an approximate 25 % decrease in cardiovascular complications.

Breathing Exercise Video:

Breathing Rate Facts & Stats

The good news is that we can all modify, retrain and improve our breathing pattern and function at any age and breathing techniques can be quietly practised throughout different times of the day (yay!). As Russo et al., (2017) explain, the act of controlling one’s breath for the purpose of enhancing one’s health has been practiced for thousands of years within Eastern cultures (5). For example, yogic breathing (pranayama) is a well-known ancient practice of controlled breathing often performed in conjunction with meditation or yoga for its spiritual and perceived health-enhancing effects (5).

The history of yoga, and pranayama was first introduced to the West in the late 1800s and its popularity rose in the mid-1900s. The interest of breathing techniques within the medical and scientific communities have stimulated research into the area.

Slow breathing practices have gained popularity in the western world due to their claimed health benefits, but yet remain relatively untouched by the medical community.

Normal Respiratory Rate
The normal respiratory rate in adults is 12 to 18 breaths per minute (BPM). Expiration or breathing out should take twice as long as breathing in (during inspiration) (3, 5).

Slow Respiratory Rate
Slow breathing can be defined as any rate from 4 to 10 breaths per minute (5).

Average Respiratory Rate
It is a surprise to learn that the typical respiratory rate amongst the population is within the range of 10–20 breaths per minute (3, 5)!

Hyperventilating
Hyperventilation is considered when a respiratory rate is more than 20 breaths per minute.

Task 1 - Try It!:
If you consider yourself a 'slow breather' during rest with good respiratory health, try now breathing twenty breaths per minute. This equates to breathing in and out within three seconds during a one minute time frame i.e. 'one-Mississippi' during inspiration and 'two-Mississippi's' during expiration (or vice-versa with two-Mississippi's during expiration and one-Mississippi during inspiration).

Having completed this task, the following might have been felt:
- Nausea and light headed.
- The feeling of hyperventilating.
- Tight upper back muscles.
- Unable to complete the one minute task with this new breathing pattern.
- Warm face with darkened pink cheeks!
- Tight and raised chest.
- Lifted chin and arching of the neck.
- Tight neck muscles.
- Raised shoulders to keep up with the number of breaths.
- Irritation and fatigue.

...Some familiar sensations and symptoms that were described at the very beginning of this post, perhaps!

The author here has established that their sitting resting breathing pattern tends to average at around three-and-a-half to four seconds during inspiration and another three-and-a-half to four seconds during expiration; equating to an average of 8 breaths per minute - noting that there is room for improvement with their breathing pattern and function.

Task 2: Breathing Exercise
Try and count how many breaths per minute you take on average per minute and notice whether you are a chest or lower abdominal breather; i.e. you notice that only the chest raises during inspiration. Or, whether you observe and feel that the abdomen slowly and steadily rises and lowers whilst you are breathing at rest. Place one hand on your abdomen and the other on your chest for if you are not sure, notice which hand raises and lowers more whilst you breathe. This is a good exercise to do to improve breathing quality. Could this breathing rate be slowed down further? I.e. could you raise your lower abdomen a bit more during inspiration? Could you slowly breathe in for another half a second? What are your shoulders and neck doing? Are they relaxed during inhalation and exhalation? Try and notice the detail and quality of your breathing pattern and try practising it through out the day, this is most likely easier to do before going to sleep.

Note; an increased respiratory rate of more than 20 breaths per minute in adults could have several causes including:

Fever
Dehydration
Asthma
Chronic obstructive pulmonary disease (COPD)
Hyperventilation
Lung conditions e.g. lung cancer, pulmonary emboli (PE).
Infections
Respiratory acidosis
Drug overdose
Heart conditions including heart failure

References

1. Bradley, H., Esformes, J. D. (2014) Breathing Pattern Disorders and Functional Movement, Int J Sports Phys Ther, 9; 1: 28-39.

2. Garg, P., Mendiratta, A., Banga, A., Bucharles, A., Victoria, P., Kamara, B., Qasba, R. K., Bansal, V., Thimmapuram, J., Pargament, R., Kashyap, R. (2024) Effect of breathing exercises on blood pressure and heart rate: A systematic review and meta-analysis , Int. J. Cardiol Cardiovasc Risk Prev., 20: 1 - 16.

3. Hill, B., Annesley, S. H. (2020) Monitoring respiratory rate in adults , 29; 1: 12-16.

https://www.researchgate.net/publication/338508974_Monitoring_respiratory_rate_in_adults

4. Marc A. Russo ,1 Danielle M. Santarelli ,1 and Dean O’Rourke (2017) The physiological effects of slow breathing in the healthy human, 13 (4): 298–309.

5. Russo, M. O., Santarelli, D., O'Rourke, D. (2017) The physiological effects of slow breathing in the healthy human, 13: 4: 298-309.

6. Yousefiyan, R., Yoosefinejad, A. K., Jalli, R., Rezaei, I. (2023) Comparison of Breathing Pattern and Diaphragmatic Motion in Patients with Unilateral Cervical Radiculopathy and Asymptomatic Group , BMC Pulmonary Medicine, 23; 498: 1-9.

7. Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., Gemignani, A. (2018)

How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing , 12: 353.

Scapula Dyskinesis & Shoulder Pain

Thu, 28 Mar 2024 18:27:56 GMT

Categories, Cause, Testing & Rehabilitation

Scapula dyskinesis (SD) can be quite a complex topic and challenging to manage for practitioners. For patients who have been found to have this condition; re-education and retraining scapula positioning requires patience, time and practising exercises on a daily basis.

Scapula dyskinesis is a term used to describe improper movement and positioning of the scapula (or shoulder blade) during shoulder movement (5). The word ‘dyskinesis’ is Greek, with ‘dys’ meaning the alteration of and ‘kinesis’ translating as motion.

Sciascia and Kibler (2022) highlight how scapula dyskinesis is not an injury as it relates to being a physical impairment and the term should not be used as a musculoskeletal diagnosis. An alternative term often used for this disorder is ‘dyskinesia’, however, Roche et al., (2015) note that this expression is less accurate as it implies abnormal active movements mediated by neurological factors.

Dyskinesis, however, is more inclusive with incorporating various other factors that may be causative for this condition such as glenohumeral angulation, AC joint strain, subacromial space dimensions, shoulder muscle activation and humeral positioning and motion (9).

The positioning of the shoulder blade or scapula contributes to both mobility and stability of the neck and shoulder region, current clinical evidence suggests a strong relationship between SD with chronic neck and shoulder pain (8).

In clinical practice, scapula dyskinesis is identified by the presence of the prominence of the border of scapula which includes superior, medial, or inferior borders and a loss of scapula control during bi-planar arm movements i.e. during flexion/extension and abduction movements (8).

Scapula dyskinesis is not to be confused with scapula “winging” as this is best reserved for altered scapular motion driven by neurological compromise (9).

Hickney et al., (2018) discovered that individuals with SD had a 43% greater risk of developing shoulder pain than those without SD. Panagiotonopoulos and Crowther (2019) note how most common shoulder pathologies are associated with some form of scapula dyskinesis including:

1. Acromioclavicular instability

2. Shoulder impingement

3. Rotator cuff injuries

4. Glenoid labrum injuries

5. Clavicle fracture

6. Nerve-related pain e.g. nerve entrapment.

SD & Three Categories

Abnormal patterns of movement in scapula dyskinesis can be observed by determining the position of the scapula with the patient’s arms resting on their side (2). A shadow that can be seen within the left inferior border of the scapula within the image above may indicate its presence.

Dynamic scapula motion testing (DSMT) can be used to understand the mechanics of scapula dyskinesis by lowering and raising the arm to 120 degrees with or without holding weights (8, 2). Abnormal scapula movement can be divided into three categories of dyskinetic patterns which can aid rehabilitation and recovery for the flexibility required by certain muscle groups.

Three types of scapula dyskinesis according to Kibler et al., (2002) are:

1. Type I is characterised by increased prominence of the inferior and medial prominence (lower angle) of the scapula. This can usually be observed during scapula rotation moving about a transverse axis.

2. Type II is characterised by representing abnormal rotation about a vertical axis, i.e. during movements of medial and lateral rotation, abduction/ adduction of the shoulder. An increased prominence of the whole medial part of the scapula can be observed.

3. Type III is characterised by the prominence of the upper and medial borders of the scapula.

Normal, symmetric scapular motion is considered type IV.

Kibler et al., (2002) suggested that mild scapular dyskinesis is more frequently evident during the lowering phase of arm movement. It is presumed that this is because of the altered neuromuscular control required during eccentric muscle contraction (3).

It was interesting to read that a study by Sattasuk (2021) concluded that out of 32 bus drivers from a private bus company with unilateral upper quadrant musculoskeletal pain, over 50% of bus drivers presented with scapula dyskinesis during shoulder flexion and abduction movements during dynamic scapula motion testing with medial border prominence (Type II pattern of SD) identified as the common pattern of SD .

Cause

Several factors can create changes in the position of the scapula including (7):

Poor posture.
Excessive resting posture.
Thoracic and cervical kyphosis.
Lumbar spine lordosis resulting to excessive scapular and acromial protraction.
Traumas including clavicle fractures and acromioclavicular joint injuries.
Glenohumeral joint instabilities.
Osteoarthritis
Changes in the function of the muscles that control the scapula.
Lesions along the long thoracic nerve, and spinal nerve injuries (7).

Poor scapula posture tends to lead to muscular imbalances of length and muscular strength in the humeral muscles which alters the mechanics of the glenohumeral joint. Protraction of the scapula creates a contraction of the pectoralis minor and serratus anterior weakness or trapezius. The humeral posture and positioning with relation to the glenoid fossa is altered as it's positioning tends to become abducted and internally rotated resulting in shortened gleno-humeral internal rotators and elongated and weakened lateral rotators (7).

Testing For Scapula Dyskinesis

Observation:
Examination usually involves clinical observation of the scapula positioning to determine whether a prominence can be seen within the inferior or medial borders of the scapula.
Assessment for scapula prominence is carried out by observing a lack of smooth coordinated movement of the scapula during forward flexion, shrugging or arm lowering from a position of full flexion (6).

Clinical tests may involve the following (6):

1. Scapula Retraction Test (SRT) (6): Performed during GHJ lateral rotation.

The clinician's hand manually stabilises the medial border of the scapula in a retracted position on the thorax and the client's arm is raised or rotated externally. When there is relief of symptoms, the test is considered positive. This test frequently demonstrates scapula and glenoid involvement in impingement lesions.

2. Scapula Assistance Test (SAT) (6): Performed during GHJ abduction.
Evaluates glenohumeral joint impingement and rotator cuff strength. The practitioner assists scapula elevation by manually stabilising and rotating the inferior border of the scapula during humeral abduction. This procedure simulates the activity of the serratus anterior and lower trapezius muscles. If symptoms of impingement are diminished or eliminated by this manoeuvre, then it is considered a positive test.

3. Lateral scapula slide Test (6): Performed with arms by side (1), hands on hips (2), elbows at 90 degrees flexion and GHJ internal rotation (3).

This testing evaluates three different positions of the scapula in relation to a fixed point on the spine. These positions offer a graded challenge to the functioning of the shoulder muscles to stabilise the scapula.

The first position is with the arms by the side. The inferomedial angle of the scapula is palpated and marked on both the injured and non-injured sides. The measurements from a fixed reference point are recorded.
The second position is with the hands on the hips with approximately 10 degrees of shoulder extension. The position of the inferomedial border of the scapula is marked, a reference point on the spine is made (i.e. spinous process of a vertebrae) and the distances are calculated on both sides accordingly.
The third position involves the arms held at or below 90 degrees of flexion with maximal internal rotation at the glenohumeral joint. The threshold of abnormality is 1.5 cm and significant asymmetry is measured.

An essential part of scapula examination is the evaluation of the shoulder pathology or injury that could be causing or exacerbating the presence of scapula dyskinesis. Rotator cuff strength, labral stability and internal impingement should be examined as they may represent the underlying cause of scapula dyskinesis (6).

Rehabilitation

Clients tend to find scapula repositioning exercises challenging as they are unable to visualise the scapula and its posterior location on the thorax. It is possible that the lack of visual feedback leads to the alterations in motion to cause scapula dyskinesis. Repositioning the scapula prior to elevating and/or rotating the humerus, called conscious correction increases scapula muscle activity and enhances scapula kinematics (6).

1. Short lever progression

An example of short lever exercise application would be to begin with exercies that require the arms to be in an adducted position i.e. the arms position against the thorax rather than positions that require the arms to be elevated or abducted for exercise performance. These early interventions attempt to establish proper scapula positioning early in the rehabilitation and begin to utilise the major of kinetic chain segments to create the integrated muscle activation and sequencing.

Although they could be classified as short lever exercises, maneuvers such as scapula shrugging or elevation should be avoided in the first 4-6 weeks of rehabilitation (6). This is intentional to not overly bias the upper trapezius which could delay the restoration of balance amongst scapular muscle activation (6).

2. Sitting and standing preferred over prone or supine exercises.

3. Exercises that target impairments in the following order; mobility, motor control, strength and endurance.

4. Longer lever maneuvers in the rehabilitation program.

5. Advance to plyometric based maneuvers.

1kg Shoulder Circuit Example Below:

Progression into dynamic motions may include limited amounts of arm elevation or abduction (approximately 30-45°). Long lever exercises of 90° arm elevation or abduction in the later or last stages of rehabilitation can then be incorporated into the treatment program in the later phases of rehabilitation, but only when the previous maneuvers have been mastered by the patient and has demonstrated little to no symptom exacerbation (6).

Dosage recommendations include beginning with 1 to 2 sets of 5 to 10 repetitions with no external resistance. Additional sets and repetitions can be added based on symptoms and exercise tolerance, with a goal of 5 to 6 sets of 10 repetitions being able to be performed without an increase in symptoms before adding resistance (6).

Resistance may be added next with light free weights of 2 to 3 pounds as a maximum before progressing to elastic resistance.

Feedback is important throughout the rehabilitation phase from clinicians, however, Roche et al., (20215) note that too much feedback can be detrimental to learning as the patient becomes reliant on the knowledge of performance.

References

1. Hickey, D., Solvig, V., Cavalheri, V., Harrold, M., & McKenna, L. (2018). Scapular Dyskinesis Increases the Risk of Future Shoulder Pain by 43% in Asymptomatic Athletes: A Systematic Review and Meta-Analysis. British Journal of Sports Medicine , 52; 2: 102–110.

2. Kibler. W. B., Uhl T. L., Maddux. J. W., Brooks P. V., Zeller. B., McMullen. J. (2002). Qualitative clinical evaluation of scapular dysfunction: A Reliability Study. Journal of Shoulder and Elbow Surgery , 11; 6: 550–556.

3. McClure, P., Tate, A. R., Kareha, S., Irwin, I.,Zlupko, E. (2009) A Clinical Method for Identifying Scapula Dyskinesis, Part 1: Reliability, Journal of Athletic Training; 44; 2: 160–164.

4. Postacchini, R., Carbone, S. (2013) Scapula dyskinesis: Diagnosis and treatment, OA Musculoskeletal Medicine, 1; 2: 20.

5. Panagiotopoulos, A. C., Crowther, M. (2019) Scapula Dyskinesia, the Forgotten Culprit of Shoulder Pain and How to Rehabilitate, SICOT-J, 5; 29: 1-6.

6. Roche, S. J., Funk, L., Sciascia, A., Kibler, W. B. (2015) Scapula dyskinesis: the surgeon’s perspective, Shoulder and Elbow, 7; 4: 289–297.

7. Sanchez, H. M., Sanchez, E. G. de M. (2018) Scapula Dyskinesis: Biomechanics, Evaluation and Treatment, International Physical Medicine & Rehabilitation Journal, 3; 6: 514-520.

8. Sattasuk, W., Sitilertpisan, P.., Joseph, L., Paungmali, A., Pirunsan, U. (2021) A Clinical Evaluation of Scapula Dyskinesis Among Professional Bus Drivers With Unilateral Upper Quadrant Musculoskeletal Pain, Workplace Health and Safety, 69, 10: 460-466.

9. Sciascia, A., Kibler, W. B. (2022) Current Views of Scapular Dyskinesis and its Possible Clinical Relevance, International Journal of Sports Physical Therapy, 17; 2: 117-130.

Four Common Reasons For Running Injuries

Sat, 09 Mar 2024 12:19:11 GMT

From Couch-to-5k, Park Running To Marathon Runner

Common Running Injuries, Their Cause & Prevention Common Running Injuries, Their Cause & Prevention

A herd of long distance runners are planning to accomplish and complete an exceptional life-time achieving event; the marathon. Whilst we might be inside watching the latest Netflix episodes, marathon runners are busy adhering to weekly training programmes and getting their miles done during the crack of dawn, freezing temperatures, late nights, dark evenings and early mornings. Us none marathon runners can (understandably) find it difficult to imagine another life like this, stand bleary eyed with a hot mug in hand whilst rain is splattering against kitchen windows and a sensible thought bubble pops up saying; 'maybe tomorrow!' (for an outdoor exercise).

However, it can be guaranteed that there will be a committed marathon runner training in the fields or roads out there. Somewhere!

Ofcourse, the 'D' in 'D-day' may stand for various words for these runners including; 'delightful', 'daring', 'doom', 'dont-really-want-to-do-this-but-I- have-to-now', 'dreading', 'dream', or 'determined'. Whichever it is, marathon season is approaching and upon us! Stats are showing that the risk of recreational runners running into injuries are high with an overall prevalence of about 85% and an annual prevalence of nearly 50% (4).

Eradicating repetitive running injuries is unrealistic, but coaches and physical therapy practitioners can help educate recreational runners about the high prevalence of potential injury by encouraging risk-reducing measures, especially for those running greater distances and with performance motives (4).

The Couch-to-5k Programme

As Relph et al., (2023) highlight, it is a devastating statistic that only a quarter of adults globally meet recommended physical activity levels for health. Two common initiatives in the UK are Couch-to-5k which is an app-assisted 9-week walk/run programme and parkrun; a free, weekly, timed 5-km walk/run (2).

The World Health Organization (WHO) highlights that to achieve good health, they recommend that adults aged 18–64 years should participate in at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of vigorous-intensity aerobic physical activity, or a combination of moderate and vigorous-intensive activtiy throughout the week (3).

It is worth noting that exercise defined as 'vigorous intensity' is exercise that will make you out of breath and sweat! Statistics are showing that only one in four adults globally meet these recommended exercise guidelines (2).

In the UK, the National Health Service (NHS) promotes a running/walking initiative targeting physically inactive individuals called the Couch-to-5k. This is a nine-week progressive programme aimed to increase physical activity levels using a free downloadable mobile ‘app’ that people can use at a time that suits them (1). The programme involves three runs or walks per week, with one day of rest in between and the programme can vary from one week to another (1). Josh Clark, the creator, wanted to create a bridge between walking and running with participants gradually progressing to a 30-minute continuous run in their final week (1).

The Couch-to-5k programme is a great start for many novice runners. Relph et al., (2023) highlight how the potential group to be attracted to this regime are inactive women who aim to lose weight and are at a maturer, middle age.

A key finding of the study was a high level of dropout rate during the programme with mainly being linked to the programme’s progressive design and individuals suffering potential MSK injury.

They concluded that Musculoskeletal (MSK) injury prevention information should be provided for individuals at the start of the coach-to-5k programme, including strength and flexibility exercise and injury treatment options (3).

Park Runners

Parkrun is a weekly, free to enter, 5-km mass participation event delivered across 22 countries (parkrun. com) that has been taking place in the UK since 2004 and is used by General Practices in the UK and Ireland as a Public Health referral option (2). A parkrun can be completed by running, walking or a combination of both and attracts people of all ages and abilities including those with limited experience of running (2).

Couch-to-5k participants often go on to become integrated park runners by performing a median of 11 per year. A study by Relph and Taylor found that individuals tend to be less motivated by fitness, but rather improve their social connections. Parkrun appears to be an effective pathway for those on the Couch-to-5k programme and the association between the two running initiatives may be effective in increasing the number of females who take part in weekly physical activity (3).

It has been advised that injury-prevention measures for these individuals should include resistance training (RT), which may improve runners’ capacity to tolerate training loads (4).

Trail Running

Interestingly, the most common anatomical locations for repetitive running injuries are foot, ankle and knee related injuries. It is appreciated that for training reasons, many runners perform trail running which has been defined by Vincent et al., (2022) as a broad spectrum of running experiences that occurs off-road in the natural environment on surfaces with a maximum of 20% paving. Trail running includes running on various different surfaces and climates that may range from desert to mountain to forest environments and distances can range from 2 to 80+ kilometres (5).

Main reasons for injuries during trail running include loading and the different load Impact on joints. Compared to level running, downhill running produces greater vertical forces on the tibia, especially within the front and medial (anteromedial) aspects of the lower limb (5).

Injury Preventative Measures Trail Runners

To cushion impacts, Vincent et al., (2022) note that runners should work on improving their flexibility during knee and hip flexion along with plantarflexion of the foot which can improve the vertical alignment of the tibia, reduce ankle stiffness and increase knee stiffness. During trail runs, runners should train themselves for repetitive braking during downhill running as bone is weaker against shear forces and poorly controlled impact loading may contribute to an increased risk in stress fractures (5).

The rest of this post will be based on information given by Vincent et al., (2022) who provided the latest evidence of musculoskeletal injuries involved in trail running. The author here believes that their findings can be applied for flat and long distance runners, including marathon runners who often combine road and trail running as part of their training programmes towards 'the big day'. Vincent et al., (2022) found four key reasons for running injuries which are listed and discussed below.

1. Running Through Fatigue

Fatigue can alter a runner's biomechanics (the way that they move and run) and change muscular activity.

Fatigue tends to increase the stance time during the gait cycle which places mechanical stress on the musculoskeletal system.
In rear foot strikes; fatigue can increase the loading at the lateral and medial areas of the heel, first metatarsal and hallux and in lesser toes during push- off.
Among forefoot strikers, fatigue can increase the loading on the first to third metatarsals and the medial-lateral force ratio during stance and push-off phases.
Inability to control running motion increases the risk for motion errors, asymmetries and the capacity to evenly distribute forces throughout the foot and joints within the lower limbs.

Injury Prevention Tip:
Exercises that promote fatigue resistance, strength and conditioning programmes that incorporate resistance training may also help mitigate pain and injury progression (4, 5).

2. Abnormal Joint Motion

Forward trunk lean is associated with running injuries as this can encourage the pelvis to drop or create an anteriorised pelvic tilt which can lead to longer stance times and create recurrent calf strain injuries. This is also called a 'contralateral pelvic drop' and has also been associated with patellofemoral pain, ITB syndrome, medial tibial stress syndrome (or shin splints) and achilles tendinopathy. Mechanistically, pelvic drop increases ITB tension and compression at the femoral condyle and increases lateral displacement of the patella. Pelvic drop will also shift the ground reaction force vector medially and produce a bending force on the medial tibia.

Excessive pronation and lateral roll-off during the push off phase is related to lower leg pain with running. Injured runners have more peak rearfoot eversion than noninjured runners.

Injury Prevention Tips:

Rehabilitation should include exercises that target ankle and foot stability in all planes of movement, preferably coupled with unstable surface and balance elements.

Gluteus medius stabilisation and hip abductor-core muscle strengthening will help develop proximal control to counteract these issues (4, 5).

Down Hill Running

When planting the feet on the ground on steep decline slope terrain or a hilly uneven surface, near full knee extension need to be avoided and controlled along with neuromuscular valgus strains. This control involves maintaining normal hip adduction, knee abduction, lumbar and pelvic positioning control, ankle eversion during knee valgus forces and knee external rotation (5).

3. Muscle Stiffness

The musculoskeletal tissue complex of the lower extremities generate joint stiffness properties which is wanted to help store elastic energy during the stance phase of gait and the running cycle. The concentric forces help joints during the push-off phase and increased knee joint stiffness is created by eccentric contraction of the quadriceps muscles.

Muscles that become too tight, however, can reduce knee flexion flexibility and lead to injuring structures within the related joint.

High levels of stiffness within the knee joint can increase the risk of injury to the proximal anterior tibia.

Low stiffness levels or hypermobility within the knees, ankles or hip joints can contribute to soft-tissue injuries such as ACL sprain/ tear or Achilles tendonitis via excessive joint motion.

Bilateral differences in leg joint stiffness are related to leg injuries within the hamstrings, calfs, groin, ankles, and quadriceps whilst running. Some evidence suggests that elevated overall ankle, hip and knee stiffness can contribute to injuries within the Achilles tendon.

Excessive knee stiffness can also be corrected by shortening step lengths. Over-striding may occur amongst individuals with a higher body weight or novice runners. Slowing their progression rate and altering their training programmes might be a requirement.

Rehabilitation Tips:

Rehabilitation to develop appropriate joint and muscular stiffness with improved movement control include the encouragement of performing plyometrics, jump landings and eccentric muscle training (5).

4. Running Through (Noncritical) Chronic Pain

Runners with persistent musculoskeletal pain demonstrate altered compensatory biomechanics and loading at other anatomical sites. Runners who initially experience pain at one site can continue training tend to develop secondary pain(s) elsewhere (5).

Individuals with patello-femoral pain is related to less knee flexion and reduced pelvic drop on the unloaded side (causing a limp). Those with ITB pain and related muscle tension tend to have increased hip adduction during foot contact, medial knee rotation during the stance phase and knee abduction during the push-off phase compared to runners who do not have this pain (5).

Rehabilitation Tips:

Individuals need to make priority of listing the cause and reasons for what is continuing their chronic injury(s) and focus on performing an event specific rehabilitation program.

What Can Help?

Education About Musculoskeletal Pain For Runners in General (5)

Four key rules can be used to educate runners before an injury becomes serious. Pain affects up to 79% of runners, but many do not know how to interpret pain to determine continuation of training.

1) Running should be stopped immediately if pain increases during a run, or changes in quality from achy to a sharp pain.

2) Joint pain should not linger or increase by 24 hours after a run, as this indicates that the volume was excessive and should be scaled back

3) If pre-existing pain is present with more than 3 points reported out of a possible 10-point numerical pain rating scale, this pain should not increase during the run or persist into the next day.

4) Run-training should stop until pain-induced compensations disappear i.e. limping or hiking a hip.

Regular Massage

Regular sports or deep tissue massages can help reduce muscle tension and stiff joints, aid blood circulation and lymphatic drainage.

Exercise to help with biomechanics:

References

1. NHS. (2020) Couch to 5k: Week by Week. https://www.nhs . uk/live-well/exercise/get-running-with-couch-to-5k/ (last accessed 7 Mar 2024).

2. Relph, N., Owen, M., Moinuddin, M., Noonan, R., Dey, P., Bullas, A., Quirk, H. and Haake, S. (2023) How can UK public health initiatives support each other to improve the maintenance of physical activity? Evidence from a cross-sectional survey of runners who move from Couch-to-5k to parkrun , Health Promotion International, Oxford, 38: 1-9.

3. Relph, N., Taylor, S. L., Christian, D. L., Dey, P., Owen, M. B. (2023) Couch-to-5k or Couch to Ouch to Couch!?” Who Takes Part in Beginner Runner Programmes in the UK and Is Non-Completion Linked to Musculoskeletal Injury? International Journal of Environmental Research and Public Health , 20; 17: 1-17.

4. Stenerson, L. R., Melton, B. F., Bland, H. W., Ryan, G. A. (2023) Running-Related Overuse Injuries and Their Relationship with Run and Resistance Training Characteristics in Adult Recreational Runners: A Cross-Sectional Study , Journal of Functional Morphology and Kinesiology, 8, 128: 2-11.

5. Vincent, H., Broenstein, M., Vincent, K. R. (2022) Injury Prevention, Safe Training Techniques, Rehabilitation, and Return to Sport in Trail Runners , Arthroscopy Sports Medicine and Rehabilitation 4(1):e151-e162.

Whiplash Associated Disorder (WAD)

Wed, 07 Feb 2024 21:44:49 GMT

Diagnosis, Biomechanics & Physical Therapy Treatment Options.

What is a Whiplash Injury?

Harold and Crewe were the first to use the term whiplash in 1928. Motor vehicle collisions (MVC) are the greatest cause for whiplash injuries and is a rather large topic within the world of physical therapies. Approximately 50% of individuals will recover following a whiplash injury within the first 3 months post injury whilst a remainder of individuals will experience mild to moderate long-term disability (9).

Whiplash-associated disorders (WAD) was defined by the Quebec task force in 1995 as ‘an acceleration–deceleration mechanism of energy transferred to the neck, it is caused by rapid hyperextension or hyeprflexion of the patient's head from sudden acceleration or deceleration (13). It may result from rear-end or side-impact motor vehicle collisions, but can also occur during driving or other mishaps.'

Despite Quebec's definition, a whiplash injury can also result from a front-end collision, however, the majority of clinical research for whiplash injuries are based around rear impact MVCs. The impact of a MVC can result in bony or soft- tissue injury (whiplash-injury). Any damage or abnormal change in soft muscular or connective tissue caused by injury are referred to as soft tissue lesions (10). A WAD is generally considered an acute soft tissue injury of the neck with symptoms such as neck pain and stiffness, shoulder weakness, dizziness, vertigo, headache, memory loss and parasthesia in the upper extremities (10).

The Classification of Whiplash

The Quebec Task Force on Whiplash Associated Disorders classifies a WAD into four grades and is based upon the severity of a person’s symptoms and signs (7):

Grade 0: No complaints of neck pain and no physical signs.
Grade I: Complaints of pain in the neck, stiffness or tenderness only. No physical signs.
Grade II: Neck complaint and musculoskeletal signs including decreased range of motion and point tenderness.
Grade III: Neck complaint, musculoskeletal signs and neurological signs including decreased or absent deep tendon reflexes, muscle weakness and sensory deficits.
Grade IV: Neck complaint and fracture or dislocation.

Incidence

The incidence of a WAD in the UK averages to about nine per one thousand people, the highest in Europe. WADs are usually seen in rear-end, low-impact collisions in 90% of road traffic accident cases at speeds of 14 mph. Injuries occur when the trunk is forced back on the seat with hyperextension of the neck followed by a sudden forward recoil (28).

Risk

Women have thinner necks which increases their risk of whiplash. Other risk factors include individuals with short necks, car seats with a low neck rest and rear-end collisions involved with a third party heavy vehicle (28).

Car seats with an elastic back minimises the risk of neck injury after a car crash. Injury site in the majority of whiplash cases (by up to 60%) is within the zygapophysial facet joints within the neck at C2/C3 and C5/C6 levels rather than the muscles (28).

Significance

Does a Whiplash Associated Disorder Exist?

WADs have been considered to be a form of 'compensation neurosis', however, evidence suggests that whiplash injuries are real and that they are a potential cause of significant impairment (24).

A study by Aarnio et al., (2022) highlighted an important factor when it comes to WAD injuries is that; 'peripheral tissue damage can not be convincingly detected with current technologies' and the development of chronic symptoms after a whiplash injury can 'be influenced by psychological and social factors as well as changes in the central nervous system (CNS)'. They go on; 'difficulties to detect and diagnose biological contributors, together with the lack of an accepted concept for what causes the symptoms in WAD, represent considerable personal, societal, and economic problems' (1).

So, what does this mean clinically? Might it suggest that there is a lack of clinical evidence to diagnose a grade I and II (or possibly III) whiplash injury? Is the very concept of a 'WAD' for these particular grades ceasing to exist?

That last question is probably a bit melodramatic, but this post aims to answer these queries.

UK Cost

Research articles dating back to 2014 report that whiplash injuries cost the UK economy approximately £3.64 billion per year (8)! Despite the UK arguably claiming to have the safest roads in Europe, whiplash claims are also likely the highest. Fast forward on to another decade, one might assume that a few pounds can be added onto the above sum.

According to the Financial Times written in 2016, more than 800,000 small injury claims had been registered through the Ministry of Justice small claims track in 2015, of which 750,000 were estimated to be whiplash injury claims. The AA director at the time, Michael Lloyd, made the comment; “It’s little wonder that the UK is shamefully regarded as the whiplash capital of the world!” (8).

The Legal Crack Down!

To be put simply from otherwise lengthy legal jargon; the government brought forward a 'Whiplash Reform Programme' in May 2021 which was developed by the Ministry of Justice as part of the 2018 Civil Liabilities Act. Their main aim of the new whiplash reform was to reduce the number of fraudulent whiplash related claims for compensation (8).

As part of the reform, claimants must provide mandatory medical evidence and a ban has been made on settling whiplash claims without such evidence ever since (8).

Biomechanics of a WAD

Surprisingly, after searching around 'the biomechanics of the neck and body during whiplash injury', it appears that the medical research world has predominantly focused their attention on rear impact collisions only, despite the possibility of injury occurring during a side or front-end collision.

Although we can accept that neck injury is mostly regarded as resulting from rear end collisions, we should remind ourselves that almost one third (or approximately 27%) of all neck injuries occur from frontal impacts (16). It has been noted that there might be research papers on the biomechanics of the neck and body during the two other types of collisions.

However, none could be found in as much detail with what biomechanically happens during a rear impact collision. The focus here will be based around the biomechanics of the body during a rear impact MVC.

Biomechanics & Neck Movement During A Rear Impact Collision

Here helps support and confirm the existence of WADs, especially for rear impact collisions. The above image demonstrates four different phases that biomechanically happen to the head and neck during such an incident. Kinematics and kinetics have been studied using crash dummies, human cadavers, human volunteers and computer models (5).

During a typical rear-end MVC, injury is caused by abnormal biomechanics of neck motion. A study by Bogduk and Yoganadan (2001) illustrated the body's response after a rear-end impact collision and showed ten different phases that the body can go through from 0 to 400 milliseconds (ms) (5). The magnitude of the cervical spine dynamics and their timing vary between subjects in different vehicles and between different subjects in the same vehicle (5).

For the sake of simplicity, it is suggested that neck movement during a rear impact collision undergoes four main stages:

I. Normal phase: The cervical spine (neck) is held in a neutral position during seated posture. Kaneoka and Ono (2002) explain how during the time period between 0-40 ms of impact, the seat already begins to press the back of an individual and the spine begins to straighten.

However, cervical motion at this stage has not yet occurred, nor is there a muscular response within the neck (15).

II. S-Shape phase: This phase occurs almost immediately following rear-impact where the neck initially undergoes a horizontal shear force. Also known as the 'retraction' phase, the neck is 'drawn back' horizontally inward to create a 'S-shaped' curvature (5, 12).

Here, simultaneous upper cervical spine (UCS) flexion occurs along with lower cervical spine (LCS) extension to force the vertebrae within the neck to create an 'S-shape' (5, 12). Neural structures in the UCS and their capsular ligaments are at risk of injury during this phase from facet joint separation and UCS flexion (5, 12, 21).

According to Panjabi et al., (2004) the potential for injury is the greatest during the s-shape phase as injurious intervertebral rotations can occur prior to when the head contacts the head rest and before cervical musculature contraction occurs to protect the spinal region (which happens later) (21). Bogduk and Yoganandan (2001) highlight how the 'sigmoid' S-shape deformation of the cervical spine occurs at between 50 to 75 ms from MVC impact.

An outcome during the S-shape whiplash phase can create changes within the cerebrospinal fluid pressure and cause a spinal ganglia injury which can potentially create pain, increased sensitivity, numbness and muscle weakness (21).

III. Cervical Spine Extension: During this phase the mandible tends to maintain its position in space whilst the upper jaw (or maxilla) lifts up off an inert mandible to open the mouth (4). The cervical spine may fully extend by approximately 200 milliseconds into a C-shape curvature post impact (5). During the extension phase, the anterior structures of the cervical vertebral column can be strained i.e. the intervertebral discs, anterior longitudinal ligaments, pre vertebral muscles and oesophagus or larynx (4). The sternocleidomastoid muscles elongate during hyperextension and posterior structures of the neck vertebrae are subject to compression such as the zygapophysial joints and the spinous processes (4).

Bogduk (1986) emphasises how the head is not thrown backwards into extension as such, rather its movement is impacted by the trunk moving forwards during this phase. The torso tends to move in a forward and upward motion upon impact whilst the head lags behind as the result of inertia (21). Thus, the torso is responsible for creating the C-shape extension curvature and not the motion of the cervical spine alone. According to Bogduk (1986), injury of the neck is at its greatest risk during the extension phase as there are no anatomical structures to stop the head from extending beyond the limit of its natural range of movement.

IV. Cervical Spine Flexion: The head achieves its maximum forward excursion by 400 ms (4). Contact of the chin with the chest limits flexion of neck movement and prevents over flexion. During this phase, the vertebrae move within the natural range of motion (4).

Medical Imaging for Whiplash

As Johansson (2006) highlight, injuries from whiplash trauma are difficult to identify objectively and x-ray imaging typically does not reveal minor injuries. Diagnosis of whiplash trauma are particularly difficult for if injuries occur at the upper segments of the cervical spine. Studies have supported that injuries to this region can cause cervicoencephalic syndrome which can cause symptoms such as; sensitivity to light, tinnitus, poor concentration, dizziness, vertigo, headache, balance, visionary problems and fatigue (14).

PET & CT Imaging
Aarnio et al., (2022) investigated whether it possible to use an objective visualisation assessment of muscular tissue inflammation in WADs using [C]-D-deprenyl positron emission tomography (PET) scan and computed tomography (CT) imaging. Whiplash injury is associated with elevated production of inflammatory mediators and PET technology has been used to detect such inflammation in tissues (1).

Their study concluded to provide evidence that tissue injury and inflammation in whiplash injury can be objectively visualised and quantified using PET and CT imaging and suggested that lesions in peripheral tissue are respnosible for the development of persistent pain and disability in whiplash injuries.

MRI Scans

Although this research study is dated back to 2006, Johansson's (2006) study is extraordinary. If litigation whiplash cases amount to the tune of over three to four billion bucks per annum, one can only ask why there are not more detailed modern research case study articles alike.

Johansson studied three injured patients post MVC who had been examined and diagnosed with no structural lesions initially. One patient, 'Patient 1', was examined via MRI scan and the second patient was examined via 'radiological examinations'. The third, 'Patient 3', underwent clinical examinations at a university hospital with no further detail provided as to what methods were used during the examination process. Two patents were initially diagnosed with 'psychogenic' or 'psychosomatic' disorders and the other signed off as 'fit to work'.

What is interesting to note is that all three patients were not diagnosed with severe lesions during their acute phases of injury post MVC after clinical examination, but were diagnosed after two to several years post MVCs. Scar tissue had been discovered in all three case studies and all underwent surgery.

In 'patient 1', scar tissue was found around the odontoid process of C2 and around C1/C2 vertebrae which affected their rotational range of movement and instability was found at C0/C1 with ligamentous injury. It was also discovered that Patients 2 and 3 had scar tissue around the odontoid process of C2 and rotational movements of their heads made either the dens or scar tissue come into contact with their spinal cord. Diagnoses originally made were reclassed as 'severe' and all patients underwent cervical surgical fixation which eradicated their extreme symptoms.

Perhaps a warning for healthcare practitioners; should patients' symptoms persist despite having had medical imaging (via MRI) during the early stages post injury of a MVC with negative findings, a request for a review via MRI, PET or CT scanning is necessary.

Treatment Options & Management

Average Prognosis:
According to the NHS, symptoms of whiplash should begin to improve after a few days and significantly improve or completely diminish within one to four weeks in about 60% of cases (20). It can sometimes take a few months for the symptoms of whiplash to disappear completely and some people still have some neck pain and stiffness for a long time after the injury (20).

Wiangkham et al., (2015) concluded that conservative intervention can be effective for managing acute WAD (Type II) injuries in terms of pain reduction in the medium to long term. None invasive treatment inclusive of both physical and psychological components such as active mobilisation exercises, manual techniques, behavioural approaches and education seems to be a useful intervention (27).

Individuals at high-risk of non-recovery should receive referral to a specialist clinician with expertise in the management of WAD (32).

Cold Application Via Ice Treatment

It is advised to apply an ice pack (with a damp towel around to avoid burns) to the neck as soon as possible after the injury has occurred to help reduce inflammation, pain and swelling (20).

NB:
To avoid burns, do not apply ice directly on to skin. Wrap a damp towel around the ice pack to provide a protective barrier (20). Apply for approximately 5 - 10 minutes at a time (or to what you can tolerate within this time frame) and apply again after 20 to 30 minutes. Allow the limb to feel warm to the toucher or have a normal body temperature sensation again before reapplying.

Exercise

As NHS guidelines suggest that if pain within the neck is severe, then it is advised to rest the neck for 24 to 48 hours until the pain eases (21). Exercising the neck gently can help prevent the neck joints from becoming too stiff. Movements need to be performed very slowly and to the range that can be achieved within each direction to gradually increase range of movement.

Certain exercises, such as strengthening exercises can slow recovery when compared with simple mobilisation exercises. Remaining active is critical but attention is needed to ensure exercise programs are not too aggressive as more aggressive programs may reaggravate healing tissues (29).

Painkillers

The NHS advises that painkillers, such as paracetamol, can help ease the pain caused by whiplash. Taking painkillers regularly rather than only when the pain is severe, please read the instructions carefully and do not exceed the recommended dose (20).

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help reduce inflammation (swelling) within the neck, check first for which medications can be medically taken. If usual painkillers are not enough, the doctor can advise and may prescribe a stronger painkiller, such as codeine (20).

Posture

Maintaining a good, upright posture whilst sitting, standing and walking can help prevent the pain and stiffness within neck getting worse (20). Supporting the head with a firm pillow will help maintain a good sleeping posture (19).

Massage

From reading the research, massage therapists need to be experienced in this field with knowing where and when it is appropriate to apply soft tissue massage. For instance, it is not appropriate to apply massage to individuals with a type III or IV whiplash injury and instead need to be referred to either their general practitioner or emergency A & E department.

Research suggests that the application to WAD Type II injuries can reproduce symptoms when applied to the upper cervical spine muscles or even make symptoms worse (22).

A study by Griffin et al., ( 2019) concluded that there was a higher incidence of recovery at 3-months post injury in individuals who had received 'non-recommended (passive) treatments' mainly including massage and a fewer percentage receiving either chiropractic and osteopathy treatment. According to this study, 'evidence-based care (EBC)' i.e. with use of WAD specialists, including rehabilitation physicians, specialist physiotherapists, psychologists and occupational physicians was not significantly associated with recovery for WAD at 3 months post injury (11).

Exercise

Conlin et al., (2005) concluded that exercise alone does not improve ROM in patients with acute WAD and that gentle hands on mobilisation techniques are recommended for the treatment of pain and compromised cervical range of motion in the acute WAD patient.

Physiotherapy

From the literature read, phsyiotherapy can help provided that the correct exercises are prescribed. Strengthening or prescribing wrong exercises, especially during the early stages of recovery can make symptoms worse.

Osteopathy

A study by Parravicini and Ghiringhelli (2021)found that cranial osteopathy and soft tissue trigger point massage application to specific regions of the cranium such as the occiput, mastoid process and the temporal bone can help alleviate symptoms. Gentle joint mobilisation or passive joint movement techniques by the therapist's hands can help restore physiological cervical spine active range of movement (18). Spinal manipulations would be a contraindication and not performed especially during the acute (up to 4 weeks) or subacute phases (4 to 12 weeks).

Long-term problems arising from whiplash

In a small number of cases, the pain caused by whiplash can become chronic (long-term). In severe whiplash cases, the pain can last for more than six months before it disappears (19).

R oad Traffic Accidents & PTSD (Post Traumatic Stress Disorder)

Road traffic accidents can be a traumatising experience for any individual involved; more information and a useful guide by NST Law can be read here (19).

References

1. Aarnioa, M., Fredrikson, M., Lampa, E., So ̈rensene, J., Gordha, T., Linnman, C. (2022) Whiplash injuries associated with experienced pain and disability can be visualized with [11C]-D-deprenyl positron emission tomography and computed tomography , Pain, 163; 3: 489-495.

2. Alicia, T., Kapur, S., Mutagi, H. (2014) Whiplash Injury, Continuing Education in Anaesthesia , Critical Care & Pain, 14; 4: 167-170.

3. Bannister, G., Amirfeyz, R., Kelley, S., Gargan, M., Whiplash Injury; Review Article, The Journal of Bone and Joint Surgery , 91; 7: 845-850.

4. Bogduk (1986) The Anatomy and Patholophysiology of Whiplash: Review Paper, Clinical Biomechanics, 1:92-101.

5. Bogduk, N., Yoganandan, N. (2001) Biomechanics of the Cervical Spine Part 3: Minor Injuries [Review Paper], Clinical Biomechanics, 16:267-275.

6. Conlin A, Bhogal S, Sequeira K, Teasell R. (2005) Treatment of whiplash associated disorders. Part I: Non-invasive interventions . Pain Res Manage, 10 (1): 21-32.

7. Ferrari, R. (2002) Prevention of Chronic Pain After Whiplash , Emerg Med J, 19: 525-530.

8. Financial Times (2016)Whiplash Injury Payouts Face Government Crack Down https://www.ft.com/content/9e155cb6-ac18-11e6-9cb3-bb8207902122 [online].

9. Ghoryab, J. H. (2021) The nosological classification of whiplash-associated disorder: a narrative review , The Journal of the Canadian Chiropractic Association, 65; 1: 76-93.

10. García, D. V., Doorduin, J., Willemsen, A, T. M., Dierckx, R. A. J. O., Otte, A. (2016) Altered Regional Cerebral Blood Flow in Chronic Whiplash Associated Disorders , 10: 249-257.

11. Griffen, A., Jagnoor, J., Arora, M., Cameron, I. D., Kifleym A., Sterling, M.,Kenardy, J., Rebbek, T. (2019) Evidence-based care in high- and low-risk Groups following whiplash injury: a multi-centre inception cohort study, BMC Health Services Research, 19: 806.

12. Hai-bin, C., Yang, K. H., Zheng-gun, W. (2009) Biomechanics of Whiplash Injury, Chinese Journal of Traumatology, 12; 5: 305-314.

13. Ivancic, P. C., Ito, S., Tominaga, Y., Rubin, W., Coe, M. P., Ndu, A. B., Carlson, E. J., Panjabi, M. M. (2008) Whiplash Causes Increased Laxity of Cervical Capsular Ligament, Clinical Biomechanics, 23: 159-165.

14. Johansson, B. H. (2006) Whiplash Injuries Can be Visible By Functional Magnetic Resonance Imaging: Case Report, Pain Res Manage, 11; 3: 197-199.

15. Kaneoka, K., Ono, K., Inami, S. et al. (2002) The Human Cervical Spine Motion During Rear Impact Collisions: A Proposed Cervical Facet Injury During Whiplash Trauma, J. Whiplash Related Disord, 1; 1: 85-97.

16. Kullgren, A., Krafft, M., Nygren, A., Tingvall, C. G. (2000) Neck injuries in frontal impacts: Influence of crash pulse characteristics on injury risk, Accident Analysis & Prevention, 32; 2: 197-205.

17. Lee, S-H., Park, S-Y., Heo, I., Hwang, E-H., Shin, B-C., Hwang, M-S. (2023) Efficacy of acupuncture for whiplash injury: a systematic review and meta- analysis, BMJ Open, 14: 1-10.

18. McClune, T., Burton, A. K., Waddell, G. (2002) Whiplash associated disorders: a review of the literature to guide patient information and advice , Emerg Med J., 19: 499-506.

19. NSTLaw: PTSD & Car Accidents [Online] Last viewed 29/07/2024, Link: https://www.nstlaw.com/guides/ptsd-and-car-accidents/

20. NHS Royal Berkshire: NHS Foundation Trust, Neck Injury (Whiplash / Neck Sprain)

21. Panjabi, M. M., Pearson, A. M., Ito, S., Ivancic, P. C., Wang, J-L. (2004) Cervical Spine Curvature During Simulated Whiplash, Clinical Biomechanics, 19: 1-9.

22. Parravicini, G., Ghiringhelli, M. (2021) Osteopathic Cranial Manipulation for a Patient With Whiplash-Associated Disorder: A Case Report , J Chiropractor Med., 20; 3: 163-169.

23. Peolsson, A., Hermansen, A., Peterson, G., Strid, E. N. (2021) Return to work a bumpy road: a qualitative study on experiences of work ability and work situation in individuals with chronic whiplash-associated disorders, BMC Public Health, 21; 785: 1-11.

24. Pho, C., Godges, J. (2004) Management of Whiplash-Associated Disorder Addressing Thoracic and Cervical Spine Impairments: A Case Report , Journal of Orthopaedic & Sports Physical Therapy, 34;9: 511-523.

25. Ronnen, H. R., Korte, P. J. de., Brink, P. R., Bijl, H. J. van der, Tonino, A. J., Franke, C. L. (1996) Acute whiplash injury: is there a role for MR imaging?- a prospective study of 100 patients, 201, 1.

26. Schofferman, Bogduk, N., J., Slosar, J. (2015) Chronic Whiplash and Whiplash-Associated Disorders: An Evidence- Based Approach, Journal of the American Academy of Orthopaedic Surgeons: 596-606.

27. Sterling, M. (2014) Physiotherapy management of whiplash-associated disorders (WAD) , Journal of Physiotherapy, 60: 5-12. *

28. Sterling, M., Vincenzino, B., Souvlis, T., Connelly, L.B. (2015). Dry-needling and exercise for chronic whiplash-associated disorders: a randomized single-blind placebo-controlled trial. Pain, 156, 635 – 643.

https://recover.centre.uq.edu.au/article/2018/04/popular-whiplash-treatment-less-effective-previousl...

29. Tameem, A., Kapur, S., Mutagi, H. (2013) Whiplash Injury, Continuing Education in Anasethesia, Critical Care and Pain: 1-4.

30. Teasell, R. W., McClure, J. A., Walton, D., Pretty, J., Salter, K., Meyer, M., Sequeira, K., Death, B. (2010) A Research Synthesis of Therapeutic Interventions for Whiplash-Associated Disorder (WAD):Part 2 – interventions for acute WAD, Pain Res Manage, 15; 5: 295-304.

31. Watson, E. D., Coopoo, Y. (2010) Popular physical therapy modalities in the management of whiplash-associated disorders, SAJSM, 22; 4: 95-98.

32. Wiangkham, T., Duda, J., Haque, S., Madi, M., Rushton, A. (2015) The effectiveness of conservative management for acute whiplash associated disorder (WAD) II: a systematic review and meta-analysis of randomised controlled trials. PLoS One.; 10.

Spinal Degenerative Disc Disease

Sun, 28 Jan 2024 15:46:42 GMT

Condition, Anatomy and Management

Introduction
Degenerative disc disease (DDD) is not a disease but a condition that usually occurs over time from ageing. The degeneration of intervertebral disc tissue starts earlier than the degeneration of other muscular and skeletal tissue (9). Interestingly, degeneration is likely to start almost ten years earlier in men than women, but women with disc degeneration are likely to be more susceptible to the effects e.g. malalignment and instability (9).

Statistics show that approximately 20% of individuals within their teenage years may show signs of mild disc degeneration and approximately 10% of individuals show severe disc degeneration in their 50's (9). The percentage rate of severe degenerative disc disease climbs to approximately 60% in 70-year olds (9). These statistics show that maintaining the health of our spine as we age is extremely important.

The Intervertebral Disc

Functions of the Intervertebral Discs
The intervertebral discs make up one fourth of the spinal column and can be described as pads of fibrocartilage-based structures found between each vertebral body within the spine (3). They are important for the following reasons:

Connecting the vertebrae and providing spinal mobility for the movements of bending and rotating (1).
Providing support, flexibility and minor load-sharing (3).
Shock absorption between vertebrae.
Help mechanical stresses to be transmitted throughout the spine during movement from the lower limbs into the neck and skull (1).

Disc Anatomy

The intervertebral disc is composed of two parts; an outer strong ring called the annulus fibrosus that surrounds a soft gel-like inner substance called the nucleus pulposus consisting of 80% to 85% of water in normal/ non pathological cases (1).

Disc Herniation/ Prolapse

Disc herniation results when there is disruption to the disc structure, mainly from tearing of the annulus fibrosis to create a protrusion of the inner nucleus pulposus against the annulus fibrosis. This creates pressure to the spinal cord or nerve root resulting to radiating pain and create specific locations of weakness within the lower back and limbs. Over 90% of herniated discs appear at segments L4/L5 and L5/ S1 (4). This compression can produce radiculopathy or referred neurological pain, muscular weakness, altered sensations (paresthesia) and the difficulty of controlling specific muscle movements especially within the the back of the leg and at front of the foot (4).

There are several causes for annual tears including (10):

Degenerative Disc Disease: The spinal discs degenerate via wear and tear to cause fluid loss and a reduction in disc height, leading to a loss of spinal flexibility and increase the risk for disc tear.

Bone Spurs: Bone spurs are boney nodules that form within the endplates of the vertebra as a result of inflammation and can cause annular tears if they extend into the disc space.

Trauma: Traumatic injuries such as sports collisions, car accidents and falls can cause damage to a spinal disc.

Overuse: Repetitive, heavy lifting and occupations that place chronic strains on the back e.g. sports, nursing, or trading jobs that require heavy lifting can cause annular tears.

Genetics: Genes often determine the strength and quality of muscle collagen which is otherwise the substance that makes up the annulus. Poor cartilage production or inferior collagen can increase risk of annular tears.

It is interesting to note that the thickness and intensity of different parts of the annulus fibrosis (AF) is different. The posterior aspect of the lumbar intervertebral disc is thinner and there are no collagen fibres interwoven which lowers the tissue intensity and explains why disc herniation often occurs at the back of the intervertebral disc (13).

'Degenerative Disc Disease'

Most intervertebral disc degenerations are asymptomatic with that patients can have the problem diagnosed from scans but not experience pain. The absence of a diagnosis via relevant medical imaging via i.e. Magnetic Resonance Imaging (MRI) can prove difficult for physical therapy practitioners to manage.

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

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

Biochemistry

The biochemistry of disc degeneration indicates that enzymatic activity contributes to this disorder by causing increased fragmentation of collagen, proteoglycan and fibronectin within the disc (13). Several families of enzymes are capable of breaking down the various matrix molecules within the disc, including cathepsins, MMPs and aggrecanases (13).

The most significant biochemical change to occur in disc degeneration is a loss of proteoglycan protein and collagen Type II. Aggrecan is the major proteoglycan of the disc and responsible for maintaining tissue hydration through the osmotic pressure provided by chondroitin and keratan sulphate chains (13). The proteoglycan and water content of the nucleus is greater than in the annulus (13).

Proteoglycan loss reduces the capacity of tissues binding to water leading to a loss of hydration within the disc and decreases intervertebral joint load-bearing (13). Proteoglycan loss causes the osmotic pressure of the disc to fall and the disc less able to maintain hydration under load (13). Degenerative discs have a lower water content than other age-matched discs within the spine which accelerates the rate of fluid loss, reduces disc height and creates a higher risk for discs to bulge (13).

Loss of proteoglycan and extracellular matrix disorganisation have an important mechanical effect within the disc with that the subsequent loss of hydration means that the degenerated disc is no longer able to behave hydrostatically under load (12). Loading may lead to inappropriate stress concentrations along the end-plate or within the annulus (12).

The Pfirrmann Grading System (4):

The Pfirrmann Grading System is a five graded system for practitioners to use for the assessment of lumbar disc degeneration with subtle changes seen within grades I-III, a moderately reduced disc height might be seen in grade IV and a collapsed disc space observed in grade V (4).

Modified Eight Graded Pfirrmann System
Griffith et al., (2017) encourages the idea for health practitioners to use a modified eight graded Pfirrmann system for the assessment of disc degeneration within the elderly spine. This can help discriminate the severity of disc degeneration in more depth and detail. Grade I corresponds to having no disc degeneration, while Grade 8 represents a severe or 'end-stage' degeneration. A grading system in Table 1 of their study was devised and showed how the disc space height is more visibly lost between Grades, 6, 7, and 8 and is broadly classified as 'mild', 'moderate', to 'severe' (loss of disc space height) between these grades (6).

Can This Create Nerve Irritation?
Progression can cause the disc to bulge and create pressure and irritation to neighbouring spinal nerves. This can lead to individuals experiencing tingling (paraethesia) into the limbs of the body such as the arms and fingers for if the region is affecting areas of the neck or buttock, thigh and/ or toes for if occurring within the lower back (12).

Recent studies have shown that atrophy and muscle weakening can gives rise to disc degeneration and cause pain and instability within the spine. The ageing process for degenerative disc disease can cause mobility issues and a reduced spinal shock-absorbing capability. Research has found disc degeneration and lumbar multifidus muscle atrophy to be commonly correlated, particularly at spinal disc levels L3-L4 (5).

Possible Causes

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

Trauma such as accidents
Sudden weight loss
Hereditary cause

Smoking & Lifestyle Choices:
Smoking creates various negative effects to the musculoskeletal system by lengthening the healing time of tissues post injury or trauma. Smoking will hinder disc healing as tissue oxygenation is reduced and cellular metabolism is disrupted.

Tissue hydration is compromised; the production rate of proteoglycans is reduced which otherwise provides hydration and swelling pressure to the disc tissue to help withstand compressional forces (14).

Nicotine causes elevated levels of pro-inflammatory cytokine protein TNF-α which prolongs pain states (7). Because smoking or vaping increase and hinder tissue healing and elevate pain levels, orthopaedic surgeons are reluctant to operate.

Diagnosis

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

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

Osteopathy Perspective - Posture and Biomechanics
In osteopathy, the somatic dysfunction (SD) addresses abnormal posture and biomechanics (the way we move). As Kessler et al., (2021) highlight, this can start a pathological cascade of degenerative disc disease and annular tearing as this can limit active range of motion and cause asymmetric loading within neighbouring joints.

Treatment and Management

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

Physical therapy is the preferred method for treating individuals with DDD and therapists mainly aim to strengthen neighbouring muscles around the affected joints. Before 'hands on' Spinal Manipulation Therapy (SMT)' can be considered as a treatment option, patients will need to be screened for possible serious pathology.

Osteopathy

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

Dynamic Lumbar Stabilization Program (DLSP)

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

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

Spinal Exercise Example:

Exercise Prescription

Exercises aims to improve the coordination between the abdominal and back muscles. The above exercise aims to help improve range of motion of the hips and knees, reduce stiffness within the spine and improving the body's mobility to roll to one side whilst in bed.

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

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

Cell Based Therapies

Experiments have been conducted to demonstrate the potential use of of cell-based therapies, however, several barriers prevent the use of these treatments clinically.

The aim of these therapies is to achieve cellular repair of the degenerated disc matrix and one approach has been to stimulate the disc cells to produce more matrix with the use of growth factors which can increase the rate of matrix synthesis by five fold (13). In contrast, cytokines lead to matrix loss as they inhibit matrix synthesis by stimulating the production of agents that encourage tissue breakdown.

However, the injection of growth factors or 'cytokine inhibitors' has not been successful as their effectiveness in the disc is short-lived.

Genetherapy is also being investigated with the aim of maintaining high levels of relevant growth factors or inhibitors within the disc tissue. In this form of therapy, the gene of interest i.e. the one responsible for producing a growth factor such as transforming growth factor-β or inhibiting interleukin-1, is introduced into target cells which then produce relevant proteins (13).

However, this therapy is still not successful for clinical use. The delivery of the genes into human disc cells still remains to be a problem along with an improved understanding for the pathogenesis of degeneration within tissues for the correct choice of therapeutic genes to be applied (13). In addition, the cell density within a normal human disc is low and many of the cells in degenerate discs are dead, thus stimulation of the remaining 'living' cells may be insufficient to repair the extracellular matrix (13).

Nevertheless, when discoverd, this one day could be the future for treating the degenerative disc.

Surgery

Surgical intervention should be reserved for those with either neurologic deficits, degenerative spondylolisthesis, or pain limiting daily functions (4) . Operative intervention of the lumbar spine include discectomy with fusion, total disc replacement or by immobilisation of the affected vertebrae (4). Surgery is offered only to one in every 2000 back pain episodes in the UK; the incidence of surgical treatment is five times higher in the USA (12).

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Role of Gluteus Maximus & Injury Prevention

Thu, 28 Dec 2023 06:39:53 GMT

Significance, Postural Control, Related Pathology & Treatment

The Gluteus Maximus

Colloquially known as the 'glute max', the gluteus maximus (GM) muscle is the largest and strongest muscle in the human body (3). It is also the most superficial of the three gluteal muscles. The GM is prone to weakness and inhibition which has been known for the cause of numerous injury types in chronic pain (3). Knowing how to use this powerful muscle to its optimum can help prevent the occurrence of lower back pain and multiple injuries.

Functions of the GM muscle are extension and external rotation of the thigh at the hip joint, it is a chief antigravity muscle that helps keep the trunk of the body in an erect posture. Proper activation of the GM during daily activity such as walking and stair climbing can greatly reduce forces acting on the knee joints (5).

After researching around the topic of Gluteus Maximus atrophy, 'dead butt syndrome (DBS)' and 'gluteal amnesia' popped up in the search. Thankfully, a useful source by Gharib (2020) highlighted how there are no reliable articles or credible medical sources available on these so called 'conditions'. They concluded that 'DBS' does not exist, it is neither a true medical diagnosis nor medical concern (6).

However, what is evident is the possibility that an individual may have a reduced sensation upon contraction of the GM, have some difficulty maximally contracting the glutes or produce gluteal atrophy (6).

The GM acts as a stabiliser during movement during trunk rotation and stabilises the pelvis during single leg stance. It reduces adduction and internal rotation of the femur and helps prevent the trunk to forward lean during movement (3).

Should a New Year’s Resolution be made this 2024 year, it might be to strengthen and focus on optimising the use of one's Gluteus Maximus!

Anatomy

The GM originates from the posterior sacrum and coccyx, the posterior gluteal line of the ilium and inserts on the iliotibial tract and gluteal tuberosity of the femur. The GM is a powerful extensor and external rotator of the hip and the superior part of the GM acts as a hip abductor as muscle fibers in the GM are directed downward and outward (8).

Hip extensors, especially the GM, are important for many functional activities of daily living such as moving from sitting to standing, climbing stairs, and maintaining an upright posture during walking (8). Because the direction of the GM muscle fibers, especially deep sacral fibers of the GM, are perpendicular to the sacroiliac (SI) joint, GM contraction improves SI joint stability and plays a part in force transmission from the lower extremity to the pelvis during ambulation (8).

The sciatic nerve enters the gluteal region, more specifically it passes below (or occasionally through) the piriformis muscle in the form of ‘flattened band’. The sciatic nerve then passes ‘deep’ to the gluteus maximus, but does not supply any structures within the gluteal region before entering the posterior compartment of the thigh and travels down between adductor magnus and biceps femoris. The sciatic nerve splits into the common peroneal nerve and tibial nerves within the popliteal fossa at the back of the knee (8).

Pathology From Glute Maximus Inactivity

Weakness of the Gluteus Maximus has been implicated in numerous injury types such as patella femoral pain syndrome (PFPS) or anterior knee pain, anterior cruciate ligament injuries (ACL), lower back pain, hamstring strains, hip (femoral acetabular) impingement syndrome and ankle sprains (3). GM muscle weakness or dysfunction may be a contributing risk factor to or the result of injury (3).

Causes for GM Dysfunction - Lifestyle

Lifestyle factors significantly contributes to the reduced activity of the GM. Prolonged sitting causes the GM to be frequently weakened and lengthened increasing the risk of lower back pain (LBP) and sacroiliac (SI) joint instability and dysfunction. The body compensates by tightening the hamstring (HAM) muscles all because of the weakening of the GM. An excessive anterior pelvic tilt, lumbar lordosis with dominant erector spinae (ES), and lumbar rotation occur in place of a weak GM or delayed GM activation during hip extension (4).

Overtime the GM will atrophy and weaken causing the body to rely on the secondary hip extensor muscles such as hamstrings and hip adductors to produce hip extension torque clinically referred to as 'synergistic dominance' (3).

Altered Posture

An altered posture of the pelvis can influence the length-tension relationship of the GM. Quite often an anteriorised pelvic tilt is created during stance and gait which can cause hip flexors to tighten and local core weakness further elongating the GM (Buckthorpe, 2019).

The Glute Max and Patella Femoral Pain Syndrome (PFPS)

According to a systematic review by Barton et al., (2012), delayed and shortened duration of gluteaus maximus muscle activity may exist in individuals with PFPS, which can cause swelling and pain at the front or medial knee joint. They also found that there is moderate to strong evidence that gluteus medius muscle activity is delayed and of shorter duration during stair ascent and descent in individuals with PFPS.

It is worth noting that Gharib (2020) concluded that delayed ‘ activation’ of the gluteal muscles is not necessarily exclusive to cause individuals lower back pain.

The Sacroiliac Joint

Weakness of the gluteus maximus can be related to abnormal loading of the SI joint and cause impairments associated with SI joint dysfunction. Anatomical studies suggest that the gluteus maximus can contribute to stabilising the SI joint with muscle fibers being perpendicular to the joint surfaces. Activation of the gluteus maximus was found to increase compressive forces across the SI joint (1). A study by Aurelio et al. (2018) found that subjects with persistent pain in the lumbopelvic region and whose clinical tests were positive for SI joint dysfunction demonstrated gluteus maximus weakness.

Men and Women and The Glute Max

A study by Vannatta and Kernozek (2021) found that males and females demonstrate differences in gluteal muscle forces and hip kinetics (motion) whilst running. Males produced greater peak gluteus maximus forces, but less gluteus medius, minimus, and hamstring forces than females during running. They also found that males demonstrated less hip adduction and greater hip flexion and anterior pelvic tilt than females. Meanwhile, healthy females demonstrate greater hip internal rotation and adduction motion whilst running. Females with ITBS demonstrated greater hip external rotation.

Females may have to generate greater gluteal medius and minimus muscle forces to meet the requirements imposed by their anatomy of having greater femoral adduction with relation to the positioning of the hip joint (10). This implies that females may utilise a different muscular strategy to generate hip extension and external rotation of the femur than males (10).

It was found that females produced a similar hip extension moment as males despite a reduction in peak gluteus maximus force whilst running. Thus, females may utilise a preferred pattern of hamstring force for hip extension rather than use muscular forces generated from the gluteus maximus (10).

PFPS - Single Leg Squat

Nakagawa (2019) found that males and females with PFPS showed increased ipsilateral trunk lean, contralateral pelvic drop, hip adduction, and knee abduction during a single-leg squat. These altered kinematics (or active motion techniques) were accompanied by reduced strength of the hip abductors and external rotators i.e. gluteal muscle. Additionally, in contrast to males, females with PFPS showed increased hip internal rotation and reduced gluteus medius activation during a single-leg squat (9).

Strength & Resistant Exercises

There is preliminary evidence that skill training and helping individuals understand better biomechanics during movement i.e. during gait/walking and running, as opposed to strength training, improves activation of the gluteus maximus and leads to the development of a biomechanics strategy to reduce loading of the knee joint (5).

Bridging exercises are the most commonly used by people with weak hip extensors and trunk muscles in physical therapy programs.

However, bridging exercises are associated with a risk of dominant hamstring and erector spinae muscle activity and excessive anterior pelvic tilt as a compensation for gluteus maximus muscle weakness regardless of the type of bridging exercise performed (4).

A study by Choi et al., (2015) studied the effect of isometric hip abduction (IHA) with the thera-band during gluteus maximus muscle activity and pelvic kinematics (or study of motion) during a bridging exercise. They found that gluteus maximus activity increased significantly (by 21.1%) during bridging with isometric hip abduction using a theraband. Applying IHA with a theraband during bridging and maintaining hip abduction with activation of the GM in advance before initiating the bridging movement consequently increases GM muscle activity.

Pilates and yoga exercises can help strengthening the lumbopelvic muscles which has been shown to improve lower back symptoms. Lumbopelvic stabilisation exercises have shown to be effective methods of pain management in chronic lower back pain patients as it has shown to improve pelvic stability through muscle strengthening and the ability to improve movement (6).

Hip and pelvis muscle strengthening exercises (glutes included) in addition to lumbar stabilization exercises increase hip joint stability, pelvic stability and increased range of motion, which is conducive to increasing strength and positively affecting low back symptoms (6).

Seated Gluteal Stretch:

References

1. Aurélio, M. N., de Freitas , D. G., Kasawara , K. T, Martin , R. L., Fukuda , T. Y. (2018) Strengthening the Gluteus Maximus in Subjects with Sacroiliac Dysfunction, Int. Journal of Sports Physical Therapy, 13 (1): 114-120.

2. Barton, C. J., Lack, S., Malliaras, P., Morrisey, D. (2013) Gluteal Muscle Activity and Patellofemoral Pain Syndrome: A Systemic Review, J Sports Med, 47: 207-214.

3. Buckthorpe, M., Stride, M., Villa, F. D. (2019) Assessing and Treating Gluteus Maximus Weakness - A Clinical Commentary, Int. Journal of Sports Physical Therapy , 14 ;(4): 655-669.

4. Choi, A-A., Cynn, H-S., Yi, C-H., Kwon, O-Y., Yoon, T-L.,Choi, W-J., Lee, J-H. (2015) Isometric Hip Abduction Using a Thera-Band Alters Gluteus Maximus Muscle Activity and the Anterior Pelvic Tilt Angle During Bridging Exercise; 25: 310-315.

5. Fisher, B. E., Lee, Y-Y., Pitsch, E.A., Moores, B., Southam, A., Saw, T. D., Powers, C. M. (2013) Method for Assessing Brain Changes Associated With Gluteus Maximus Activation , Journal of Orthopaedic & Sports Physical Therapy, 43; 4: 214-221.

6. Gharib, S. (2020) Dead Butt Syndrome: Is It Real? https://www.researchgate.net/publication/346108868_Dead_Butt_Syndrome_is_it_real [online], last visited 28/12/2023.

7. Lewis, C. L., Foley, H. D., Lee, T. S., Berry, J. W. (2018) Hip-Muscle Activity in Men and Women During Resisted Side Stepping With Different Band Positions , Journal of Athletic Training, 53,;11: 1071-1081.

8. Meena, R., Doddamani, R. S., Singh, S., Singh, P., Agrawal. (2021) Exploration of Sciatic Nerve in the Gluteal Region: Transgluteal vs Infragluteal Approach, J Peripher Nerve Surg., 5: 34-37.

9. Nakagawa, T. H., Moriya, E. T. U., Maciel, C. D., Serão, F. V. (2012) Trunk, Pelvis, Hip, and Knee Kinematics, Hip Strength, and Gluteal Muscle Activation During a Single-Leg Squat in Males and Females With and Without Patellofemoral Pain Syndrome , Journal of Orthopaedic and Sports Physical Therapy, 42, 6: 491-501.

10. Vannatta, C. N., Kernozek, T. W. (2018) Sex Differences in Gluteal Muscle forces During Running, Sports Biomechanics, 20; 3: 319-329.

Osteoarthritis - 'Wear and Tear' in Joints

Wed, 22 Nov 2023 00:00:00 GMT

The term 'wear and tear' is used to refer to joints with arthritis. Osteoarthritis is a degenerative condition of the articular joints and presents in more than one joint within the body. The condition affects each individual differently by causing no symptoms at all but signs are present or cause a gradual change to how joints and muscles feel, especially during specific times of the day. Approximately 80% of older adults at the age of 55 years and older have evidence of osteoarthritis on X-ray and of these an estimated 60% experience symptoms (8). Post-menopausal women have an increased incidence of knee osteoarthritis compared to men (6, 9).

The most commonly affected joints are:

Knees - Knee osteoarthritis is more usual in older and obese populations with the epidemicity of knee osteoarthritis in females ( 10.3 % ) being higher than that in males ( 5.7 % ) (7).
Neck
Lower back
Hands and fingers

The symptoms of the condition depend upon the severity of the condition but they may include:

Pain
Stiffness
Joint swelling
Crepitus or crunchy grinding sound of the joint

Primary & Secondary OA

Osteoarthritis is also known as degenerative joint disease (DJD) that creates joint stiffness and pain (NHS). In the UK approximately one in 10 adults aged 20 years or older have symptomatic GP clinically diagnosed OA, with the knee joint being the most prevalent (9).
There are two main types of osteoarthritis:

Primary OA: Most common form with no known (idiopathic) cause and primarily affects the fingers, thumbs, spine, hips, knees, and big toe.
Secondary OA: Occurs with a pre-existing joint abnormality or be caused by injury or trauma from repetitive strain from e.g. a manual job or sports-related activity. Inflammatory arthritis is another example such as r heumatoid , psoriatic , or gout ; infectious arthritis; genetic joint disorders, such as Ehlers-Danlos (also known as hypermobility or "double-jointed"), congenital joint disorders or metabolic joint disorders (9).

Interestingly, the incidence of OA may differ geographically within the UK with Scotland and the middle regions of England having a higher incidence compared to the rest of the country (8). The reasons for regional variation could be differences in socio-economic conditions, lifestyles and health activity behaviours. A higher prevalence of OA in the Northern regions largely matched the obesity distribution of the UK compared to the South which is a risk factor for the deverlopment of OA (9).

Who is at Risk For Developing Osteoarthritis?

Main risk factors that increase the chance of developing osteoarthritis:

Obesity - Obese men and women are 4 to 5 times more at risk of developing OA within the knee.
Diabetes
Hyperlipidemia (high cholesterol and elevated lipids)
Low estrogen levels as experienced by post-menopausal women
Genetics: hereditary conditions such as Ehlers-Danlos syndrome or joint hypermobility can contribute to OA.
Abnormal biomechanics
Smoking - studies showing strong evidence that smoking is positively associated with the prevalence of OA (8).

What Is Considered Good Exercise to do For Osteoarthritis?

Activities that maintain flexibility, muscle strength, and coordination protect the cartilaginous surfaces and help to maintain joint function in joints that have already been injured and in which arthritic changes have developed or are developing. The forms of exercise that meet these criteria include bicycling, weightlifting (with emphasis on closed-kinetic-chain exercises) and pool exercises.

The Weather & Osteoarthritis

Weather conditions appear to be associated with OA pain, however, studies tend to be inconclusive or have inconsistent findings (9). For the specific meteorological condition, quantitative analysis showed a moderate correlation between OA pain and temperature or Barometric pressure, with relative humidity has a weak correlation.

One study found there to be no association between rainfall on the day of the appointment or rainfall during the week or preceding week and proportion of joint and back. This was concluded after having analysed millions of outpatient appointments and visits of older Americans aged over 65 years old during 2008- 12 including those with rheumatoid arthritis (4).

Diet & OA

There are various studies that conclude A high fat diet exacerbates the progression of osteoarthritis in mice metabolic changes and systemic inflammation brought about by a high fat diet (HFD) appear to be key players in the onset and progression of OA (7).

Several studies show that obesity causes certain metabolic factors that induce the release of specific cytokines (proteins that help control inflammation), such as IL-6, CCL2 and IL-8, proinflammatory adipokines (cytokines produced via adipose tissue) nitric oxide, and metalloproteinases that contribute to the degradation of joint cartilage (1).

There seems to be a mixed view on whether statins can help the development of osteoarthritis, although most studies have found a significant reduction in the risk of developing OA and a reduced risk of radiographic progression in statin users vs. non-users (4).

How Physical Therapy Can Help

Conventional treatments for OA include nonsteroidal anti inflammatory (NSAIDs) drugs and COX inhibitors, moderate exercise such as walking, light weights and aerobic activity and eventually surgery to repair joints.

Massage Therapy

Massage therapy may diminish symptoms and improve the course of OA by increasing local circulation to the affected joints, improve tone of supportive musculature, enhance joint flexibility and relieve pain (10).

A study by Perlman (2018) concluded that 8 weeks of massage provided a statistically and clinically significant improvement of osteoarthritic symptoms by reducing pain, stiffness, timed 50-foot walk and improving physical function compared to a control group in adults with knee osteoarthritis.

References

1. Baures, M. B., Ivorra, I. M. (2019) Mediterranean Diet and Osteoarthritis, Reumatol Clin., 15:125–126.

2. Cleveland Clinic https://my.clevelandclinic.org/health/diseases/5599-osteoarthritis [online] last visited 1/10/2023.

3. Heidari, B., Babaei, M., Yosefghahri, B. (2021) Prevention of Osteoarthritis Progression by Statins, Targeting Metabolic and Inflammatory Aspects: A Review, Mediterr J Rheumatol., 32 (3): 227-236.

4. Jena, A. B., Olenski, A. R., Molitor, D., Miller, N. (2017) Association Between Rainfall and Diagnoses of Joint or Back Pain: Retrospective Claims Analysis, BMJ: 1-4.

5. Perlman , A., Fogerite , S. G., Glass ,O., Bechard , E., Ali , A., Njike , V. Y. (2019) Efficacy and Safety of Massage for Osteoarthritis of the Knee: a Randomized Clinical Trial, J. Get Intern Med., 34 (3): 379–386.

6. Sandmeiser, R. H. (2000) Osteoarthritis and Exercise: Does Increased Activity Wear Out Joints? Perm J., 4 (4): 26–28.

7. Sansone, V., Applefield, R. C., Luca, De. P., Pecoraro, V., Gianola, S., Pascale, W., Pascale, V. (2019) Does a high-fat diet affect the development and progression of osteoarthritis in mice? A Systemic Review, 8; 12: 582-592.

8. Swain, S., Sarmanova, A., Mallen, C., Kuo, C. F., Coupland, C., Doherty, M., Zhang, W. (2020)

Trends in incidence and prevalence of osteoarthritis in the United Kingdom: findings from the Clinical Practice Research Datalink (CPRD), Osteoarthritis and Cartilage, 28; 6: 792-801.

9. Wa ng , L., Xu , Q., Chen , Y., Zhu . Z., Cao , Y. (2023) Associations between weather conditions and osteoarthritis pain: a systematic review and meta-analysis, 55; (1).

10. Yu, C. (2023) Research progress in the treatment of Knee Osteoarthritis, Bio Web of Conferences, 59: 1-6.

Diamond Peel Microdermabrasion (MD)

Wed, 08 Nov 2023 00:00:00 GMT

What is A Diamond Peel Facial and Who Is It For?

A Diamond Peel is a crystal-free microdermabrasion (MD). The diamond tipped hand-piece gently removes dead cells and debris on the outermost epidermal layer of the skin known as the stratum corneum. This helps to exfoliate, clean and reduce large pores within the skin.

People might choose to get the procedure if they have the following skin concerns:

Hyperpigmentation, age spots and brown spots

Enlarged pores and blackheads

Acne and acne scars

Stretch marks

Dull-looking skin complexion

Uneven skin tone and texture

Melasma

Sun damage

Phyiological Effects

Over time, the stratum corneum layer becomes dehydrated which causes the appearance of fine lines and the supportive dermal structure underneath becomes thin, less vascular and loses collagen.

Before MD treatment is performed, the skin is cleansed to remove makeup and debris, the diamond tip lifts away dead skin, unblocks pores and stimulates collagen production.

Microdermabrasion helps rejuvenate the skin as the removal of dead skin cells reveals the younger cells below and allows skincare products to absorb into the skin. The gentle vacuum removes debris and stimulates microcirculation which increases cell renewal to help reduce the appearance of fine lines and pigmentation.

The Diamond Peel gently, safely removes the outer layers of the stratum corneum, and any debris on the skin such as surface blackheads, whiteheads, oil and dirt. The Diamond Peel is excellent for anyone whose skin is dull, flaky, dry, and anyone with clogged pores. The Diamond Peel can also help improve the appearance of brown pigment spots and wrinkles, and can also help patients with mild to moderate acne by opening up the pores and allowing them to breathe.

Why Have a Diamond Peel?

The Diamond Peel uses a diamond tipped precision hand piece to gently exfoliate the skin. The Diamond Peel is safe, effective, gentle, clean, won't leave any residue on the skin, and allows you to see exactly how much dead skin and debris is removed.

What is the treatment like?

Microdermabrasion treatments are not aggressive; they are gentle and progressive, and best of all, they work! Most patients find Diamond Peel Microdermabrasion treatments to be quite relaxing. The treatment is like a "superficial skin polishing". In as little as thirty-five minutes, this gentle technique efficiently produces satisfying results. Following the treatment, we will apply toner and creams to further soften and moisturise the skin.

Who are the best candidates for a Diamond Skin Peel Microdermabrasion?

A Diamond tip Microdermabrasion are for those that:

Cannot afford to take time off for healing from a chemical peel or an invasive laser procedure.
Don't like or want injections.
Don't want to put off their outdoor activities like golf, tennis or skiing.
Have skin sensitivities to chemicals or make-up. • Have acne-prone skin that has not responded well to other acne remedies.
Diminish fine lines or skin that shows signs of ageing.
Wish to freshen their skin's appearance.
Wish to diminish scars and stretch marks.

Does the Diamond Peel hurt?

No, a feeling of some abrasion and slight suction might be felt but the procedure is not painful.

How long is the Diamond Peel procedure?

A Diamond MD procedure takes approximately 10 -15 minutes.

Can I go back to work and put on makeup after the procedure

Going back to work after is fine, but it is not advised to wear make up for the first 24 hours post MD treatment to allow the skin to heal.

Is Diamond Peel Microdermabrasion safe?

Yes. Diamond Peel Microdermabrasion is non-invasive. The procedure only removes the outermost layer of dead skin cells to reveal the fresher, younger cells beneath. Regardless of the skin type, fine lines, acne scars and stretch marks can be reduced.

How soon will I see results?

Immediately. After your first treatment your skin will have a fresh pink glow. It will look healthier and feel smoother and softer. Your improvement will continue throughout your treatment program.

What if I am using Retin-Actin or Retinol?

Clients are asked to not use these products for 24 hours before an MD treatment. Clients are advised to not apply for 72 hours post treatment.

Roaccutane/ Accutane

Steroid creams or medication such as Roaccutane/accutane significantly thins the skin. Clients are advised not to have a microdermabrasion treatment until 6 months after the last use of Roaccutane/accutane.

How often should Can Clients have a Diamond Peel?

Depending on your particular concerns and your treatment program, clients can have a Diamond Peel every 2-4 weeks.

What is included in the aftercare advise?

Aftercare advise will include the avoidance of direct exposure to the sun for at least 48 hours after treatment, to use a sunscreen to block UVB and UVA rays each day, preferably SPF factor 30. To avoid excessive exercise for 48 hours post treatment. Within 7 days post treatment clients are advised to not perform: waxing, apply exfoliants or scrubs. To avoid exfoliants, injections (e.g. collagen and botox, laser treatments, facials or masks, chemical peels, electrolysis and tweezing.

Why should I choose Diamond Peel Microdermabrasion?

Microdermabrasion takes less time than other more invasive procedures. There is no recovery period, no discomfort and you can resume regular activities immediately. If you are unhappy with age spots, acne scars, stretch marks, fine wrinkles or flaking skin, Diamond Peel Microdermabrasion can be a good option for you. Diamond tipped microdermabrasion treatments combined with our other skin care therapies are a safe approach to skin care.

Who Should Not Have Microdermabrasion:

Microdermabrasion is not suitable for individuals with delicate skin that is reactive or sensitive and/or is prone to dilated veins as it will exacerbate the veins and can damage an already compromised protective skin barrier.

Contraindications for this treatment include:
* Cuts and abrasions * scar tissue from recent minor surgery or 2 years post major surgery * bruising and swelling * sunburn * post medium or deep skin peels * botox injections - 6 to 8 weeks prior * dermal fillers 4 to 6 weeks prior * recent laser resurfacing * pregnancy * laser hair removal - 1 week prior * client is taking oral blood thinners * Oral Roaccutane medication * neuralgia and loss of skin sensation * skin cancer * during cancer treatment * Rosacea * Anaemia or medical conditions that cause clients to bruise easily * bacterial infections such as impetigo, boils, cellulitis, folliculitis * parasitic infestation such as scabies * Viral Infections such as herpes and warts fungal infections such as Ringworm * Autoimmune disorders.

Diabetic clients would need permission from their GP. Diabetes can compromise the nerves, blood circulation and oxygen supply and any damage to the skin will take longer to heal.

Severe Acne; Microdermabrasion can spread any bacteria Congested skin with grade 4 acne should not be treated

Diamond Peel Microdermabrasion Summary
Diamond Peel Microdermabrasion is a simple, straight forward, non-invasive procedure that revitalizes dull skin, reduces large pores, erases fine lines and wrinkles, acne scars, reduces pigment irregularities (hyperpigmentation), stretch marks and age spots. Most importantly, it allows you to get back to your daily routine immediately after treatment.

Tennis Elbow

Sun, 10 Sep 2023 00:00:00 GMT

Anatomy & Pathology

Tennis elbow is also known as lateral epicondylalgia (LE) or lateral epicondylitis, it is a common musculoskeletal condition and mainly affects the extensor carpi radialis brevis (ECRB) muscle (figure 1) (Heales et al., 2016).

Tennis elbow can cause the following symptoms (from NHS guidelines):

Pain is mainly reported within the outside of the arm.
Pain that can radiate down into the forearm and wrist.
Pain when twisting the forearm – for example, when turning a door handle or opening a stubborn lid on a jar.
P ain and stiffness when fully extending the arm.
Pain when writing or gripping small objects – for example, when holding a pen.
Pain when bending of lifting the arm .

Extensor Carpi Radialis Brevis

Figure 1

Prevalence

The condition is equally prevalent in men and women and affects 5-15% of the working population and occurs more commonly in the dominant arm (1).

Symptoms

Pain within the lateral or outer aspect the elbow is the primary symptom of LE and often creates impaired gripping and activities of daily living (ADLs).

Cause

Usually brought about from overuse or a repetitive strain or exertion of the extensor tendons and structures supporting the joint (repetitive strain injury or RSI). It is characterised as microtears, collagen degeneration and angioblastic proliferation for the extensor tendon (1).

Tennis elbow can be caused by physical activity involving gripping or manipulating objects with the hand and can hinder a person's function of their limb during the participation of recreation and occupational activities.

Tennis elbow may also be associated with other related symptoms and complaints such as a painful grip (2).

Magnetic Resonance Imaging (MRI) scan and Imaging

An MRI scan has been previously used to evaluate the degeneration of the common extensor tendon origin in LE patients and has shown that the area corresponds to degeneration and neovascularisation.

The field of view should cover the distal humeral metaphysis to the bicipital tuberosity of the radius. The latter is particularly crucial in known or suspected cases of biceps tendon injury or rupture. Imaging should be performed in all 3 planes, as certain structures are best seen in different planes.

Anatomy

The elbow joint comprises of articulations among 3 bones: the humerus, radius and ulna which allow for flexion (bending of the joint), extension (joint straightening) and supination of the forearm (turning the arm to face the ceiling). The joint capsule is thickened laterally and medially to form the collateral ligament complexes.

The Ulnar Collateral Ligament (figure 2)

Comprises of 3 bands:

1.) The anterior band is the most important stabiliser and restrains the joint from valgus stress. This aspect of the ulnar collateral ligament extends from the medial epicondyle to the sublime tubercle of the medial base of the coronoid process of the ulna.

2.) The radial collateral ligament which provides varus stability and comprises of 4 parts.

3.) The posterior band which is the least significant transverse band.

Figure 2: Ulnar collateral ligament

The Radial Collateral Ligament has 4 parts (Sampath et al., 2013:

The radial collateral ligament has a low attachment to the lateral epicondyle of the humerus. The distal fibres blend with the annular ligament that encloses the head of the radius, as well as with the fibres of the supinator and the extensor carpi radialis brevis muscles.

1.) The annular ligament: wraps around the radial head and attaches to the sigmoid notch of the ulna.

2.) The radial collateral ligament: extends from the lateral epicondyle to the annular ligament.

3.) The lateral ulnar collateral ligament (LUCL) runs posteriorly from the lateral epicondyle to the supinator crest of the ulna. Its function is to restrain the elbow joint from varus stress and isolated tearing of the ligament may result to posterolateral rotator instability.

4.) The accessory collateral ligament, which is variably present

Figure 3: The Radial Collateral Ligament

The Common Flexor Tendon Groups

The common flexor tendons comprise of small muscles within the inner, medial muscle group of the arm; the pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, palmaris longus which insert on the medial epicondyle just proximal to the ulnar collateral ligament.

The common extensor tendon Group:

Comprises tendons of the lateral group muscles; the brachioradialis, extensor carpi radialis longus and brevis, extensor digitorum, extensor carpi ulnaris and the supinator. These insert on the lateral epicondyle.

The anterior muscle compartment includes the biceps brachii and brachialis the posterior group comprises the triceps tendon and anconeus.

The neurovascular structures of the elbow, which are well visualized on MRI, include the ulnar nerve, which takes a superficial course along the posteromedial humerus and lies within the cubital tunnel; the median nerve, which runs in a superficial course posterior to the bicipital aponeurosis (lacertus fibrosus) and anterior to the brachialis muscle; the radial nerve, which is found anterior to the lateral epicondyle, between the brachialis and brachioradialis muscles; and the brachial artery, which runs medial to the biceps tendon in the antecubital fossa.

Pathology & Medical Imaging

Magnetic resonance imaging (MRI) is the modality of choice for the detection of fractures, particularly of the radial head, which are often suspected on the basis of persistent pain or joint effusion (5).

An magnetic resonance angiogram (MRA) might be useful for partial thickness tears, especially distal deep fibers of the anterior band of the ulnar collateral ligament near its insertion onto the sublime tubercle have been described as having a T-shaped appearance (“T sign").

Bone Marrow Edema for Tennis and Golfer’s Elbow

Bone marrow edema can also help to define discrete patterns of injury, which are encountered in both recreational and elite athletes. For instance, both medial epicondylitis (golfer’s. inner elbow pain) and lateral epicondylitis (tennis/ outer elbow pain) can be seen in association with bone marrow edema. In such cases, bone marrow edema can provide a clue for closer scrutiny of tendon or ligamentous injury.

Biceps Tendon

The main distal tendon of the anterior muscle group is the biceps tendon, which inserts onto the radial tuberosity and is involved in both flexion and supination of the forearm. Rupture of the distal biceps tendon is rare, representing less than 5% of all biceps tendon injuries.

Physical Therapy Treatment Options

Physical therapy for tennis or golfer's elbow at the Leagrave Therapy Clinic would involve a postural analysis, particularly paying close attention to the positioning and movement of the neck, upper back and shoulder complex relative to the affected elbow. Massage application aims to reduce tensions within the associated areas and osteopathic manipulation techniques would be discussed. Acupuncture and cupping techniques may also be considered for deep tendinous muscle tissue tensions within the shoulder, upper arm and forearm.

References

1. Chourasia, A. O., Buhr, K. A., Rabago, D. P., Kijowski, R., Sesto, M. E., (2012) The Effect of Lateral Epicondylosis on Upper Limb Mechanical Parameters, Clinical Biomechanics, Elsevier; 27: 124-130.

2. Heales, L. J., Hug, F., Macdonald, D. A., Vicenzino, B., Hodges, P. W. (2016) Is Syndergistic Organisation of Muscle Coordination Altered in People With Lateral Epicondylalgia? A Case-Control Study, Clinical Biomechanics, Elsevier; 35: 124-131.

3. Kijowski, R., Tuite, M., Sanford, M., 2005. Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves. Skeletal Radiol. 34, 1–18.

4. NHS, https://www.nhs.uk/conditions/tennis-elbow/symptoms/

5. Sampath S. C., Sampath, S. C., Bredella, M. A. (2013) Magnetic Resonance Imaging of the Elbow: A Structured Approach, 5: 1; 34-49.

Median Nerve Neuropathy & Injury

Tue, 01 Aug 2023 00:00:00 GMT

Different Sights of Impingement and How Manual Therapy Might Help

Median nerve injuries are among the most commonly recognized nerve entrapments involving the upper extremity and the primary cause of emergency department access for peripheral nerve injuries. Also referred to as the 'eye of the hand', the median nerve innervates a group of flexor-pronator muscles in the forearm and most musculature in the radial portion of the hand. The nerve controls abduction of the thumb, flexion of the hand at the wrist and flex the fingers.

Anatomy of The Median Nerve

The median nerve is a peripheral nerve formed by the convergence of the lateral and medial cords of the brachial plexus from the anterior rami of cervical nerve roots five to eight and the first thoracic spinal segment. The median nerve descends medially to the brachial artery at the level of the humerus and enters the forearm between the two heads of pronator teres. The nerve is very superficial in the cubital fossa and lies deep to bicipital aponeurosis. In the forearm, the median nerve lies deep to the flexor digitorum superficialis and superficial to flexor digitorum profundus. It then enters the palm under the flexor retinaculum lateral to the tendon of flexor digitorum superficialis and posterior to the tendon of palmaris longus.

Function of The Median Nerve
The median nerve is a mixed (sensory and motor) nerve. It is classically described as the nerve of pronation, of thumb, index finger, middle finger, and wrist flexion; of thumb antepulsion and opposition; as well as the nerve of sensation for the palmar aspect of the first three fingers. The median nerve is named so because of its middle position at the end of the brachial plexus and the forearm.

Sensory Innervation of the Median Nerve

sensory innervation to the flying face of the thumb, index, middle and radial side of the ring finger and the entire palmar region of the radial half of the hand. It also provides sensitivity to the dorsal skin of the last two phalanges of the index and middle fingers.

Median Nerve injury

Pathology and injury to the median nerve can occur anywhere along the length of the nerve by acute or chronic trauma or compressive lesions which can affect the median nerve at various levels along its long path from the brachial plexus and axilla to the hand.

Peripherally, the median nerve can become compressed under the fascial sheath of the flexor retinaculum, which often causes burning pain, numbness, and tingling (neuropathic pain) commonly known as carpal tunnel syndrome (CTS). CTS is the most commonly recognised entrapment neuropathy and can be further read in another post here. It is worth to noting that CTS is idiopathic and also associated with hypothyroidism, pregnancy, and diabetes. This article will concentrate on investigating other entrapment sites of the median nerve and how it may affect the innervated arm.

Median Nerve Entrapment at the Elbow

The median nerve can be entrapped at four locations around the elbow:
1. The distal humerus by the ligament of Struthers.
2. Proximal elbow by a thickened biceps aponeurosis.
3. Deep heads of pronator teres muscle.
4. Proximal forearm via flexor digitorum superficialis muscle.

This blog will specifically study the following syndromes and link the above listed with association to the median nerve:

1. Ligament of Struthers syndrome
2. Pronator Teres Syndrome
3. Lacertus Tunnel Syndrome
4. Anterior Interosseous Nerve Syndrome

The Ligament of Struthers Syndrome

The median nerve can be entrapped by the ligament of Struthers , which consists of a fascial band extending from the humerus to the medial epicondyle, often with a bony protuberance from the humerus. These “high lesions” can result in attenuation of all motor and sensory function of the median nerve below the elbow. There can be thenar wasting , described as a “ simian ” or “ benediction ” hand (figure 2). There can also be numbness of the palmar aspect of the first three and a half fingers, including the thenar eminence.

Lacertus Tunnel Syndrome

Lacertus tunnel syndrome is a compression of the median nerve which occurs under a sheet of ligamentous tissue (lacertus fibrosus) just past the elbow joint.

The most common complaints in patients with lacertus syndrome are:

A loss of tip pinch strength
Reduced fine motor skills and sense of clumsiness (dropping objects).
Burning sensations and numbness in the palmar cutaneous branch of the median nerve distribution.
Weakness when manually testing the strength of the muscles innervated by the median nerve distal to the lacertus fibrosus, especially the FPL, FDP II, and FCR.
External pressure of the median nerve at the level of the lacertus fibrosus will elicit distinct pain and, at times, a positive Tinel’s sign.

If someone is still having symptoms after carpal tunnel release, the hand should be examined for lacertus syndrome originating at the elbow. A reduction in muscle power of the flexor muscles within the forearm and tenderness within the region will help make the diagnosis. Nerve conduction studies are not helpful. Other symptoms are vague with pain commonly reported within the distribution of the median nerve distal to the site of compression with forearm/ hand fatigue and achiness.

Pronator Teres Syndrome

Pronator teres syndrome, refers to entrapment of the median nerve between the two head of the pronator teres muscle (PT). This condition can present similarly to carpal tunnel syndrome with patients often complaining of discomfort within the forearm during activity. It can also be dynamically compressed by repetitive elbow flexion or forearm pronation; repeatedly weightlifting heavy dumbbells for example can create irritation.

The anterior interosseous nerve is a purely motor nerve and supplies the pronator quadratus muscle, flexor muscles of the forearm and muscles for the index and middle fingers. This syndrome mimics CTS, but it does not respond to splinting, NSAIDs, steroid injection, or carpal tunnel surgery.

Symptoms
Patients with pronator syndrome present with pain and paresthesia (pins and needles) within the elbow, forearm and hand affecting the thumb to middle fingers and lateral half of the ring finger. The most common distribution of sensation is loss within the lateral palm and sensory loss over the thenar eminence (base of the thumb).
The hand symptoms are similar to carpal tunnel syndrome and both syndromes may be aggravated by overuse. Pronator syndrome can be associated with numbness of the palm because of compression of the palmar cutaneous nerve, whereas symptoms that wake the patient at night are more common with carpal tunnel syndrome.

Tinel sign should be positive over the wrist in patients with carpal tunnel syndrome, whereas it is positive over the elbow and proximal forearm in patients with pronator syndrome. In addition, symptom reproduction during resisted forearm pronation suggests median nerve compression by the pronator teres compared to symptom reproduction during resisted elbow flexion and supination, suggesting biceps aponeurosis as the cause of compression.

Clinic Presentation
The clinical presentation is typically aching pain in the hand/wrist with activities involving sustained pronation, such as typing, writing, using a mouse or cell phone, or driving a car. The pain is in the distribution of the terminal, sensory branch of the AIN (i.e., the volar wrist). As the syndrome progresses, patients may complain of numbness in the entire hand, particularly at night, especially with any pressure on the proximal forearm or about the medial elbow. In theory, a way to differentiate CTS from pronator teres syndrome is the presence of sensory symptoms in the thenar eminence at the base of the thumb. The pronator teres is ironically spared in pronator teres syndrome and it is important to note that there are no symptoms at the site of nerve compression, but rather where the cutaneous nerve ends.

The condition can often be observed in individuals who perform certain actitivities in different trades such as regular and daily use of screw drivers. Asking individuals to extend the elbow with repeated pronation of the forearm can often reproduce symptoms of pronator syndrome.

The syndrome is also seen in professional cyclists. Treatment of pronator teres syndrome includes limiting activity that produces symptoms. NSAIDs, local corticosteroid injections into the tender points of pronator teres, and median nerve decompression surgery have also demonstrated effectiveness.

Anterior Interosseous Nerve Syndrome (AINS) & 'OK' Sign

The anterior interosseus nerve (AIN) is a branch of median nerve which is motor in nature (supplies only muscles) and arises just below the elbow.

Injury
Damage or compression of AIN causes anterior interosseus nerve syndrome ( also called the Kiloh-Nevin syndrome) which causes a palsy of the three muscles that the nerve supplies. The three muscles are flexor pollicis longus (which flexes the thumb at the distal phalanx), pronator quadratus (causing pronation at the radioulnar joint) and the radial half of flexor digitorum profundus (creates flexion of the index and middle fingers). Neuropathy of the AINS nerve presents with muscular weakness with no sensory deficits. Traumatic causes of the syndrome include penetrating injuries, fracture at the level of the forearm and cast fixation. Compression of the nerve can be due to nerve entrapment in pronator teres, occlusion of the radial or ulnar artery, and enlarged bicipital tendon bursa.

Presentation - The 'OK' Sign
Patients with AINS are unable to pinch objects or make a clear "OK" sign with their index finger and thumb. The “O” sign is otherwise acheived via the index finger and thumb (via flexor pollicis longus). Upon physical examination, the patient is unable to approximate the thumb and index finger. An injury to the anterior interosseous nerve most commonly occurs with complex trauma.

Patients with anterior interosseous nerve (AIN) syndrome, after the two authors who described the syndrome in 1952 observed motor weakness typically manifested by weakened ability to pinch the thumb and index finger together, tested by asking the patient to make an “OK” sign with the hand, reflecting the palsy of the flexor pollicis longus muscle and flexor digitorum profundus muscle to the index finger.
Sources read do state that this sign should not purely be relied upon to make this diagnosis and to test for strength of the flexor pollicis longus.
The pinch grip test is positive and the patient cannot demonstrate an “OK” sign which is possible when the Anterior interosseous nerve is intact. Sensory loss is not present in the case of anterior interosseus nerve syndrome (AINS) which differentiates it from other nerve palsies such as carpal tunnel syndrome and pronator syndrome.

Treatment:

Surgical treatment is needed for patients who do not show any improvement with anterior interosseus nerve syndrome during the first three months. Decompression of the nerve is necessary at the compression site. There is no proper treatment and the diagnosis is made with the help of MRI and the presenting complaints by the patient.

Treatment

Physical Therapy & Exercise

Conservative therapies include physical therapy, yoga, and therapeutic ultrasound. Again, first-line for conservative management in the case of mild to moderate carpal tunnel are corticosteroid injections and night splints. Massage application, acupuncture or electrotherapy might be used to help reduce tensions within the related muscles mentioned above particularly within the forearm, upper back and neck.

Surgical Intervention

Proximal median nerve release is considered if symptoms persists when conservative treatment prevention has been unsuccessful. The consideration of relevant structures to be incisionally released via surgical measures include; the fascia of Struthers, the bicipital aponeurosis, the deep fascia of the ulnar origin of the pronator teres and the fascial arch of the superficial flexors (6).

Use of Wrist Splinting

Management of median nerve injury depends on the etiology. Splinting is considered a first-line treatment option for mild to moderate carpal tunnel. Research shows it to be superior to placebo, but no single splint stands out as superior. However, a separate study has shown a neutral wrist splint to be twice as effective in symptomatic relief compared to that of an extension splint. If initially starting with night splints, and the patient does not have relief after one month, the recommendation is to continue for another one to two months but add another conservative treatment modalities to the care plan. Splints can be worn at night or continuously, but have continuous use has not been shown to be superior to night time wearing the splint.

Corticosteroid Injection

A local corticosteroid injection has been shown to delay the need for surgery at one-year following an injection. The risks of a local corticosteroid injection include possible injection into the median nerve as well as tendon rupture. The recommendation is to do a carpal tunnel injection under ultrasound guidance to limit risks and improve the accuracy of the injection. A repeat corticosteroid injection may be offered six months following the initial injection. If symptoms recur after the second injection, then surgery is recommended to be considered.

References

1. Abdalbary , S. A., Abdel-Wahed, A., Amr, S., Mahmoud, M., El-Shaarawy, E. A. A., Salaheldin, S. Fares, A.

(2021) The Myth of Median Nerve in Forearm and Its Role in Double Crush Syndrome: A Cadaveric Study, Frontiers in Surgery; 8: 1-8.

2. Caetano, E. B., Neto, J. J. S., Vieira, L. A., Caetano, M. F., de Bona, J. E., Simonatto, T. M. (2017) Struthers' Ligament And Supracondylar Humeral Process: An Anatomical Study And Clinical Implications; Acta Ortop Bras; 25 (4): 137-42.

3. Dydyk, A. M., Negrete, G., Cascella, M. (2021) Median Nerve Injury , https://www.ncbi.nlm.nih.gov/books/NBK553109/ [online]

4. Lalonde, D. (2015) Lacertus syndrome: a commonly missed and misdiagnosed median nerve entrapment syndrome ,

5. Miller, T. T., Reinus, W. R. (2010) Nerve Entrapment Syndromes of the Elbow , Forearm, and Wrist, AJR; 195: 585-594.

6. Singh, V., Ericson, W. B. (2016) Median Nerve Entrapments (Chapter 37); Peripheral Nerve Entrapments: Clinical Diagnosis and Management, Springer International Publishing, Switzerland: 369-382.

The Femoral Nerve Entrapment And Anterior Thigh Pain

Tue, 11 Jul 2023 00:00:00 GMT

Course, Anatomy, Supply

The femoral nerve originates from the lower back and runs down the front of the thigh into the lower leg. The nerve helps the muscles bend the hip and straighten the leg. It innervates the muscles and skin of the hip and thigh and is the longest branch of the lumbar plexus (4).
The Neve's course specifically rises from the ventral rami of the 2nd, 3rd and 4th lumbar nerves and emerges from the lower lateral border of the psoas major muscle, travels through the iliopsoas muscle under the iliac fascia, passes deep to the inguinal ligament and enters the femoral triangle (discussed below) (4).

The iliac fascia along with the iliopsoas thickens to form the iliopectineal band that separates the femoral vessels from the nerve. The femoral nerve then divides into the superficial and deep terminal branches in the femoral triangle.

The Superficial Branch
The superficial branches include the lateral musculocutaneous nerve which innervates the sartorius muscle and the skin of the anterior thigh. It also contains the medial musculocutaneous nerve which divides to innervate the pectineus muscle, the articular surface of the acetabulum and skin of the medial thigh (4).

The Deep Branch
Comprises of the saphenous nerve which is sensory only, supplies the skin of the medial leg to as far as the medial malleolus (inner ankle). It is the largest terminal cutaneous branch of the femoral nerve and the longest nerve in the body (4).

Femoral Nerve Entrapment

Nerve entrapment may occur around the musculotendinous, osseous and ligamentous structures as a result of potential increased strain and compression of the peripheral nerve at these sites.

In rare cases, femoral neuropathy may also arise as a result of traumatic iliacus haemotoma which is more common amongst young athletes. In these cases, patients often complain of groin pain and neurological findings such as myotome (muscle) weakness.

Entrapment of the femoral nerve can lead to various symptoms and functional impairments and result to several underlying causes that may include:

Compression: often due to structural issues or anatomical abnormalities e.g. muscles and hernias.
Trauma: or injury to the femoral nerve or surrounding structures such as fractures, dislocations, surgical procedures.
Inflammatory conditions; such as diabetic neuropathy, vasculitis or infections which cause swelling and inflammation and compression of the femoral nerve.
Misplaced catheter into the femoral artery within the groin.
Frequent use of tight seatbelts, clothing or waist belts combined with excess body weight.
Underlying tumour or growth.

Femoral Nerve and the Innervation of Structures

The main muscles innervated by the femoral nerve are:

Sartorius
Quadriceps femoris (rectus femoris, vastus lateralis, intermedius and medialis)
Ilopsoas
Pectineus

Osteotomal Innervation

Anterior wall of the hip (acetofemoral) joint.
The anterior aspect of the femur
Anteromedial walls of the knee joint

Femoral Triangle

Within the medial aspect of the proximal thigh is the femoral triangle and where the femoral pulse can be palpated, specifically at the mid-inguinal point.

Shahab (2023) uses the acronym NAVEL for the structures within the femoral triangle where the femoral nerve lies laterally out of all the contents within the femoral triangle (4).

The anatomical orientation of contents within the femoral triangle that lay from LATERAL to MEDIAL are:

N - Femoral Nerve
A - Femoral Artery
V - Femoral Vein
E - Femoral Canal (Empty Space)
L - Lymphatics

Meralgia Paresthetica (MP)

Meralgia paraesthetica (MP) is thigh pain that refers to mononeuropathy of the lateral femoral cutaneous nerve commonly caused by the entrapment or compression of this nerve (1). Patients often complain of burning, numbness, paraesthesia or reduced sensation over the anterolateral thigh which can often limit daily activities and sleep (1).

MP has also been linked to obesity and diabetes myelitis (DM), pregnancy, the wearing of tight clothing; trousers or belts or leaning against hard objects (1). It has been reported to be from vitamin B12 deficiency (folate deficiency anaemia).

Physical Therapy Treatment

In most cases, related symptoms subside on their own.
However, manual therapy i.e. deep tissue massage and physical therapies can help by aiming to reduce muscular tensions, improve joint mobility, any postural defects and lifestyle habits that might be maintaining the condition.

Stretching of the Iliopsoas:

References

1. Grossman, M. G., Ducey S. A., Nadler, S. S., Levy, A. S. (2001) Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg. ;9: 336-344.

2. Martin, R., Martin, H. D., Kivlan, B. R. (2017) Clinical Commentary: Nerve Entrapment in the Hip Region: Current Concepts Review, IJSPT, 12; 7: 1163-1173.

3. Murray,I. R., Perks, F.J., Beggs, I., Moran, M. (2010) Femoral Nerve Palsy Secondary to Traumatic Iliacus Haematoma; A Young Athlete’s Injury, BMJ Case: 1-5.

4. Shahab, S. (2023) Femoral Nerve [online] www.kenhub.com (last visited 16/07/2023).

5. Szucs, S., Morau, D., Iohom, G. (2010) Femoral Nerve Blockade, Medical Ultrasonography, 12; 2: 139-144.

The Facial Nerve

Mon, 05 Jun 2023 00:00:00 GMT

The facial nerve is the seventh cranial nerve responsible for controlling facial expression and transmitting sensory information from the face. Its intricate network of fibres and branches allow dynamic movements that shape our facial expressions and contribute to non-verbal communication. This post will delve into the anatomy, functions, and clinical significance of the facial nerve.

The facial nerve carries sensory information for the anterior two-thirds of the tongue, including taste perception. This gustatory component is the chorda tympani and plays a role in our sense of taste and enjoyment of food.
The nerve originates from the brainstem, specifically the pons, and consists of both motor and sensory components. It emerges from the skull through the stylomastoid foramen, a small opening located behind the ear. From there, it travels through a complex course, branching out into various segments that innervate the muscles of the face.

Muscles of the Facial Nerve

Cause

Motor Function: The primary function of the facial nerve is to control the muscles of facial expression. It supplies muscles responsible for intricate facial expressions such as eye closure, smiling, frowning and raising the eyebrow and give the ability to express a wide range of emotions and communicate non-verbally.

Facial nerve fibres consist of 10,000 neurons, 70% (7,000) of which are motor neurons and 30% (3,000) are sensory. The facial nerve (cranial nerve VII) is responsible for supplying motor innervation to the muscles of facial expression. Here are some of the key muscles supplied by the facial nerve :

1. Frontalis: Located in the forehead and responsible for raising the eyebrows and creating horizontal forehead wrinkles.

2. Orbicularis oculi: Surrounds the eye, closes the eyelids and aids blinking, and squinting.

3. Orbicularis oris: Surrounds the mouth and responsible for lip closure, puckering, and various movements involved in speech and expression.

4. Depressor anguli oris: Lowers the corners of the mouth for frowning expression.

5. Mentalis: elevates the lower lip and the chin.

6. Depressor labii inferioris: pulls the lower lip downward and forward.

7. Corrugator: maintains the position of the brow.

8. Zygomaticus major and minor: Located in the cheek area and involved in smiling and raising the corners of the mouth.

9. Buccinator: This muscle is situated in the cheek and is responsible for compressing the cheeks inward, assisting in activities like blowing air and sucking.

9. Platysma: This muscle extends from the lower jaw to the collarbone and is involved in movements such as lowering the jaw, pouting, and tensing the neck and lower face.

10. Levator labii superioris: This muscle is responsible for elevating the upper lip.

Facial Nerve Palsy (FNP)

Paralysis can occur by pathology anywhere along the facial nerve's peripheral portion and lead to facial nerve palsy (FNP) or Bell's palsy. Bell’s palsy is a neuromuscular idiopathic disorder that affects about 23 individuals per 100,000 per year. The condition causes unilateral facial paralysis and although it can happen at any age, the average age of onset is 40. While the exact cause of Bell's palsy is often unclear, it is believed to result from viral infections such as the herpes simplex virus.

Symptoms include:

Dry eye
Facial droop
Difficulty closing the eyes
Asymmetrical expressions
Reduced corneal reflex
Drooling
Hyperacusis (sound sensitivity)
Altered taste
Otalgia (earache)
Speech articulation problems
Difficulty smiling, frowning and expressing emotions
Tearing of the eye.
Facial pain.
Palpebral fissure to expand.
The nasolabial fold to flatten.
One corner of the mouth to droop when smiling.
The eyeball cannot close without moving upward and outward at the same time.

Prognosis of recovery following Bell’s Pasly tends to be good with two thirds of individuals progressing to a full recovery within three months. Signs and symptoms all occur at the same side of the face as the lesion and tend to peak at about two weeks from its onset.

Cause

The cause of paralysis can be due to;

Vasospasm after exposure to cold or draughts.
Vascular insufficiency
Secondary ischemia
Some form of viral infection.

The risk of Bell’s palsy is increased in patients with hypertension or diabetes and in pregnant women; either late in the pregnancy or in the early postpartum period (4).

Bell’s Palsy and Diabetes Mellitus

Diabetes is associated with as many as 10% of cases and occurs more often in the last trimester of pregnancy (4).

A study by Pecket and Schattner (1982) found that out of 126 patients with Bell’s Palsy, 39% of cases had either chemical or overt diabetes mellitus. Interestingly, a high frequency of taste disturbance (83%) was discovered in in patients who did not have diabetes mellitus compared to 14% of diabetic patients whose taste was affected.

It is possible that diabetic small vessel disease can affect the blood supply of the distal portion of the facial nerve by causing localised facial nerve ischaemia and oedema which is thought to compromise the nerve’s supply by increasing the rigidity of the bony fallopian or facial canal that the facial nerve passes through.

Treatment

Bell’s palsy is mainly treated by trying to identify the cause of nerve injury, strengthening the facial muscles and restoring facial function (3).

The management of facial nerve palsy varies depending on the underlying cause and severity of the condition. In some cases, the nerve may regenerate spontaneously, leading to gradual improvement over time. In more severe cases, various treatment approaches may be employed, including medication, physical therapy, and sometimes surgical intervention.

Surgical Considerations: Due to its intricate course and multiple branches, the facial nerve is vulnerable to injury during certain surgical procedures. Surgeons must exercise caution during surgeries involving the ear, parotid gland, or other adjacent structures to minimize the risk of damage. Preoperative evaluation and meticulous surgical technique are vital in preserving the facial nerve and preventing postoperative complications.

Electrical Stimulation

Current evidence suggests that there is a conflict of opinion for the use of electrical stimulation when treating individuals with Bell’s Palsy. The Bell’s Palsy Association of the United Kingdom discourages the use of electrical stimulation within the early phases of the condition to prevent unintentional damage to muscle fibres (3). Alakram and Puckree (2011) concluded that the application of TENS in the acute stage of Bells palsy is at best, safe and doesn’t interfere with recovery, but is indistinguishable from spontaneous recovery (2).

Facial Massage

Massage can potentially provide some benefits for facial nerve injury by considering:

1. Encouraging relaxation of taught muscles and encourage stress reduction; Massage therapy can help promote relaxation and reduce stress, which may indirectly benefit individuals with facial nerve injury. Stress can exacerbate muscle tension and increase discomfort, facial massage techniques may help alleviate these symptoms.

2. Increase circulation; massage technique such as effleurage can improve blood circulation in the affected taught areas. This may help deliver oxygen and nutrients to the facial nerves and muscles, promoting healing and reducing inflammation.

3. Muscle Tension Relief; Facial nerve injury can lead to muscle stiffness, spasms, or tension in the face. Massage techniques like kneading, myofascial release, or trigger point therapy may help release tension and reduce muscle tightness, potentially providing relief.

4. Lymphatic Drainage; Facial massage techniques that incorporate gentle, rhythmic movements can assist in lymphatic drainage, promoting the removal of waste products and reducing swelling or edema in the affected area.

However, it's crucial to remember that every facial nerve injury is unique, and the appropriateness and effectiveness of massage therapy may vary. It is essential to consult with a healthcare professional, such as a physical therapist or a specialist in neurology or rehabilitation medicine, who can assess your specific condition and provide appropriate guidance.

Additionally, certain precautions need to be taken when massaging the face, especially in cases of acute or severe facial nerve injury. Applying excessive pressure or manipulating the affected area without proper knowledge or training can potentially worsen symptoms or cause further damage. Therefore, seeking professional advice and guidance is highly recommended to ensure safe and effective treatment.

References

1. Alakram, P., Puckree, T. (2011) Effects of Electrical Stimulation in Early Bell’s Palsy on Facial Disability Index Scores, South African Journal of Physiotherapy, 67; 1: 35-40.

2. Almutairi, S., AlFaris, D., Alshawi, S., Alkhalifah, S., Al Shihri, A., Alshehri, L., Team ENT 435, Facial Nerve [online] https://ksumsc.com/download_center/Archive/4th/435/435%20TeamWork/ENT/F/12-%20Facial%20Nerve%20%28Updated%29.pdf Last visited 31/05/2023.

3. Bharti, N. (2021) Role of Neuromuscular Electrical Stimulation in Bell’s Palsy: A Case Study of Three Patients , International Journal of Science and Healthcare Research, 6; 4: 235-241.

4. Masterson,L., Vallis, M., Quinlivan, R., Prinsley, P. (2015) Assessment and management of facial Nerve Palsy, Education Practice , BMJ, 351; h3725: 32-34. doi: 10.1136/bmj.h3725

5. Pecket, P., Schattner, A. (1982) Concurrent Bell’s Palsy and Diabetes Mellitus: A Diabetic Mononeuropathy; Jounral of Neurology, Neurosurgery and Psychiatry, 45: 652-655.

6. Saxby, E., Kerr, J. (2021) Update on Facial Nerve Palsy: Diagnosis and management of ocular complications , Royal College of Ophthalmologists, Focus [online]

Biceps Tendinitis

Wed, 26 Apr 2023 00:00:00 GMT

Primary Biceps Tendinitis

Biceps tendinitis is inflammation of the tendon around the long head of the biceps muscle within the bicipital groove of the humerus (figure 1). This is known as primary biceps tendinitis and occurs in 5% of patients with with the condition (3).

Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff muscle tears or SLAP (superior labrum anterior to posterior) lesions (3). Patients often complain of a deep, throbbing ache in the anterior shoulder. Repetitive overhead motions of the arm initiate or exacerbate the symptoms.

The most common isolated clinical findings in biceps tendinitis is bicipital groove point tenderness whilst the arm is moved to 10 degrees of internal rotation (Figure 1). Pathology of the biceps tendon is most often found in patients 18 to 35 years of age who are involved in sports (3).

Anatomy

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

Gross Anatomical Components:

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

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

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

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

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

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

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

Stages of Biceps Tendinitis

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

Occasionally, a partial or complete tear of the tendon can occur depending on the injury or damage. A complete tendon tear can result to a deformity of the arm (3).

Biceps tendinitis commonly occurs with other shoulder problems that can accompany the condition:

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

Cause

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

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

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

Long Head Biceps Tendon (LHBT)

The main function of the biceps muscle is supination (turning the palm of the hand to face the ceiling) and elbow flexion. The muscle contributes approximately 10% of the total power in shoulder abduction when the arm is held in external rotation.
The function of the LHB tendon tends to play a passive stabilising role in the shoulder and it has been proposed that the stability of the LHBT is dependent on the elbow's positioning (figure 2) (9).

Treatment

Physical therapy treatment would involve the practitioner assessing positioning and posture of the neck, shoulders and back and performing clinical tests to understand which specific muscles or joint related compensations might be contributing to maintain a biceps tendonitis.

At the Leagrave Therapy clinic, the practitioner does not prescribe medications, but biceps tendinitis or tendinosis may respond to analgesia with nonsteroidal anti-inflammatories (NSAIDs), ice, rest from overhead activity (if perform related activities), or physical therapy.

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

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

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

References

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

Six Possible Causes For Lower Back Pain in Women

Wed, 08 Mar 2023 00:00:00 GMT

Lower Back Pain in Women

Lower back pain (LBP) can be defined as pain, muscle tension, or stiffness localized below the costal margin of the ribs and above the inferior gluteal folds, with or without leg pain (sciatica) (9). Studies have concluded that women have a higher prevalence of lower back pain (LBP) than men (9). Across all age groups, gender prevalence ratios have also revealed a higher prevalence of pain in females for headaches, migraines, temporomandibular pain, burning mouth pain, neck pain, shoulder pain, back pain, knee pain, abdominal pain and fibromyalgia (9).

Occupational lower back pain, however, is seen in higher proportions in men. This posts aims to explore why women might be more susceptible to experiencing lower back pain.

1. Sacroiliac (SI) Joint Dysfunction

The female sacroiliac joint (SIJ) differs to men with that the sacrum is wider, posteriorly tilted, less curved and has a wider sciatic notch and acetabula (3). As a result, the female SIJ has greater loads, stresses and pelvic ligamentous strains. The increased pubic angle and reduced SIJ curvature makes the joint more mobile which can play a role in the higher incidence of pelvic stress fractures and SIJ pain. The differences of the SIJ between the sexes may contribute to increased rate of the joint's misalignment and instability in young and middle aged women with pain more commonly arising on one side (3).

During gestation and in preparation for birth, the SIJ loosens with the presence of hormonal and biomechanical factors, relaxin, estrogen, and symphysiolysis (separation of the pubic symphysis) providing an increase in joint mobility. While these changes may be necessary for child birth, they can cause an increased risk for pelvic pain (3).

The combination of increased weight gain, exaggerated lordotic posture, mechanical trauma of parturition, and hormone-induced ligamentaous laxity can all contribute to sacroiliac joint pain by causing SIJ subluxation. In the majority of women, the pain usually resolves within four months after giving birth but persists in approximately 20% of women (3).

2. Menopause and Hormonal Issues

Women going through premenopause (usually defined at the age range between 45-55) to post menopause is as a result of a slower production of the female hormones; estrogen and progesterone which are secreted by the ovaries. This process is gradual, spreads over time and is a natural part of ageing (10).

Numerous symptoms associated with perimenopausal include spine and joint pain, hot flushes, night sweats, chronic tiredness; psychological symptoms including irritation and anxiety, mood swings, depression and sleeping disorders. Within the spine, it is widely hypothesised that postmenopausal women show accelerated disc degeneration due to estrogen deficiency (10).

Post menopause, lumbar discs in females degenerate at a notably faster rate than lumbar discs in males, after their later 50s with disc space narrowing becomes more apparent and more severe than age matched males (10).

Wang et al,. (2016) found that overall, the cross-sectional areas of women's vertebral bodies are 25% smaller than men. Thus, it is estimated that the mechanical stress within vertebral bodies are 30%-40% higher in women than men during equivalent applied loads. The study concluded that smaller vertebral bodies in women confer biomechanical disadvantages that may contribute to more vertebral fractures in elderly women (10).

The Significance of Estrogen Levels in Women's Health

Reduced estrogen levels predominantly occur post menopause and commonly contributes to collagen wasting observed in bone and skin. This leads to reduced bone density, osteoporosis and aging of the skin.

When estrogen levels decline post menopause, levels of plasma low density lipoprotein cholesterol (LDL, the harmful kind) increase and plasma high density lipoprotein cholesterol (HDL) decreases which leads to the build up of cholesterol in the arteries and can contribute to cardiovascular diseases such as heart attack and stroke.

3. Intervertebral Disc Degeneration

Lumbar disc degeneration(DDD) is a common musculoskeletal condition, the prevalence of which increases with age and can cause discs to reduce height and become stiff (10). The associated changes of lumbar disc degeneration can progress to nerve impingement, bone and joint inflammation, disc space narrowing and herniation, spinal canal stenosis, facet joint arthrosis and degenerative spondylolisthesis (the slipping forwards of a vertebra) (10).

4. Spinal osteoporosis

Osteoporosis is a condition characterised by low bone mineral density (BMD) and micro-architectural bone deterioration resulting to a reduction in bone mass which can cause abnormal structure, decreased bone strength and an increased risk of fracture (6). Osteoporotic fractures can affect one in three women and one in five men over the age of 50 (4).

The condition of reduced bone mass and abnormal bone structure can remain asymptomatic, but clinical symptoms tend to appear when a fracture occurs. In osteoporosis, bone density and strength of the vertebral body reduces to about 70% and 50% compared to a healthy person.

However, even if bone mass decreases due to osteoporosis, the vertebral body can still endure up to 3 to 5 times the body weight.

A fracture caused by an external force is called a traumatic fracture and differs from a fracture caused via osteoporosis, known as a 'fragility fracture' which occurs when weakened bone is destroyed via an external force that exceeds the strength of the presenting bone (6). The external force to cause a fragility fracture can widely range from a light force from everyday living activities such as lifting a heavy item from the floor to a strong force to cause a normal traumatic fracture (6).

There are two types of vertebral fractures due to osteoporosis: 'morphometrical fracture' and 'clinical fracture' (6). A morphometrical fracture is a vertebral fracture without pain which occurs over a chronic course and judged based on X-rays. When vertebral body tissues are destroyed, sharp pains in the lower and upper back usually occur. A clinical fracture is a fracture with rapid deformation of the vertebral body accompanied by acute pain (6). In the acute phase, deformity of the vertebral body is not clear on X-rays in some cases. Vague dull pain sometimes continues in the entire lower and upper back after the original acute (sharp) pain disappears.

5. Endometriosis

The endometrium is the tissue that lines the uterus. Endometriosis is a chronic condition that can cause lower back pain in women and happens when the endometrium grows outside the uterus in the pelvic cavity or other areas (2). It is this tissue that can respond to hormonal changes by causing swelling, pain, bleeding and spotting between menstrual cycles. The condition can be difficult to diagnose as the symptoms can vary and other conditions can cause similar conditions.

A particular case by Cricco et al., ( 2021) reported a 45 year old female attended physiotherapy complaining of left buttock pain that spread into the hypogastric, left inguinal and left pubic region. Physical therapy treatment aimed at treating the lumbar spine and left sacroiliac joint and no improvement of their condition or symptoms occurred after receiving five physical therapy treatment sessions. After being referred to a gynaecologist consultation, her symptoms resolved after a laparoscopy and eradication of the endometriosis (2).

6. Pregnancy

Pain in the lumbosacral spine and pelvis commonly occurs in almost half of women during pregnancy. During this time, the body posture often changes with a centre of gravity shift along with weight gain, commonly resulting to the pelvis leaning forward and hyperlordosis in the lumbar spine.

Wójcik et al., (2020) note that the size of the lumbar lordosis angle can be a predictor for the occurrence for lower back pain and should be taken into account when planning treatment by practitioners. A larger lumbar lordotic angle can correlate with a higher body weight (11).

Aim of Physical Therapy

Video Showing Supine Lying Gluteal Stretch:

The overall aim of applied physical therapies for the above listed conditions would be to provide appropriate exercises to help strengthen the associated surrounding muscles, joint tendons and ligaments. Hands-on physical therapies applied to the affected joints and muscles would aim to improve mobility and reduce and establish appropriate pain management.

References

1. Cleveland Clinic, Estrogen and The Heart: Risks, Benefits and Side Effects [online] https://my.clevelandclinic.org/health/articles/16979-estrogen--hormones , last visited 15/04/2023.

2. Cricco, C., Daugenti, A., Angilecchia, D., Ceron, D. (2021) Differential Diagnosis of Endometriosis in Patient with Nonspecific Low Back Pain: A Case Report , J Body Mov Ther, 27:227-232.

3. Fiani, B., Sekhon, M., Doan, T., Bowers, B., Covarrubia, C., Barthelmass, M., De Stefano, F., Kondillis, A. (2021) Sacroiliac Joint and Pelvic Dysfunction Due to Symphysiolysis in Postpartum Women , Cureus, 13 (10).

4. Ibrahim, N. I., Ahmad, M. S., Zulfarina, M. S., Zarius, S. N. A. S. M., Mohamed, I. N., Mohamed, N., MOKHTAR, S. A., Shuid, A. N. (2018) A ctivities of Daily Living and Determinant Factors Among Older Adult Subjects with Lower Body Fracture after Discharge from Hospital : A Prospective Study, 15(5): 1002.

5. Kozinoga, M., Majchrzycki, M., Piotrowska, S. (2015) Low Back pain in Women Before and After Menopause , Prz Menopauzalny ,14 (3): 203–207

6. Nakamura, T. (2003) Low Back Pain Accompanying Osteoporosis, JMAJ 46(10): 445–451.

7. Patryca, P., Sobera, M. (2019) Lumbar Lordosis, Pain Intensity and type of Work In Women Participating In Fitness Activities , Pol. J. Sport Tourism, 26 (4), 22-27.

8. Smith , D. R., Mihashi , M., Adachi , Y., Shouyama , Y., Mouri , F., Ishibashi , N., Ishitake , T. (2009) Menstrual Disorders and their Influence on Low Back Pain among Japanese Nurses, Ind Health., 47(3):301-12.

9. Tsujimoto, R., Abe, Y., Arima, K., Nishimura, T., Tomita, M., Yonekura, M., Miyamoto, T., Matsubayashi, S., Tanaka, N., Aoyagi, K., Osaki, M. (2016) Prevalence of Lumbar Spondylosis and Its Association with Low Back Pain Among Community-dwelling Japanese Women , BMC Musculoskeletal Disorders: 1-6.

10. Wáng, Y. X. J., Wáng, J-Q., Káplár, Z. (2016) Increased Low Back Pain Prevalence in Females Than in Males after M enopause Age: Evidences Based on Synthetic Literature Review; Quant Imaging Med Surg ;6 (2): 199-206.

11. Wójcik, G., Rutkowska, E., Mysula, I., Szepeluk, A. (2020) Value of Lumbar Lordosis and Back Pain in the Female Population Over 50 Years of Age , Aluna: l22-26.

12. Zhang, S., Ye, C., Lai, Q., Yu, X., Liu, X., nie, T., Zhan, h., Dai, Zhang, b. (2018) Double-level lumbar spondylolysis and spondylolisthesis: A retrospective study , J of Orthopaedic Surgery and Research, 13: 55.

Cardiological Signs and Symptoms and Referred Shoulder Pain; A Case Study Analysis

Tue, 07 Feb 2023 00:00:00 GMT

Acute Myocardial Infarction (AMI) and Related Referred Shoulder Pain

The most common shoulder conditions that patients consult healthcare professionals in primary and secondary care are usually diagnosed with subacromial impingement syndrome, rotator cuff tendinopathy and adhesive capsulitis (2).

However, in addition to musculoskeletal or mechanical origin of pain, healthcare professionals must be aware of visceral or serious potential life-threatening illnesses that may refer pain to the shoulder, such as cardiovascular disorders. Patients with cardiovascular pathologies, especially for acute myocardial infarction (AMI), commonly present with either chest, upper limbs or abdominal pain. Other sites of pains may present with the following signs and symptoms (1):

Crushing, substernal chest pain
Jaw pain
Neck pain
Diaphoresis (excessive sweating)
Dyspnea
Fatigue

Unfortunately, the above listed signs and symptoms could lead to a misleading diagnosis of other pathologies even within an emergency department (ED). This post may help highlight why careful questioning and attention to detail of patient case history taking is so important to establish when shoulder pain could be an indicator for a cardiological visceral somatic cause (2).

Acute Myocarditis Case Study; Summary and Discussion

An interesting recent clinical case study report by Storari et al., ( 2021) explains how a 46 year old male tiler presented to the emergency department with right shoulder pain, particularly, at the right acromial and scapular region. The nature of pain was described as a continuous intense, constant dull ache (8/10 NPRS) that he had experienced for over one week with no clear onset. The case study described the onset as 'subtle'. At the time he was working longer hours than usual; for 13-14 hours per day. He was a smoker for over 20 years, smoking up to 30 cigarettes per day. He presented with a blood pressure reading of 130/90 mmHg and heart rate of 72 bpm and BMI of 27.6 kg/m2. He reported no family history of cardiovascular diseases, he had a congenital history of right side shoulder dislocations and his physical and neurological examination testing were unremarkable.

Over a short nine day period, he overall attended two appointments at the emergency department for continuous right shoulder pain who diagnosed right MSK shoulder syndrome on both occassions. He was given an intramuscular injection of diclofenac during his first visit and prescribed an infusion of saline solution (100 mL and 250 mL), ranitidine hydrochloride (50 mg/5 mL) and diazepam (10 mg). Upon discharge, the patient was also advised to take eperisone hydrochloride (100 mg) twice and ibuprofen (600 mg) twice a day for 5 days, rest from work for 1 week and a prescription of antalgic electrotherapies.

First Physiotherapy Appointment
He then attended a physical therapy appointment. The physical therapist observed how the client arrived at the clinic holding his upper limb in an antalgic posture, with 'his arm adducted and internally rotated using a foulard knotted behind the neck'. The physiotherapist recorded limited shoulder joint active and passive ranges movement of 70 degrees whilst performing elevation and abduction and gave him exercises to help with the pain.

Second ED Appointment
On the same evening of the physiotherapy appointment, the patient attended the emergency department (ED) for a second time due to a reoccurrence and increase in pain. The patient's BP was 110/90 mmHg, RR of 16 rpm, HR of 98 bpm and the ED again recorded unremarkable clinical findings, gave the same diagnosis as the first ED appointment and performed an intramuscular injection of thiocolchicoside (4 mg/ 2 ml) and diclofenac (75 mg/ 3 ml) for pain-relief. Upon discharge, the patient was instructed to perform a daily intramuscular injection with the same dosages and drugs.

Second Physiotherapy Appointment
The morning of the day after the ED and physiotherapy appointments and the ninth day post onset of his original right shoulder pain, the patient went back to visit his physical therapist for the second time. He reported a change of symptoms with that his pain had shifted from his right shoulder into his left shoulder and the left pectoral region along with constant radiating and oppressive radiating pains (NPRS = 9/10) down his left upper limb. Furthermore, he was experiencing symptoms of dyspnea , fatigue, shortness of breath and diaphoresis (excessive sweating). His physical therapist correlated the current new symptoms to a suspected underlying cardiovascular condition and referred him to his general practitioner who referred him back to the emergency department after suspecting an acute myocardial infarction.

Third ED Appointment Testing and Results:
On admission at the emergency department, the patient underwent a third medical assessment. His vitals were BP of 130/90 mmHg, HR of 98 bpm, RR of 25 rpm, pulse oximetry saturation levels were 97%. Neurologic and pulmonary systems were normal and abdominal palpation revealed minimal tenderness in the epigastric region.

During the cardiologic visit a 12-lead electrocardiography (ECG) and routine blood test was performed and revealed findings for the need of further drastic cardiological treatment and surgery.

Cardiologist Test Results:

The ECG showed elevation of the ST-segment. The ST segment represents the interval between the depolarisation of the ventricles and an elevation indicates a blockage (or occlusion) of the involved coronary artery.
A low voltage of the QRS complex was also found which can be caused by the “damping” effect of increased layers of fluid, fat or air between the heart and the recording electrode.
High levels of cardiac troponin 4.9 ng/mL was detected (with normal ranges being 0-0.04 ng/mL). Very high levels of troponin are a sign that a heart attack has occurred and most patients who have had a heart attack have increased troponin levels within 6 hours. After 12 hours, almost everyone who has had a heart attack will have raised levels. Troponin levels may remain high for 1 to 2 weeks after a heart attack.
Bedside echocardiogram and color Doppler showed anterolateral septal-apical necrosis (Anterior wall myocardial infarction is often caused by occlusion of the left anterior descending coronary artery).
Severe left ventricular dysfunction and right pulmonary arterial hypertension.
A coronary angiography demonstrated a complete occlusion of the proximal portion of left anterior descending artery (LAD).

Cardiology Surgery and Care:
The patient was admitted to the intensive cardiologic care unit with a diagnosis of acute ST-elevation myocardial infarction due to occlusive coronary artery disease. Percutaneous transluminal coronary angioplasty (PTCA) was performed to open the blocked coronary arteries to improve blood flow to the heart muscle and a drug-eluting stent (DES) on LAD was planted in the cath lab immediately after.

After a week of hospitalization in the surgical unit, the heart surgeon decided to subject the patient to the implantation of an implantable cardioverter defibrillator (ICD) due to persistent arrhythmia.

At 3 months follow-up, ICD has been evaluated and no signs of intervention were detected. Furthermore, neither signs nor symptoms of shoulder pain or viscerogenic disease had been reported. Thereafter, the cardiologist allowed performing a cardiological physiotherapy program and the patient made a full recovery after six months.

Further Study Discussion:
Medication intake of non steroidal anti-inflammatory drugs (NSAIDs) in patient cases with a suspected cardiovascular disease is potentially an aggravating factor in the case of an acute myocardial infarct (AMI). Specifically, diclofenac-based medications should be carefully administered under medical prescription due to their high cardiovascular associated risks.

Moreover, attention must be given to patients who use other NSAIDs such as ibuprofen or paracetamol, which despite having shown lower risks of cardiovascular events than diclofenac still pose a substantial aggravating risk in the case of an AMI.

In this case, the patient's prescription of listed NSAIDs listed above could have accelerated his symptoms and contributed to the sudden shift and change of symptoms from the right shoulder pain to the left shoulder. Other red flags noted was a consistent blood pressure diastolic reading of over 90 mmHg and an idiopathic non specific recent cause for constant right shoulder pain.

It is appreciated, however, that it was difficult to distinguish the present shoulder pain caused via a visceral somatic pathology and a previous history of multiple shoulder dislocations. In this case, other signs and symptoms including dyspnea, fatigue, shortness of breath and diaphoresis established the final need for a referral. It has also been observed that clients should be encouraged to regularly self monitor their own blood pressure should a practitioner suspect a cardiological visceral somatic cause as a differential diagnosis for a related musculoskeletal complaint.

References

1. Lin, K-T., Lai, S-W., Hsu, S-D., Fan, C-Y., Wang, H-J., Chang, P-K., Wei‐Hsiu Liu, W-H., Chen, Y-L., Yen, I-C., Lee, S-Y. (2019) Shoulder Pain and Risk of Developing Hypertension and Cardiovascular Disease: A Nationwide Population‐Based Cohort Study in Taiwan, J Med Sci, Wolters Kluwer, MedKnow; 39; (3):127-134.

2. Storari, L., Barbari, V., Brindisino, F., Testa, M., Filippo, M. (2021) An unusual Presentation of Acute Myocardial Infarction in Physiotherapy Direct Access: findings From a Case Report, Archives of Physiotherapy, 11; (5): 1-9.

Frozen Shoulder, Management and Cause

Sun, 15 Jan 2023 19:23:48 GMT

Pathology, Cause & Treatment

Frozen shoulder medically termed 'adhesive capsulitis (AC)' has an incidence of between 3 to 5% worldwide and characterised by the development of dense adhesions and thickening of the joint capsule (2, 3). The condition leads to progressive pain, stiffness and limited active and passive ranges of motion within the shoulder joint. Symptoms are often worse at night and radiological scanning appears normal (3).

The typical patient that develops adhesive capsulitis are women aged between 50 to 70 and has been reported to occur within both shoulders simultaneously in up to 40-50% of patients. Adhesive capsulitis is commonly associated with other systemic and nonsystemic conditions. By far the most common is the co-morbid condition of diabetes mellitus, with an incidence of 10–36%.

Codman (1934) was the first to describe AC and the common criteria shared by individuals with frozen shoulder which include the slow onset of pain, inability to sleep on the affected side, painful and restricted shoulder abduction and external rotation motions. Plain x-rays of shoulders with AC may range from a normal appearance to osteopenic or degenerative changes (2).

Other co-morbid conditions include hyperthyroidism, hypothyroidism, hypoadrenalism, Parkinson’s disease, cardiac disease, pulmonary disease, stroke, and even surgical procedures that do not affect the shoulder such as cardiac surgery, cardiac catheterization, neurosurgery, and radical neck dissection.

Duration

Although some have described adhesive capsulitis as a self-limiting disorder that resolves in 1–4 years, other studies report that 20 - 50% of patients with adhesive capsulitis which suffer long-term range of movement deficits may last up to 10 years. Up to 15% of FS patients will suffer from a long-term disability

Clinical Phases (6):
The condition progresses in three stages:
1. Freezing; pain is most severe during this phase. This inflammatory phase typically lasts between 3 and 9 months. The stage is characterised by an acute synovitis of the glenohumeral joint, when the synovium or of the connective tissue that lines the inside of the joint capsule becomes inflamed.
2. Frozen or adhesive, stiff phase whereby the pain gradually reduces but the range of motion in all planes becomes severely restricted. This stage lasts anywhere 4 to 12 months.
3. Thawing or recovery phase involves the gradual spontaneous improvement of shoulder function (5-26 months).

Cause; Primary & Secondary Frozen Shoulder

It is generally believed that frozen shoulder develops as a result of perivascular inflammation and fibroblastic proliferation, followed by capsular fibrosis and contracture.

Frozen shoulder syndrome has been classified into “primary” and “secondary”.

Primary adhesive capsulitis is idiopathic with the cause being unknown and classified to patients who present with no significant findings within their case history, clinical examination, or radiographic evaluation to explain their loss of joint motion and pain (1).

Primary idiopathic frozen shoulder can be associated with other diseases and conditions such as diabetes mellitus and might be the first presentation of a diabetic patient. Patients with systemic diseases such as thyroid, cardiovascular and lung diseases along with open heart surgery, depression, polymyalgia and Parkinson’s disease are also at higher risk.

Patients with secondary adhesive capsulitis disclose a trauma or surgery to the affected upper extremity prior to their shoulder symptomatology (1).

Adhesive capsulitis usually manifests itself in 12-42 months, but it may be as early as 6 months or as late as 10 years (1).

The Pancreas, Diabetes & Shoulder Problems

The pancreas is a large gland located behind the stomach and has the function of maintaining healthy blood sugar levels by producing insulin, glucagon and other hormones (5).

Diabetes is a metabolic condition characterised by hyperglycemia caused by insulin deficiency and / or impaired effectiveness of insulin action. The disease is considered one of the most challenging and disabling health problems in the 21st century with being the fifth leading cause of death in most developed countries (1).

The disease can be classified into two main types. Type 1 diabetes (T1D) is an organ-specific autoimmune disease caused by an autoimmune response against pancreatic islet beta cells which results to the loss of insulin production (1). Type 2 diabetes occurs from insulin deficiency and/ or insulin resistance (1). Diabetic patients are five time more likely than nondiabetic patients to develop frozen shoulder (1).

Classic Warning Signs and Symptoms for Diabetes

Polyuria (increased urination), polydypsia (increased thirst) and polyphagia (increased hunger) which occurs commonly in type 1 and 2 diabetes with very high levels of hyperglycaemia are usually clear signs and symptoms. Severe weight loss is common only in type 1 diabetes or if type 2 diabetes remains undetected for a long period. Unexplained weight loss, fatigue, irritability and restlessness and body pain are also common signs of undetected diabetes. The condition can be difficult to catch as symptoms can be mild or have a gradual development and remain unnoticed.

Other signs and symptoms include (3):

Repeated infections especially in the genital areas, urinary tract, skin, oral cavity and delayed wound healing.
Dry mouth
Burning, pain, numbness on the feet along with Itching.
Reactive hypoglycaemia
Acanthoses nigricans or the presence of velvety dark patches of the neck, arm pit, groin which is an indication of insulin resistance.
Reduced vision
Impotence or erectile dysfunction

Advanced Glycation End Products (AGEs)
Advanced Glycation End Products or AGES are proteins or lipids that become glycated by having an added sugar molecule after having undergone glycation. Glycation end products are believed to play a causative role in the vascular complications of diabetes mellitus. In diabetic tissue, hyperglycemia can cause a non-enzymatic covalent bonding of sugar molecules to collagen fibers. Over time, AGEs increase the cross linking of collagen fibres of the shoulder capsule, thus changing the mechanical properties of tissue by making the structures stiffer and weaker (1).

Management

Particularly for clients with a primary AC, it is advisable to have a blood test to understand whether there might be an associated undiagnosed underlying cause listed above. Available management strategies may include the use of analgesia, such as non‐steroidal anti‐inflammatory drugs (NSAIDs) and/or intra‐articular steroid injection. Encouragement of activity by performing specific exercises is crucial to improve joint range of motion. In rare cases, surgical procedures can be considered, such as manipulation under anesthesia or capsular release under arthroscopic guidance.

As Ben-Arie et al., (2020) highlight, there is still disagreement upon which treatment is the most effective for reducing pain and restoring ROM for patients with FS but most research has found strong evidence in favor of laser therapy and steroid injections for pain treatment in the short term (4).

How Might Physical Therapy Modalities Help?

Massage
Massage modalities can be applied with the aim to increase blood circulation, relieve pain by interfering with pain signals' pathway to the brain via the 'gate control theory', stimulate the release of endorphins, encourage lymphatic drainage, relieve muscle tension and spasms.

Dry Cupping

Two case studies investigated the effectiveness of dry cupping (hijamah) whilst individuals were in phase two of having adhesive capsulitis. Suctioning of cups with gliding techniques were applied at the affected areas (1, 8).

The treatment modality aims to encourage blood flow to the area and increase the permeability of blood vessels which helps aid exudation of plasma proteins and fluid into the tissue to create swelling or oedema (1). The vacuum technique also aims to help the circulation of lymphatic fluid, reduce inflammation and facilitate recruitment of immune cells and support the healing process (1). Both case studies found significant improvements with reduced pain levels, active range of joint movement and muscular tenderness.

Acupuncture

A systematic review and a meta-analysis by Ben-Arie et al., (2020) concluded that acupuncture had shown to be a safe treatment with a significant effect in regard to reducing pain, improving shoulder function, and flexion ROM in the short term and midterm after analysing a total of 966 FS patients from 13 publications (4).

References

Abicd, M., Shazia, H., Khan, S., Nazli, T., Mahto, R. R. (2021) Effect of Hijamah (Dry Cupping) on Frozen Shoulder: A Case Study, Journal of Advanced Research in Ayurveda, Yoga, Unani, Sidhha & Homeopathy, 8; (1,2): 14-17.
Alsubheen, S. A., MacDermid, J. C., Overend, T. J. Faber, K. J. (2019) The Diabetic Shoulder – A Literature Review, J Diabetes Clin Res., 1; 2: 59-70.
Ambady, R. (2014) Know the Signs and Symptoms of Diabetes, Indian Journal Medical Research, 579-581.
Ben-Arie, E., Kao, P-Y ., Lee, Y-C., Ho, W-C., Chou , L-W., Liu, H-P. (2020) The Effectiveness of Acupuncture in the Treatment of Frozen Shoulder: A Systematic Review and Meta-Analysis, Hindawi, Evidence-Based Complementary and Alternative Medicine: 1-14.
Chan, H. B. Y., Pua, P. Y., How, C. H. (2017) Physical Therapy in the Management of Frozen Shoulder , SMJ, 58 (12): 685–689.
Hsu , C. L., H‐H Sheu , W. (2016) Diabetes and Shoulder Disorders, 7(5): 649–651.
Hwanga, K. R., Murrell, G. A. C., Millar, N, L., Bonar, F., Lam, P., Walton, J. R. (2015) Advanced glycation end products in idiopathic frozen shoulders , J Shoulder Elbow Surg., 25; 6: 981–988.
Imam, H., Ishtiyaque. Alam, M. I., Perveen, A., Goswami, A., Khan, Q., Ahmad, T. (2019) Management of Frozen Shoulder with Oil Cupping Massage: A Case Study, Journal of Applied Sciences, 2; (2): 49-53.
Kawasaki, E., (2014) Type 1 Diabetes and Autoimmunity, Clin Podiatry Endocrinol, 23; (4): 99-105.
Manske, R. C., Prohaska, D. (2008) Diagnosis and Management of Adhesive Capsulitis. Curr Rev Musculoskelet Med 1(3–4): 180–189.
Serna, de la D., Navarro-Ledesma, S. N., Alayón, F., López, E., Pruimboom. L. (2021)
A Comprehensive View of Frozen Shoulder: A Mystery Syndrome ., Frontiers In Medicine, 8; 663703: 1-10.
Whelton, C., Peach, C. A. (2017) Review of Diabetic Frozen Shoulder, Eur J Orthop Surg Traumatol, Springer.

The Trigeminal Nerve, Facial Pain & Trigeminal Neuralgia

Tue, 15 Feb 2022 23:01:29 GMT

The Trigeminal Nerve & Trigeminal Neuropathy

Trigeminal neuralgia (TN) is a common type of severe chronic facial disorder characterised by brief electric shock-like (paroxysmal) pains in one or more divisions of the fifth cranial nerve. The condition is also termed 'tic douloureux' as the pain can cause individuals to distort or wince their face from the severe pain (7). The intense pain in the face caused by TN is also known as the 'Suicide Disease' or Fothergill's disease.

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

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

Symptomatology

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

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

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

In the early stages of this condition the individual may experience short, mild attacks. But trigeminal neuralgia can progress and cause longer, more-frequent periods of searing pain. Overall, women are more affected by this condition than men with an average age above fifty (13).

Anatomy of the Trigeminal Nerve

The trigeminal nerve is the largest and most complex of all the 12 cranial nerves in the skull with carrying a motor supply to muscles for mastication (chewing) that include:

The mylohyoid
Anterior belly of digastric
Tensor tympani

Sensory transmission from the trigeminal nerve occurs to innervate the scalp, face, orbit, paranasal sinuses, anterior two thirds of the tongue from the face, most of the scalp, sinus mucosa and the oral and nasal cavities (Liu and Smith and Kenhub.com).
The trigeminal nerve is fascinating for it's unique trait of having four nuclei which sends fibres to its tracts and is associated with three separate main branches distal to the trigeminal ganglion (Figure 1, 2 and 3):

Ophthalmic (V1): The first branch controls sensation in a person's eye, upper eyelid and forehead.
Maxillary (V2): The second branch controls sensation in the lower eyelid, cheek, nostril, upper lip and upper gum.
Mandibular (V3): The third branch controls sensations in the jaw, lower lip, lower gum and some of the muscles used for chewing.

The mandibular branch (V3) carries efferent motor fibers to the muscles of mastication. The Maxillary(V2) and Ophthalmic (V1) branches both pass through the cavernous sinus. The Ophthalmic nerve exits the skull via the superior orbital fissure to enter the orbit, and the Maxillary travels through the foramen rotundum to enter the pterygopalatine fossa (PPF ).The Mandibular branch courses downward from the trigeminal ganglion through the foramen ovale to enter the nasopharyngeal masticator space where it branches to supply the muscles of mastication, and sensation to the lower lip, chin, tongue, and mandibular teeth
A hyperactive masseteric (jaw-jerk) reflex is commonly seen in dementia and various neurological conditions but has no clear diagnostic significance.

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

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

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

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

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

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

Figure 4 shows how trigeminal nerve divides into three smaller branches after leaving the brain from a side on view. The branches extend to different territories and control sensations throughout the face and join at the trigeminal ganglia which are located within the Meckels cave of the cranial cavity (Figure 4) (19).

Figure 4 shows how each branch provides sensation to particular areas of the face and depending on which branch part of the nerve is irritated, trigeminal neuralgia pain can be felt anywhere in the face. Most commonly, symptoms are felt in the lower part into the jaw region. The intensity of the pain is exceptional with some people reporting it to be more severe than experiencing a heart attack, passing a kidney stone or even giving birth.

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

Trigeminal Neuropathies: Trigeminal Neuropathy (TNO) Vs Trigeminal Neuralgia (TNA)

Trigeminal disease related symptoms often involve pain in the earlier stages but may include loss of sensation or masticatory muscle weakness. Trigeminal neuropathy (TNO) should not be confused with trigeminal neuralgia (TNA). Trigeminal neuropathy (TNO) is characterised by numbness in the skin or mucosal membranes in the distribution of the trigeminal nerves or neuropathic weakness in the muscles of mastication (19). In TNO, pain predominately presents as an early clinical symptom but as the underlying disorder progresses and neurons are destroyed, numbness and weakness can later appear along with a loss of function in the affected nerve branches (19).

Trigeminal neuralgia (TNA) is characterized by brief attacks of lancinating or stabbing sensation like pain, but not cause sensory impairment or motor weakness.

Causes

The International Headache Society (IHS) describes two classifications of TN: classical or primary and symptomatic or secondary (16).

Classical or Primary TN
Classical or primary TN is due to a vascular compression of the trigeminal root by tortuous or aberrant blood vessels (14).

Primary trigeminal neuralgia has been linked to the compression of the trigeminal nerve, typically in the base of the head where the brain meets the spinal cord. This is usually due to contact between a healthy artery or vein and the trigeminal nerve at the base of the brain. This places pressure on the nerve as it enters the brain and causes the nerve to misfire (15, 16).

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

Symptomatic or Secondary TN

Secondary Trigeminal neuralgia is caused by pressure on the nerve from either a tumor, Multiple sclerosis, a cyst, facial injury or another medical condition that damages the myelin sheaths (16).

Symptomatic TN can be related to cerebello-pontine angle tumours which compress the trigeminal nerve root. Multiple sclerosis (MS) is typically associated with TN (2-4% of patients with TN) (14).

Treatment Options

Non-Surgical Treatments

There are several effective ways to alleviate the pain, including a variety of medications which are generally started at low doses and increased gradually based on patient’s response to the drug (13). Sodium channel blockers of either Carbamazepine or Oxcarbazepine are effective in most TN cases for treating symptoms. However, they can cause possible side effects of dizziness, double vision, drowsiness and nausea. Oxcarbazepine may be preferred for the minor risk of drug interactions and tolerability (14).

Surgery

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

How Might Physical Therapy Help?

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

Acupuncture - Case Study

A previous case study by Sert et al., (2009) reported that acupuncture treatment helped relieve their symptoms after having received 5 treatment sessions. A 66 year old lady who suffered from chronic TN pain on the left side of her face for over 25 years found that acupuncture helped relieve her symptoms completely despite trying primary care intervention methods first. The primary care methods included medication (carbamazepine, gabapentin and valproic acid), nerve block and radiofrequency rhizotomy of the infraorbital branch of the trigeminal nerve (16).

However, research has concluded that although acupuncture may have some positive effects on Trigeminal Neuralgia, the level of evidence is low or very low and a firm conclusion can not yet be drawn on the efficacy of acupuncture for Trigeminal Neuralgia (16).

Deep Tissue Massage & Acupuncture - Case Study

Another case who suffered from TN was studied by Omar and Bakar (2020) who found that acupuncture with massage therapy had significantly improved their symptoms after four treatment sessions. The massage applied involved using deep pressure along the distribution of the trigeminal nerve around the regions of the ear, maxilla, mandibular, and forehead. The massage aimed to stimulate the nerve by repeatedly stroking along the distribution of the V2 trigeminal nerve. Dry needling was executed at five location points, namely the temporalis muscle, the junction of the temporo-mandibular joint and along the lower end of the maxillary bone including masseter muscle (13).

Spinal manipulation and Chiropractic Care - Case Study

Another case study who received chiropractic care and suffered from chronic TN pain was written by Rodine and Aker (2010). In this particular case, there was evidence to suggest that there were three sources of pathology contributing towards the individual's pain including; neck pain caused by degenerative disc disease (DDD), temparomandibular joint (TMJ) syndrome and trigeminal neuralgia (16). The chiropractic practitioner observed the relief of symptoms by performing ultrasound electrotherapy, manual therapy of manipulation and mobilisation, soft tissue therapy techniques and home exercises.

Osteopathic Treatment & Cranial Osteopathy

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

References

Birnbaum G and Iverson JDalfampridine may activate latent trigeminal neuralgia in patients with multiple sclerosis.Neurology 2014;83(18): 1610-161
Campbell, S., M., Winkelmann, R. R., Walkowski, S. (2014) Osteopathic Manipulative Treatment Novel Application to Dermatological Disease, Clinical Aesthetic, 5; 10: 24-32.
Crevier-Sorbo, G., Brock, A., Rolston, J. D. (2019) Trigeminal neuralgia plus hemifacial spasm caused by a dilated artery: a case of painful tic convulsif syndrome, Lancet, 394, e36.
Cruccu G, Gronseth G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. (2008) AAN‐EFNS guidelines on trigeminal neuralgia management. European journal of neurology; 15 (10): 1013-28.
Dalessio D, J. (1982) Trigeminal neuralgia. A practical approach to treatment. Drugs; 24 (3): 248-55. Physiotherapy/Physical Therapy. Available from: Physiotherapy / Physical Therapy.
Gerwin, R. (2020) Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome—An Evidence-Based Narrative Review and Etiological Hypothesis, MDPI, 17, 7012.
Headache Classification Committee of the International Headache Society (IHS) (2013) The International Classification of Headache Disorders. Cephalalgia; 33:629–808. 3rd edn.
Kataria, S., Ahmed, Z., Ali, U., Ahmad, S., Awais, A. (2020) Trigeminal Neuralgia Induced Headache: A Case Report and Literature Review, Cureus, 12; 7: 1-4.
Khanal, D., Khatri, S. M., Anap, D. (2014) Is there Any Role of Physiotherapy in Fothergill's Disease. Journal of Yoga & Physical Therapy. 1; 4 (2): 1.
Kim, J.I., Kim, H.J., Lee, J.J., Jun, J.H., Choi, T-Y., Lee, M. S. (2018) Acupuncture for the treatment of trigeminal neuralgia A protocol for the systematic review of randomized controlled trials, Medicine, 97; 11: 1-3.
Liu, G. T. (2001) Neuro-ophthalmology: Diagnosis and Management : The Trigeminal Nerve and Its Central Connections; Chapter 25: pp. 1233-1268.
Liu, H., Li, X-W., Du, J. (2019) Acupuncture Treatment on Idiopathic Trigeminal Neuralgia, Study Protocol Systemic Review, Medicine, 98; 4: 1-5.
Longo, D. L., et al., (2017) eds. Trigeminal neuralgia, Bell's palsy, and other cranial nerve disorders. In: Harrison's Principles of Internal Medicine. 19th ed. New York, N.Y.: McGraw-Hill Education; 2015. https://accessmedicine.mhmedical.com . Accessed June 5.
Omar, W. A. W., Bakar, N. L. A. (2020) Improvement of trigeminal neuralgia after massage therapy and dry needling , Malaysian Journal of Medicine and Health Sciences ;16 (102): 81-83.
Maarbjerg, S., Stefano, G. D., Bendsten, L., Cruccu, G. (2017) Trigeminal Neuralgia; Diagnosis and Treatment, Cephalalgia, International Headache Society, 37, 7; 648-657.
Reeta, Kumar U, Kumar V, Alam M, Islami D, Lal W et al (2016). A Survey to Observe the Commonly Used Treatment Protocol for Trigeminal Neuralgia by Physiotherapist. International Journal of Physiotherapy; 3 (5): 643-646.
Rodine, R. J., Aker, P. (2010) Trigeminal Neuralgia and Chiropractic Care: A Case Report, JCCA, 54;3: 177-186.
Sert, H., Usta, B., Musla, B., Gozdemir, M. (2009) Successful Treatment of a Resistance Trigeminal Neuralgia Patient By Acupuncture, Clinics, 64(12): 1225–1226.
Smith, J. H., Cutrer, M. F., (2011) Numbness Matters: A Clinical Review of Trigeminal Neuropathy, Cephalalgia, International Headache Society; 0 (0) 1–14.
Truini. A (2015), Trigeminal Neuralgia, Journal of Headache and Pain, 16; A42.
Trigeminal neuralgia. Available from: https://www.physio.co.uk/what-we-treat/chronic-pain-fatigue/trigeminal-neuralgia.php (Accessed on 2nd October, 2020).
Wikipedia (2022) [online] https://en.wikipedia.org/wiki/Mental_nerve#:~:text=The%20mental%20nerve%20is%20a%20branch%20of%20the... . (last visited 07/02/2022).

Neck Pain and Levator Scapulae Syndrome

Tue, 19 Oct 2021 12:51:36 GMT

Causes, Symptoms, Diagnosis and Treatment

The levator scapulae muscle is frequently involved when the neck becomes stiff or tight from certain muscle strains (1). The muscle runs down either side of the neck, attaches to the shoulder blade and the dominant shoulder most commonly becames affected (82%) (2). Individuals may complain of pain that radiates to the neck and shoulder, but rarely to the arm (3).
The word 'levator' comes from the Latin 'levare', meaning "to raise" and scapulae refer to the scapulas, or shoulder blades, possibly originating from the Greek "skaptein," meaning "to dig" (2).

The levator scapulae's main pain zones are the sides of the neck and the upper shoulders. This muscle can cause discomfort in the shoulder blade and the margo medialis or the zone along the inner boundary of the shoulder blade. It can also contribute to deep, aching sensations and tightness felt in the neck, over the top of the shoulders, or between the shoulder blades. Patients may also experience painful neck and impaired movement whilst rotating their head or lifting the neck from a supine position.

The levatore scapulae muscle can have involvement in numerous pathologies including the following (2):

Snapping scapula syndrome: this may present as painful crepitus or 'clicking' and commonly manifests secondary to a chronic injury, overuse, or muscle imbalance that impacts the scapulothoracic articulation (2).
Levator scapulae syndrome: pain over the upper medial angle of the scapula.
Sprengel deformity.
Cervical myofascial pain; myofascial pain is not completely understood but commonly results from postural mechanics, muscle overuse, trauma, or secondarily to another pathologic condition such as fibromyalgia. Cervical myofascial pain can be local, regional, or characterised by trigger points (2).
Fibromyalgia.

Anatomy

The levator scapulae muscle originates from the posterior tubercles of transverse processes of C1 (atlas), C2 (axis), C3, and C4 vertebrae. They connect to the first four vertebrae (C1 to C4)of the cervical spine and the superior medial aspect of the scapula, known as the angulus superior (2).

Function
The primary action of the levator scapulae is to elevate the scapula and works with the trapezius and rhomboid muscles to accomplish this motion . The levator scapulae also inferiorly rotates the scapula, depressing the glenoid cavity and assists in neck extension, ipsilateral (same side) rotation, and lateral flexion (2).

Etiology of levator scapulae syndrome

Sitting for prolonged periods, especially with poor posture can cause levator scapulae syndrome. The syndrome is most commonly found in office workers as they frequently sit for long hours with their shoulders and head protruding forward creating a 'hunch back' position at the upper back and lower neck joints which become stiff and inflexible overtime. The chronic stress placed on the levator scapulae results to reduced flexibility and chronic overuse.

The levator scapulae might affect military personnel. Such individuals are commonly known for carrying heavy equipment and perform repetitive load bearing activities that may compromise their upper body posture and lead to chronic stress or recurrent injury to muscles or joints within the neck including the levator scapulae.

Trigger Points

The levator scapulae is a common location for trigger points and frequently has a tender point associated with the diagnosis of fibromyalgia (3). Two trigger points in the lower portion of the Levator Scapulae muscle can cause pain. The lower trigger point is located directly above the superior angle of the scapula, and the higher trigger point is located 1-3 inches above it. Both trigger points are located deep within the upper trapezius muscle and convey pain laterally to the shoulder blade. Patients with mechanical neck discomfort are more likely to have active trigger points. and symptoms of levator scapulae pain can cause restricted range of movement, especially reduced cervical flexion and side flexion to the contralateral side.

Treating Levator Scapulae Tendonitis, How Might Osteopathy Help?

Identifying the cause of pain and correcting any biomechanical issues contributing to the condition, such as neck or shoulder muscle imbalances, postural issues, or thoracic/ upper back mobility problems are usually addressed first. Physical threapy treatment may assist patients in reducing the amount of stress exerted on the neck muscles such as the levator scapulae and create better postural habits. Patients are often given home exercises for the shoulder, neck, and upper back muscles for strength and flexibility.

Manual therapy applied techniques may include active release tecniques (ART) where the clinician applies deep tension at the area of tenderness whilst the patient is instructed to actively move the injury site from a shortened to a lengthened position . Other deep soft tissue massage techniques may be considered along with passive stretching and osteopathic adjustments depending on the individual's medical case history and appropriateness.

References

1. Deuk Spine Institute, Levator-Scapulae Tendonitis; https://deukspine.com/conditions-we-treat/levator-scapulae-tendonitis/ [online], last visited 19/10/2021.

2. Henry, J. P., Munakomi, S. (2021) Anatomy, Head and Neck, Levator Scapulae Muscles, StatPearls Publishing LLC.

3. Physiopedia (2021) Levator scapulae Syndrome, https://www.physio-pedia.com/Levator_Scapulae_Syndrome [online], Last visited 19/10/2021.

Nerve Entrapment, Injury and Neuropathy; The Radial Nerve

Sun, 05 Sep 2021 00:00:00 GMT

Anatomy & Treatment Options

Figure 1. Radial nerve cutaneous innervation of the upper limb

The radial nerve is the largest nerve of the upper limb and is described as having ‘a long tortuous course'. Due to the nerve's length, it is known as the most frequently injured nerve out of all the three major peripheral nerves in the upper extremity as there are various potential sites for injury (1, 3). The radial nerve predominantly gives sensation to the back of the arm, forearm, and hand.

The radial nerve's anatomical position with relation to it's close proximity to the humeral shaft of the humerus makes it particularly vulnerable should a fracture occur. Injuries to the radial nerve may occur at any point along the nerve’s route and radial nerve palsy can result from a variety of aetiologies.

Although most common to injury, a radial nerve injury is the least debilitating for upper limb nerve injuries and treatment is often non-operative.

Sensory Provision

Four branches of the radial nerve provide cutaneous innervation to the skin of the upper limb (figure 1):

Lower lateral cutaneous nerve of the arm: from the inferior aspect of the deltoid insertion of the humerus and innervates the lateral aspect of the middle to lower arm.

Posterior cutaneous nerve of the arm: innervation to the posterior surface of the arm.

Posterior cutaneous nerve of the forearm: innervates a strip of skin down the middle aspect of the posterior forearm.

Superficial branch of the radial nerve: Innervating the dorsal surface of the lateral two and half digits of the dorsum hand, although some sources state the lateral three and half digits.

Anatomy

Figure 2. Course and anatomy of the radial nerve

From the Neck and Axilla
The radial nerve originates as the terminal branch of the posterior cord of the brachial plexus at nerve roots C5 to C8 and T1. The nerve arises from the posterior aspect of the axilla and descends along the posterior surface of the humerus (figure 1) before passing through the cubital fossa and terminating in the posterior compartment of the forearm into two main branches; the sensory and motor branch.

The radial nerve gives off three sensory branches and innervates three heads of the triceps muscle and the small anconeus muscle. The nerve then snakes its way down the humerus in the spiral groove and gives muscular branches to the following muscles before bifurcating into superficial (sensory) and deep (motor) branch (figure 2):

Brachioradialis (beneath)
Ext. Carpi Radialis
Supinator

The Superficial Radial Nerve - the "sensory branch"
This part of the radial nerve travels down the forearm over the radial bone and over the extensor tendons to the thumb and supplies the majority of the dorsal surface of the hand (6).

The Posterior Interosseous Nerve
This nerve is a motor branch that runs along the lower neck of the humerus before entering the extensor compartment and piercing through the supinator muscle where it supplies the remaining extensors of the wrist, thumb and finger.

The Posterior Antebrachial Cutaneous Nerve
Upon entering the cubital region and before its division, the radial nerve provides the posterior antebrachial cutaneous nerve which is also a sensory branch and innervates the strip of skin down the middle of the posterior forearm, as mentioned above (4).

The Deep Branch - the "motor branch" of the Radial Nerve
Provides motor innervation (i.e. innervating muscles to produce motion) to the posterior compartment of the forearm.

Injury, Entrapment Sights and Clinical Examination of the Radial Nerve

Figure 3. Neuropathy and 'wrist drop' of the Radial nerve

Radial Nerve Entrapment
Entrapment of the radial nerve is uncommon but the most frequent location, should it happen, may occur at the proximal forearm or in proximity to the supinator involving the posterior interosseous nerve branch (2).

Radial Tunnel Syndrome (RTS)
The radial tunnel extends from the radial head to the inferior border of the supinator muscle and the boundaries consist of the supinator, extensor carpi radialis longus and brevis and the brachioradialis muscles.
The injury is more prevalent in women between ages 30 to 50 years old and mainly occurs via intermittent compression on the radial nerve from the radial head to the inferior border of the supinator muscle without notable extensor muscle weakness (2, 3, 4).

Entrapment of the radial nerve may occur as a result of overuse or repetitive actions and exercise involving pronation or supination (e.g. frequent use of a screw driver), direct trauma, fractures, or involve the posterior interosseous nerve due to it being situated at the level of the radiocapitellar joint (between the radial head and the lateral condyle of the humerus) (2, 4) (Figure 3).

Four other Sites for Radial Nerve Entrapment:

Fibrous bands around the radial head.
Recurrent Radial vessels.
Arcade of Frohse.
Tendinous margin of the extensor carpi radialis brevis.

Overall, the radial nerve is most vulnerable to injury at the mid-humeral level.

Radial Palsy & Wrist Drop (Figure 3.)
The main clinical feature of a radial nerve injury is wrist drop as the flexor tone overpowers the nonfunctional wrist extensors and the hand is pulled into a flexed position. The wrist might be able to be passively extended into place, but the patient is unable to actively maintain the position. Extension of the the fingers at the metacarpophalangeal joints and the inability to extend or abduct the thumb can also be lost, thus causing the patient the inability to open the hand prior to initiating grasp (2, 4).

As Figure 3 demonstrates, occupational performance can be affected as the absence of oppenens pollicis may reduce muscle power whilst grasping a hammer or screw driver handle or whilst writing with a pen.

The Spiral Groove & ' Saturday Night Palsy'
External compression or trauma via fracture along the shaft of the humerus at the spiral groove can also cause radial neuropathy and be attributed from immobilisatoin of the arm. A common cause can be from patients falling asleep with their arm draped over a chair (usually after intoxication) and is classically known as "Saturday Night Palsy" (2). Clinically, patients present with wrist drop, weakness of finger extension and dysesthesia along the distribution of the superficial radial nerve. Often, supination is weakened but elbow extension is spared as the branches to the triceps originate before the spiral groove.

Radial Neuropathy and the Use of Crutches
External compression from inadequate use of crutshces can also cause vulnerability to the radial nerve which can cause weakness in elbow extension and sensory loss within the proximal cutaneous branches. This can entrap the posterior interosseous branch of the radial nerve within the supinator muscle under the arcade of Frohse along with the patient showing signs of wrist drop and weakness in supination (6). Clinical signs for this might involve radial deviation as the patient attempts to extend the wrist and sensory dysesthesia.

Osteopathy & Possible Treatment Management

Radial Nerve Flossing Exercise:

Osteopathic treatment may consist of gentle soft tissue massage applied to the local and relevant muscles along with articulation to neighbouring joints to areas such as the neck, mid back and shoulders with the aim of reducing muscle tightness, tissue swelling and providing physical space for the trapped nerve. Other treatment modalities might also be offered such as medical acupuncture to reducing muscle spasm, and trigger points along with passive and active stretching, muscle energy techniques, electrotherapy, home exercises such as a nerve 'flossing' home programme and postural adaptations and lifestyle advice.

If the problem is severe or not resolving, a Magnetic Resonance Imaging (MRI) scan is usually referred to establish the cause of the neuropathy and the result can help the practitioner know whether a medical referral for a surgical opinion or rheumatologist is necessary.

References

1. Agarwal, A., Chandra , A., Jaipal , U., Saini , N. (2018) A panorama of radial nerve pathologies- an imaging diagnosis: a step ahead, Springer; 9: 1021–1034.

2. Buchanan, B. K., Varacallo, M. (2018) Radial Nerve Entrapment, StatPearls, NCBI Bookshelf,

3. Colditz, J. C. (1987) Splinting for Radial Nerve Palsy, Journal of Hand Therapy, 18-27.

4. Kenhub (2020), the Radial Nerve, Available From: https://www.kenhub.com/en/library/anatomy/radial-nerve [online] last viewed 2/09/2021.

5. Ljungquist, K. L., Martineau, P., Allan, C. (2015) Radial Nerve Injuries, ASSH, Elsevier, 40: 166-171.

6. McNamara, B. (2003) Clinical Anatomy of the Radial Nerve, ACNR, 3; 3: 28-29.

Nerve Entrapment, Injury and Neuropathy; Ulnar Nerve

Thu, 13 May 2021 08:41:11 GMT

Anatomy and Management

Figure 1. Course, hand claw and dermatome distribution of the ulnar nerve

Individuals with compressive neuropathy of the ulnar nerve commonly describe symptoms of dysesthesia (altered sensations with numbness or paraesthesia/ tingling) of the small finger and ulnar half of the ring finger or atrophy and muscle weakness within the affected hand (3). The altered sensations are usually worse at night and begin intermittently particularly if the elbow is flexed whilst sleeping (3).

The ulnar nerve is broadly described as 'the nerve of the hand' as it innervates the majority of intrinsic hand muscles and is clinically significant for its role in hand function (4). The ulnar nerve is also the largest nerve in the human body to not be protected by either muscle or bone which is why injury is common (10).

Most ulnar (and median) nerve palsies are as a result of traumatic transection which results in function impairment, can cause different levels of motor and sensitive dysfunction and is common in the upper extremity of young males (1). Significant injury to the ulnar nerve can lead to the characteristic presentation of a 'claw hand' (Figure 1). The ulnar nerve is also responsible for causing an 'electric shock' sensation by striking the medial epicondyle of the humerus posteriorly, or inferiorly with a flexed elbow. At this point, it can become trapped between the bone and the overlying skin and is commonly referred to as bumping one's " funny bone " (10).

Clinical Relevance of Ulnar Neuropathy

The ulnar nerve passes through several small spaces as it courses through the medial side of the upper extremity, and at these points the nerve is vulnerable to compression or entrapment. The nerve is particularly vulnerable to injury when there has been a disruption in the normal anatomy and the most common site of ulnar nerve entrapment is at the elbow (cubital tunnel syndrome), followed by the wrist (Guyon's canal syndrome) (7).

Causes or structures which have been reported to cause ulnar nerve entrapment or compression include (7):

At the neck: thoracic outlet syndrome, cervical spine pathology, anterior scalene muscles.
At the chest: pectoralis minor muscles.
Brachial plexus abnormalities.
Elbow: fractures, growth plate injuries, cubital tunnel syndrome, flexorpronator aponeurosis, arcade of Struthers.
Forearm: tight flexor carpi ulnaris muscles
Wrist: fractures, ulnar tunnel syndrome, ganglion, hypothenar hammer syndrome
Artery aneurysms or thrombosis
Other: Infections, tumors, diabetes, hypothyroidism, rheumatism, and alcoholism

While most cases of injury are minor and resolve spontaneously with time, chronic compression or repetitive trauma may cause more persistent problems. Commonly cited scenarios include (7):

Sleeping with the arm flexed behind the neck or positioning the elbow in a prolonged flexed position.
Pressing the elbows upon the arms of a chair while typing.
Resting or bracing the elbow on the arm rest of a vehicle.
Bench pressing.
Intense exercising and strain involving the elbow.

Certain positioning of the elbow may create symptoms; cadaveric studies have demonstrated that the action of elbow flexion can cause the ulnar nerve to be predisposed to both compression and traction (2).

For laborers, tradesmen and women who have a physically demanding job and or throwing athletes who repetitively use their elbows, symptoms may be precipitated by intense or prolonged periods of increased activity. These individuals may also present with concurrent bony and soft tissue pathologies at the elbow, such as medial epicondylitis, lateral epicondylitis and ligamentous instability (5).

Anatomy & Nerve Course

Figure 2. Anatomy of the carpal bones with relation to the ulnar nerve

As can be viewed from figure 2, the ulnar nerve (8) is sandwiched between the ulnar artery (9) and to only one carpal bone; the pisiform (P).
Being a terminal branch of the medial cord of the brachial plexus, it contains fibers from the ventral rami or the anterior division of C8 and T1 and can sometimes carry fibers from C7 (3, 5). The nerve travels distally through the axilla and is positioned medially to the axillary artery before descending the medial aspect of the upper arm ( 3).

Ulnar Nerve Journey Through the Arm
The ulnar nerve does not give branches in the upper arm or axilla, but starts giving muscular and cutaneous branches in the upper forearm and the hand (9). The nerve lays medially to the brachial artery and exits the posterior compartment of the arm before descending down the humerus to enter the anterior compartment of the arm through the medial intermuscular septum and runs anteriorly to the medial head of triceps brachii muscle (11).

Interestingly, in 70-80% of people, this nerve passes under the arcade of Struthers which is a thin aponeurotic band that extends from the medial head of triceps to the medial intermuscular septum which is another possible site for compression of the ulnar nerve (11, 3, 5).

Cubital Tunnel & Cubital Tunnel Syndrome

Figure 3. Anatomy of Cubital Tunnel Syndrome

The ulnar nerve continues anterior to the medial head of the triceps brachii muscle, passes posterior to the elbow and enters the cubital tunnel (also known as ulnar tunnel) located on the posteromedial aspect of the elbow which transmits the ulnar nerve from the arm into the forearm (5).
The borders of the carpal tunnel are (5):

Medial wall – medial epicondyle of the humerus.
Lateral wall – olecranon of the ulna.
Floor – the elbow joint capsule and medial collateral ligament of the elbow.
Roof – the cubital tunnel retinaculum or the arcuate ligament of Osbourne which runs between the ulnar and humeral heads of the flexor carpi ulnaris muscle (2).

Cubital Tunnel Syndrome
The cubital tunnel is yet another site for compression of the ulnar nerve and is the second most common peripheral neuropathy of the upper limb (after carpal tunnel syndrome) (2).

Ulnar Nerve Journey; the Forearm

The ulnar nerve passes between the medial epicondyle and olecranon in the groove for the ulnar nerve to enter the anterior compartment of the forearm (6). Posterior to the medial epicondyle, the ulnar nerve is easily palpable and is commonly referred to as the "funny bone" in this region (6).

After exiting the cubital tunnel, the ulnar nerve gives off 2 or 3 muscular branches to the flexor carpi ulnaris (FCU) muscle. The ulnar nerve passes beneath the humeral and ulnar heads of the FCU muscle to enter the volar aspect of the forearm, where it continues deep to the flexor pronator aponeurosis. In the forearm, the nerve passes anterior to the flexor digitorum profundus (FDP) muscle to supply motor branches to the ulnar half of FDP. The ulnar nerve travels the remaining length of the forearm between the FDP and the flexor digitorum superficialis (FDS) muscles (5, 6).

The ulnar nerve supplies all intrinsic muscles of the hand except the L OAF muscles listed below; note that the 'OAF' muscles move and activate the thumb (6). These muscles are the L ateral two lumbricals (of 4th and 5th fingers); the O pponens pollicis which produces opposition of the thumb, bringing the tip of the thumb in contact with any other fingertip of the same hand and allowing precise movements of the hand, e.g. grasping round objects or fine gripping of a pencil (6). The A bductor pollicis brevis; Pulls the thumb away from the index finger and F lexor pollicis brevis bends the thumb towards the small finger (6).

Figure 4. Illustartion of the Ulnar nerve journey from the cervical spine into the hand its cutaneous innervation of the hand

Ulnar Nerve Branches At the Wrist & Hand

As Pearce et al., (2009) highlight, ulnar nerve entrapment at the wrist is uncommon and can be difficult to diagnose. It is important to understand the nerve’s anatomical course and distribution to allow for accurate diagnosis (8).

Proximal to the wrist, the dorsal cutaneous nerve branches off to the dorsal hand followed by the palmar cutaneous branch to the proximal palm (8) . These two sensory branches to the hand do not pass through the Guyon's canal (8).
The Dorsal Cutaneous Branch arises from the medial aspect of the ulnar nerve approximately 8cm proximal to the pisiform bone and provides dorsal branches to the little finger, the lunar aspect of the ring finger and the ulnar aspect of the carpus and hand (11).

The Guyon's Canal
The ulnar nerve and artery then enter the hand by travelling through the Guyon's canal (or ulnar canal) which is a groove between the pisiform and hook of the hamate and bridged by the palmer carpal ligament (5).
At the distal aspect of the Guyon's Canal and as the ulnar nerve exits under the palmaris brevis muscle, the ulnar nerve bifurcates into the superficial sensory branch and the deep motor branch (11).

Deep Motor Branch of the Ulnar Nerve
The deep motor branch passes between the flexor and abductor digiti minimi (ADM) muscles and gives off a branch to the hypothenar muscles, including the ADM. The Deep motor branch then turns about the hook of the hamate and deviates laterally across the palm to innervate the dorsal interossei, the third and fourth lumbricals, the adductor pollicis (AP), the flexor pollicis brevis (FPB), and terminates in the FDI (8).

Superficial Branch of the Ulnar Nerve
Supplies sensation to only the ulnar surface of the hypothenar eminence, the ulnar half of the fourth digit and the fifth digit (8). The superficial branch of the ulnar nerve gives off two small motor branches to the palmaris brevis muscle (11).

Guyon's Canal Syndrome

Ulnar nerve impingement along the anatomical space of the Guyon's canal is known as Guyon's canal syndrome , or ulnar tunnel syndrome. Recognised causes of ulnar nerve impingement at this location include local trauma, fractures and ganglionic cysts (7).

Cyclists who place prolonged pressure against bicycle handlebars (also known as handlebar neuropathy) along with various sports and activities such as weight lifting who experience repetitive trauma and place pressure on the hypothenar eminence are at an increased risk for compression of the ulnar nerve at the Guyon's canal (3, 6, 8). This form of ulnar neuropathy comprises of two work-related syndromes: so-called "hypothenar hammer syndrome," seen in workers who repetitively use a hammer, and "occupational neuritis" due to hard, repetitive compression against a desk surface (7).

Incidences And Location of Ulnar Neuropathy

From studying the anatomy above, one can gain a clearer picture as to where and why ulnar compression may occur. Like most other peripheral nerves, ulnar nerve injuries can occur at various sites along its course from the neck to the upper limb.
A listed summary of sites are (7):

The medial epicondyle
The cubital tunnel (most common)
Guyon's canal

Sensory loss following an ulnar nerve injury depends on its site of injury. According to Woo et al., (2015) and Kenhub (2020)the ulnar nerve can be divided into a low/ distal injury (where injury occurs closer to the hand) and high/ proximal injury (closer to the elbow) (6, 11). A distal ulnar nerve injury results to a higher impact of devastation as the hand muscles are denervated.

Proximal/ High Ulnar Nerve Injury (Closer to the Elbow)
In high injuries, the nerve is damaged above the origin of the motor branch of the FCU and FDP muscles. A high ulnar nerve injury results in less claw hand deformity as the loss of FDP function (6, 7).

Proximal Ulnar Nerve Compression; often occurs when a person rests their elbow on the table for a long time, or on a window (for long distance drivers). It can also occur as an athletic injury, particularly in throwing athletes e.g. baseball pitchers, cricketers, and javelin throwers. The rapid movement of the elbow joint from flexion into whip-like extension can results in compression of the ulnar nerve (6).

Distal/ Low Ulnar Nerve Injury (Closer to the Hand)
Re-examining the ulnar nerve anatomy, a distal or 'low ulnar nerve injury' can involve damage to the nerve distal to the motor branch of the Flexor Carpi Ulnaris (FCU) and/or motor branch to the Flexor Digitorum profundus (FDP) of the ring and little finger (11). As a result, sensibility to the palmar ulnar hand is lost and paralysis commonly occurs to all 7 interosseous, the ulnar 2 lumbrical muscles, the 3 hypothenar, the adductor pollicis, and the deep head of the flexor pollicis brevis muscles (11).

The Ulnar Paradox

Figure 5. Muscles of the forearm with highlighting flexor digitorum profundus and flexor carpi ulnaris

The ulnar nerve innervates the ulnar (medial) half of the flexor digitorum profundus muscle (FDP) of the forearm which flexes the forearm and the fingers (figure 5).

Proximal (High) Ulnar Nerve Injury

Proximal (or high) ulnar nerve lesions are commonly as a result of trauma at or above the elbow and cause palsy and denervation of the flexor digitorum profundus (FDP) muscle (1, 7).

However, a proximal injury leads to an open palm and there is more capacity for hand function (6). As a result, flexion of the IP joints are weakened and this reduces the claw-like appearance of the hand. Instead, the fourth and fifth fingers are paralysed in their fully extended position (6, 7).

Distal (Low) Ulnar Nerve Injury

This is opposite to a distal injury in the hand which denervates muscles that flex the hand. This is called the "ulnar paradox" as one would expect a proximal ulnar nerve injury to result in a more debilitating and deformed appearance. As re-innervation occurs along the ulnar nerve and the patient recovers after a proximal (high) lesion. In a proximal injury, the deformity will at first get worse (as the FDP will be re-innervated) - hence the use of the term "paradox" (7). A simple way to remember this is: 'the closer to the Paw, the worse the Claw' (10).

'Claw Hand'

As explained in the ulnar paradox section, the severity of a 'claw hand' depends on the location of injury. Proximal injuries within the elbow, for example, may denervate the ulnar part of flexor digitorum profundus which may mean that a flexed appearance may not be apparent (6).

Individuals with the claw hand deformity have hyperextension of the 4th and 5th metacarpophalangeal (MCP) joints due to the denervation of the 3rd and 4th lumbricals which flex the MCP joints (7|). The unopposed action of the long finger extensors cause these joints to be extended by the long finger extensors; extensor digitorum and the extensor digiti minimi (7).

The lumbricals and interossei also extend the interphalangeal (IP) joints of the fingers by insertion into the extensor hood and their paralysis results in weakened extension (7). The combination of hyperextension at the MCP and flexion at the interphalangeal (IP) joints (Duchenne's sign) gives the hand its 'claw' like appearance (7, 11).

Examination

To better understand the deficiency associated with low ulnar nerve palsy, 5 areas of pathology are explored (3):

pinch
digital motion
grip
clawing of the ring and little finger
digital abduction/adduction.

In cases of advanced ulnar neuropathy, further inspection may reveal atrophy in the hypothenar eminence and in the first dorsal interosseous muscle bulk (3).

Clinical Tests

Froment’s sign : overt flexion of the thumb interphalangeal joint while attempting resisted pinch (3)
Wartenburg’s sign P ersistent abduction posture of the small finger due to unopposed action of the radial-innervated extensor digiti minimi (3).
Tinel’s sign; Percussion testing over the areas of entrapment sites.
Direct pressure applied over known compression points of the nerve. The most sensitive (91 %) provocative test for ulnar nerve compression at the elbow is direct pressure over the ulnar nerve posterior to the medial epicondyle while the elbow is in flexion (3).
Scratch collapse test to identify distinct or concurrent points of ulnar nerve compression (3).
Ten Test: Sensory examination with subjective responsiveness to sensation to light touch (3).
Muscle Power Testing: motor examination of the flexor carpi ulnaris, flexor digitorum profundus, finger abduction and finger adduction.
Two point discrimination.

Treatment and Management

Conservative treatment for cubital syndrome and ulnar nerve entrapment will include the need to perform a regular exercise program and routine. The NHS has written a good guidance for conservative treatment here (4). Exercises should have the goal of gradually recover wrist extension and all finger movement (1). Passive and active-assisted ROM exercises are introduced depending on the patient's progress and current case.

Ulnar Nerve Flossing Exercise:

Splinting
The use of splints in peripheral-nerve injury, specifcally for the ulnar nerve should have the following aims (1);

Keeping the denervated muscles from remaining in an overstreched position.
Prevent joint stiffness.
Develop strong movement patterns and to maximize functional use of the hand (1).
The goal in splinting a low lesion of ulnar nerve is to prevent overstretch of denervated intrinsic muscles of the ring and little fingers (1).
Splints that blocks the MP joints in slight flexion prevent de claw deformity by forcing the extrinsic extensor to transmit forces into the dorsal hood mechanism of the finger (1).

How Might Osteopathy Help?
Assessment of the posture and placing careful attention to head, cervico-thoracic spine, scapula, upper and lower arm positioning will be of great importance. One must take into consideration the uniqueness of each case and techniques might be applied around the known entrapment site. Techniques may involve soft tissue techniques to the areas already mentioned along to the axilla, ribs/ intercostal and erector spinae muscles. Gentle articulation and osteopathic techniques might also be applied along with electrotherapy and kinesiology taping to encourage enhanced postural positioning.

References

1. Barbosa, R. I., Fonseca, M. de C. R., Valéria, V. M. C., Mazzer, N., Henrique, C. (2012) Median and Ulnar Nerves Traumatic Injuries Rehabilitation, Basic Principles of Peripheral Nerve Disorders, Chapter 15, Available From: https://cdn.intechopen.com/pdfs/34135/InTech-Median_and_ulnar_nerves_traumatic_injuries_rehabilitati... [Last Accessed 09/05/2021].

2. Becker, R. E., Manna, B. (2020) Anatomy, Shoulder and Upper Limb, Ulnar Nerve, Available From: https://www.ncbi.nlm.nih.gov/books/NBK499892/ [Last Accessed 03/05/2021].

3. Dy, C. J., Mackinnon, S. E. (2016) Ulnar Neuropathy: Evaluation and Management, Curr Rev Musculoskelet Med, Springer, 9: 178-184.

4. Guy's and St Thomas' NHS Foundation (2020) Cubital Tunnel Syndrome, Available From: https://www.guysandstthomas.nhs.uk/resources/patient-information/therapies/hand-therapy/cubital%20tu... [Last Accessed 11/05/2021]

5. Jones, O. (2021) The Ulnar Nerve, Teachmeanatomy, Available From: https://teachmeanatomy.info/upper-limb/areas/ulnar-tunnel/ [Last accessed 03/05/2021]

6. Kenhub (2020) The Brachial Plexus, Available From: https://www.kenhub.com/en/study/the-brachial-plexus [online; last viewed 18/10/2020].

7. Neurology Needs, Ulnar Nerve, Available From: https://www.neurologyneeds.com/neuroanatomy/peripheral-nerves/ulnar-nerve/ [Last Accessed 12/05/2021]

8. Pearce, C., Feinberg, F., Wolfe, S. W. (2009) Ulnar Neuropathy at the Wrist, HSSJ, 5: 180–183, Available from:

https://www.researchgate.net/publication/26276661_Ulnar_Neuropathy_at_the_Wrist , [Last accessed 03/05/2021]

9. Physiopedia. Ulnar Nerve. Available from: https://www.physio-pedia.com/Ulnar_Nerve [last accessed 03/05/2021]

10. Wikipedia (2021) Ulnar Nerve, Wikipedia, the free encyclopedia, Available From: https://en.wikipedia.org/wiki/Ulnar_nerve [Last Accessed 03/05/2021]

11. Woo, A., Bakri, K., Moran, S. L. (2015) Management of Ulnar Nerve Injuries; Current Concepts , ASSH, Journal of Hand Surgery Am., 40: 173-181.

Scoliosis

Sun, 21 Feb 2021 16:24:09 GMT

Cause, Ideology & Treatment Options

Scoliosis is the most common deformity of the spine and often consists of lateral displacement with associated rotation of the vertebral bodies (7). The term scoliosis is a condition first described in detail by the Greek physician Hippocrates who took its name from the Greek word 'scolios' meaning 'crooked' (7). A scoliosis is normally considered if there is a Cobb angle (explained below) of at least ten degrees of spinal angulation with lateral curvature shown on a posterior-anterior radiograph (5).

As the UK Scoliosis Association highlights, scoliosis is neither infectious nor contagious, but can develop at any age and usually becomes most clinically evident during growth, growth spurts or rapid somatic growth especially during puberty (7). The condition is classified broadly as congenital, neuromuscular, syndrome-related, idiopathic and spinal curvature due to secondary reasons (5).

Presently, the cause of scoliosis is thought to be multifactorial, but 80% of cases are largely idiopathic (undetermined cause) (1, 11).

The different stages of occurrence are as follows:

- Before birth (congenital)

- Infantile (0-3 years); structural malformation that more commonly affects boys than girls with most cases developing within the first year of life and tending to have a leftward trending curvature (levoscoliosis) (6).

- Young children; juvenile (4-10 years)

- Older Children; adolescent idiopathic scoliosis (AIS) (11-18 years) more commonly developed in girl and involves a structural curvature that commonly has a rightward trend (dextroscoliosis) (5, 6).

- Adults (degenerative or de novo)

The classification of scoliosis is dependent upon which region of the spine is affected with usually being termed either 'thorcaic', 'lumbar' or 'thoracolumbar' and the involvement of any of these areas is of significance as one must take organ function into consideration. For instance, the thoracic spine is primarily responsible for the respiratory and cardiovascular complications of scoliosis (7). A lumbar spine scoliotic pattern can later affect an individual's pelvic floor strength, incontinence or cause bowel and bladder related pathology or disorder (8).

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

The Nature of the Scoliosis

A scoliosis is classified with accordance to the side of its occurrence into either left or right sided curves and each curve of a scoliosis is classified as either having a convex or concave side as well as a primary curve and a secondary curve (10). The primary curve is usually stiffer and the curve site is classified with accordance to the location of the apical or apex vertebra in the coronal plane within either the cervical, thoracic or lumbar spine (6).

Locations & Types of Scoliosis: Dextroscoliosis & Levoscoliosis

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

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

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

Structural or Non Strucutral Scoliosis

Structural:

Scoliosis may be structural which is when the patient's spine has an anatomical physical curve that can be observed whilst the patient is standing or sitting. Because of vertebral morphologic changes (eg, wedging and rotation), a structural curve is not correctable with ipsilateral bending or whilst curving to the same side (6).

Structural scoliosis can be idiopathic which tends to affect girls during adolescence more so than boys. A UK study found that scoliosis in girls over 8 years of age outnumbered boys by almost 3 to 1 ( Nnadi, 2018) . Idiopathic scoliosis can be further classified into infantile, juvenile and adolescent types or early and late onset (1,2).

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

Non Structural:

Also known as a functional scoliosis with the latter to be caused from conditions such as lower limb disorders such as limb length discrepancy, herniated discs, hip dysplasia or limb deficiency syndromes (1). By contrast, no vertebral morphologic changes take place in a non structural curve, which is a mild compensatory curve that can be corrected during ipsilateral bending (4, 6). A non structural curve does not usually progress.

Cobb's Angle

The Cobb angle is useful for assessing initial stages of a scoliotic curve, its increasing magnitude and helping to decide whether it appropriate to operate or not (4, 6). The size of the curve within a scoliosis is assessed via the measurement of the cobb angle which is formed via the intersection of two lines drawn perpendicular to the transverse axes containing the upper (or superior) end vertebra and lower (inferior) end vertebra.

Thus, the upper or lower end vertebra are the most cephalad and caudal whose superior and inferior surfaces have the most maximal tilt towards the concavity of the spinal curve (which is either concave or convexed). Where the two lines intersect is the cobb angle and is measured using specialised computer software.

The vertebra or disc with the greatest rotation or farthest deviation from the centre of the vertebral column is identified as the apex or apical vertebra. The end vertebrae have maximal tilt towards the apex of the curve and are used to measure the Cobb angle (6).

A progressive curve that requires management is defined by a Cobb angle increase of 5° or more between consecutive radiographic examinations (6).
Kim et al., (2010) highlight that the Cobb angle measurement has limitations with that it is performed via using a two dimensional radiographic image of a three dimensional deformity and does not take rotation into account .

Adolescent and Infantile ScoloisisAdolescent and Infantile Scoloisis

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

In the 1980s, adolescent idiopathic curves have been classified by King and Moe who found that there are five distinct curve patterns based on standing radiographs of the spine (Figure 3.) (4). The aim of this system was to determine a reliable method for selecting vertebrae for fusion (4). The curve types were stratified from I-V with type II and III being most common. Type II is a thoracolumbar curve while Type III is a thoracic curve.

Critique for the use of this system state that there is poor intra/inter observer reliability with this system as curves in the coronal plane are only assessed and it fails to address lumbar/thoracolumbar/double major/triple major curves. The system also fails to consider a 3-dimensional scope of deformity (4).

Neuromuscular Scoliosis

Some syndromes where scoliosis is likely to happen are connective tissue disorders such as Marfan’s and Ehlers-Danlos syndrome, trisomy 21, Prada-Willi, Retts syndrome and Beale’s syndrome (9). Duchenne muscular dystrophy or spinal muscular atrophy can prevent or severely reduce muscle activation, encourage the development of muscle imbalance, muscle atrophy and progress to spinal scoliotic curvature (9).

Patients with connective tissue related disorders can often develop scoliosis or kyphosis, or both. As they grow and their trunk muscles becomes weaker, the spine gradually begins to collapse, which can create a long, C-shaped collapsing scoliosis (9). Curves are usually progressive which means they continue to grow bigger. For children who use a wheelchair, progressive curves can make it difficult for them to sit comfortably (9). Large curves (measuring 80 degrees or above) in the upper or middle parts of the spine may cause lung problems.

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

Signs and Symptoms

In the majority of cases, pain is not usually a reason for patients to obtain further medical assistance but patients may present with either back or rib prominence pain (4). Night pain in one constant area is an unusual complaint and should be referred for further imaging to rule out another pathology such as a spinal tumour (4).

Other important features may include balance and gait disturbances, re-duced bowel and bladder control or neurological deficit(s)(4). As Haleem and Nnadi (2018) explain, such revealed symptoms should alert the examiner to suspect or keep in mind other pathological causes including tumours (both intra and extradural) and central causes such as syringomyelia (4).

Curve progression needs to be carefully monitored, in younger children (particularly those less than 10 years of age) lung volume growth may be impaired and if untreated severe or progressive scoliosis can lead to or worsen chronic restrictive respiratory disease .

Treatment

Treatment for scoliosis is based on the type of scoliosis, magnitude of the curve, the number of years of growth remaining and the patient’s opinion about the shape of their back (5). The trunk deformity and balance is also included in the decision-making process (5).

As Janicki and Alman (2017) report, the management and treatment of patients with either congenital, neuromuscular, syndrome-associated, idiopathic scoliosis or individuals who are younger than 10 years of age presents a number of controversies.
The treatment options for AIS include observation, bracing and surgery. While many other factors must be considered, the general goal is to keep curves under 50° during maturity (5).

Observation
Typically, observation is recommended for immature patients with curves less than 25° (5). The most reliable method of monitoring growth is simple height measurements and primary physicians often possesses this information from their annual examinations (5).

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

Surgery
Surgery is usually performed during adolescence, but newer techniques have allowed good correction to be accomplished into early adulthood (5). Surgical correction of idiopathic scoliosis is considered for curves greater than 45° in immature patients and for curves greater than 50° in mature patients.

T he goals for surgical treatment include prevention of progression, improve spinal alignment and balance and help improve alignment between hips and shoulders and the head over the sacrum (5). The spine is corrected with a combination of rods, hooks, screws and wires while being fused by bone graft either from the patient, a cadaver or artificially. Operative techniques for spinal correction are updated frequently, long-term results have not yet been obtained for the newest techniques, but good results have been found with older technologies within a 20-year follow-up period (5).

References

Choudhry, M. N., Ahmad, Z., Verma, R. (2016) Adolescent Idiopathic Scoliosis, The Open Orthopaedics Journal, 10: 143-154.
Fadzan, M., Bettany-Saltikov, J. (2017) Etiological Theories of Adolescent Idiopathic Scoliosis: Past and Present, The Open Orthopaedics Journal, 11: pp. 1466-1489.
Francis, M. J. O., Sanderson, M. C., Smith, R. (1976) Skin Collagen in Idiopathic Adolescent Scoliosis and Marfan's Syndrome, Clinical Science and Molecular Medicine; 51: 467-474.
Haleem, S., Nnadi, C. (2018) Scoliosis: A Review ; 28: 5; 2019 – 217.
Janicki, J. A., Alman, B. (2017) Scoliosis: Review of diagnosis and Treatment; Orthopaedic Subspeciality Article , 12; 9: 771 – 776.
Kim, H., Kim, H. S., Moon, E. S., Yoon, C-S., Chung, T-S., Song, H-T., Suh, J-S., Lee, Y, H., Kim, S., (2010) Scoliosis Imaging: What Radiologists Should Know , Radiographics, 1823-1842.
Koumbourlis, A. C. (2006) Scoliosis and the Respiratory System, Paediatric Respiratory Reviews , Elsevier, 7: 152 - 160.
Perkins, J., Boyer, A., Mcleish, A., Grossnickle, K. (2013) Idiopathic Scoliosis and Pelvic Floor Dysfunction, IJTR, 19;2:
Scoliosis Association UK https://www.sauk.org.uk/types-of-scoliosis/syndromic-scoliosis ONLINE
Scoliosis Research Society, https://www.srs.org/patients-and-families/conditions-and-treatments/parents/scoliosis [Online] Last visited 21/02/2021.
Stitzel , Clayton. (2017) The Different Scoliosis Locations & Types of Spinal Curvatures [ONLINE], https://www.treatingscoliosis.com/blog/scoliosis-spinal-curvature-types/
Uden, A., Nilsson, I. M., Willner, S. (1980) Collagen Changes In Congenital And Idiopathic Scoliosis, Acta Orthop. scand; 51: 271-274.

Differentiation of Hamstring Tendonitis and Strains Vs. Hamstring Syndrome.

Tue, 17 Nov 2020 18:43:43 GMT

Assessment & Treatment Management

Figre 1. Anatomy of the hamstring muscles and posterior view of the sciatic nerve within the lower limb

Hamstring related injuries are commonly known to be associated with individuals who participate in sport and according to Ahmad et al., (2013) they account for approximately 29% of all sporting related injuries. Further statistics have included hamstring strains to make up around 50% of muscle injuries in sprinters, are most commonly found in hurdling and have an immense reinjury risk of 12% to 31%. With this rate of a reinjury, it is not surprising that there is so much information out there on hamstring strains and injuries (1).

However, severe hamstring muscle tightness can also be found in individuals who do not participate in sport.
All be it, hamstring tightness is frequently associated with lower back pain related disorders. But, hamstrings are crucial for postural control and everyday activity, it is little wonder that they are discovered to be taught in the majority of cases and can lead to sciatic nerve irritation.

In my previous years of practise, I have came across and treated individuals with a hamstring condition who have worked in several trading industries such as; construction workers, gardeners, landscapers, postmen and women, carpenters, farmers, roofers, scaffolders, tilers, road workers, brick layers, electricians, window fitters, welders, cooks, hairdressers and plumbers; the list goes on.

Desk bound office workers who find themselves prolonged sitting for many hours during the day also commonly gain tight hamstring muscles due to long hours of being stuck in a seated position in front of computer screens and endless meetings. It is time to discover the differentiation between a hamstring tear and proximal hamstring syndrome (or 'hamstring syndrome') and understand, study and analyse the 'why'.

Anatomy

Figure 2. The origins and insertions of the hamstring muscles with the sciatic nerve

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

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

Figure 2 shows the posterior view of the sciatic nerve exiting the pelvis via the sciatic notch under the piriformis muscle and continues distally, lateral to the ischial tuberosity. In the proximal thigh, the long head of the biceps femoris crosses obliquely over the nerve (10).
From the posterior view, the sciatic nerve exits the pelvis through the sciatic notch under the piriformis muscle, then continues distally, lateral to the ischial tuberosity which is in close proximity before supplying the foot. In the proximal thigh, the long head of the biceps femoris crosses obliquely over the sciatic nerve.

Hamstring Muscle Strain Injuries

Figure 3. Types of hamstring injury

The clinical presentation of patients with a hamstring injury is related to the grade, location, and mechanism of injury (2). Individuals who experience an acute hamstring strain injury will typically describe sudden onset of sharp, stabbing or twinge-like posterior thigh pain. Athletes or individuals performing a sudden vigorous activity may describe an audible “pop” which has been reported primarily in type II (overstretched) hamstring strains (2). The muscle strain usually stops them from continuing the activity or sport and they may present with a "stiff-legged" gait pattern to avoid simultaneous hip and knee flexion ( 1). Chu and Rho (2016) explain how there are two main types of acute hamstring strains; Type I and Type II.

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

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

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

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

Distal Hamstring Injuries
These can have a similar presentation to that of patients with proximal injuries, as patients often report weakness during in knee flexion as well as feeling a "pop" or snap in the posterior aspect of the thigh associated with pain and stiffness in the injured area which prevents them from fully weight-bearing. Depending on the degree of tear, patients may have a loss of active knee or hip flexion and in some cases may have difficulty with active extension. In patients with an isolated biceps femoris rupture, pain can be localized to the lateral or posterolateral aspect of the knee (1). In addition, cramps and spasms in the posterior aspect of the thigh are not uncommon. Patients with chronic injuries usually present because of profound weakness rather than pain (1). In addition, some patients present with gluteal sciatica symptoms due to excessive scarring in the area of injury and subsequent sciatic nerve tethering (1).

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

Grade 1 = mild muscle strain, characterized by overstretching but minimal loss of the structural integrity of the muscle-tendon (1). The patient reports minor discomfort, minor swelling, no or a minimal loss of strength, and restriction of movement (5).
Grade 2 = moderate strain having partial or incomplete tearing. The patient has marked discomfort and diminished ability to contract (5).
Grade 3 = severe occurrence with complete muscle rupture. There is distinct pain and a total loss of muscle function (5).

MRI grading system for muscle injury includes:

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

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

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

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

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

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

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

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

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

Hamstring Syndrome

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

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

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

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

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

Treatment Management, How Can Physical Therapy Help?

Hamstrings Stretch

The main purpose of any rehabilitation program following nonoperative treatment of a hamstring injury is to restore the preinjury level of function and to control the pain and inflammation ( 2).

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

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

Phase II

Involves a gentle increase in intensity of activity and exercise to improve range of motion, introduce eccentric resistant exercises, and neuromuscular training at faster speeds. Exercises involve a gradual increase in range of motion and lengthening of the hamstrings. Hamstring lengthening to end range of motion is avoided as there is still weakness within the muscle during this phase (3).

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

Phase III

At this stage, rehabilitation involves more advanced neuromuscular control and eccentric strengthening exercises and sport/ activity-specific exercises with the goal of returning the athlete/ individual back to play. Progressive ability and trunk stabilization exercises should incorporate more sport-specific drills and dynamic agility exercises. Eccentric hamstring strengthening exercises can be progressed toward end range of motion by e.g. using hamstring curl machines, reverse cable curls, weight bearing hamstring curls on exercise ball, reverse plank, kneeling Nordic leg curl, standing single or double leg dead lifts (3,4,10). Return to sport criteria include no pain with palpation over the injury site, full concentric and eccentric strength of the hamstrings without pain.

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

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

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

Operative intervention is usually considered for chronic injuries if the patient cannot return to his or her desired activity because of persistent weakness, pain, or both and nonoperative treatment efforts have not worked (2,3). Delayed operative repair of complete proximal ruptures has found to have worse postoperative strength, with the potential for sciatic nerve involvement by surrounding scar tissue formation.
Full return to sport should only be allowed once the patient is asymptomatic with regard to pain and strength has returned to a grade 1 of the contralateral leg.

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

References

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

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

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

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

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

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

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

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

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

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

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

The Brachial Plexus (From Roots to Cords), Nerves of the Neck & Related Injuries

Sun, 18 Oct 2020 00:00:00 GMT

Nerve Branches, Roots, Course and Innervation

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

The brachial plexus is a significant structure within the body that transmits signals for motor and sensory innervation for the upper extremities including the shoulder, arm, and hands. It could be thought as our upper body's neural 'underground' system. A network of nerves that supplies and controls the skin, musculature, sensations and movements of our arms, fingers and hands.

Quite simply, the importance of our brachial plexus is such that without it, we would be unable to perform the various hundreds, upon thousands of simplest or complex movements which we automatically perform on a daily basis with our upper limbs. When studying and breaking down the brachial plexus into parts, it could be considered astonishing how this hidden delicate framework is so heavily relied upon for our upper limb movements, muscle strength and skin sensation.

Both 'brachial' and 'plexus' are Latin words, with 'Brachial' stemming from 'brachialis', meaning 'belonging to the arm'. The term 'plexus' means a network (i.e. blood vessels or nerves) or a structure containing a complex network of parts (1).
The plexus starts in the neck and is positioned between the neck muscles of the anterior and middle scalenes before passing through the axilla (or armpit) and descending down the arm to supply and innervate muscles, joints and skin of the whole arm and hand (11).

Knowing the brachial plexus and its neural branches is important for practitioners to know, as it can help determine whether a portion of the brachial plexus has been injured which can help tell us which of the associated muscles might be affected before being tested for evidence of a nerve injury (5).

Our 'Underground' Network of Nerves

"Read That Deadly Cadaver Book"; Roots, Trunks, Cords & Branches

When looking at the above diagram of figure 2 for the first time, it may seem complicated and possibly daunting. But, when broken down, it isn't and imagining it like a 'London Underground' or 'road map' might help remember each neural branch's positioning.

As the nerve roots exit the cervical and thoracic intervertebral foramen, or bony openings found between adjacent vertebrae, they unite and branch in the following order: roots, trunks, divisions, cords, terminal branches (and peripheral nerves) (11, 4). A helpful mnemonic for this is; R ead T hat D eadly C adaver B ook (11). There is no difference in terms of function between each division and they are simply used as an aid to further explain or remember the brachial plexus (11).

The Roots
The roots are the first section of the brachial plexus. Each spinal level has four nerve roots and there are two spinal nerve roots for the left and right side; the posterior (dorsal) and anterior (ventral) nerve roots. The anterior (ventral) nerve roots carry motor signals from the brain to the muscles and the posterior (dorsal) roots carry sensory signals from the skin to the brain (11). The anterior and posterior roots combine to form a spinal nerve at each intervertebral foramen (10).

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

The Trunks

The three trunks of the brachial plexus originate from the roots and are located within the lower part of the posterior cervical triangle and pass laterally over the first rib before entering the axilla (2, 4) Figure 4).

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

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

The Lower (inferior) Trunk: is composed of two nerves via the anterior rami of C8 and T1.

Each trunk then divides into anterior and posterior divisions which pass beneath the clavicle where there are no nerve branches at this level as can be seen from my labelled painting below in figure 5 where the dotted golden lines represent the divisions that pass beneath the clavicle (5).

The Divisions

Overall, there are six divisions situated beneath the clavicle comprising of an anterior and posterior division from each of the three trunks with three anterior division fibres supplying flexor muscles and ultimately give rise to nerves associated with the anterior compartments of the upper limb (4). The posterior division fibres tend to supply extensor muscles and give rise to nerves associated with the posterior compartments of the upper limb (4).

The Cords
The cords are the fourth section of the brachial plexus, are named based on their positioning with respect to the axillary artery found distally to the clavicle and at this level are termed 'the infraclavicular brachial plexus ' (5) (Figure 6). The cords, axillary artery and vein are located deep to the pectoralis minor and major muscles in the infraclavicular fossa and is a target site for anaesthesia of the upper limb and for brachial plexus nerve blocks (3).

The cords are formed as follows:

The Lateral Cord (on top):
The lateral cord gives gives a branch to the lateral root (or 'head') of the median nerve and gives rise to the lateral pectoral nerve before it continues into the upper limb as the musculocutaneous nerve (figure 1 and 2).
The distal branch of the lateral cord, the lateral pectoral nerve, innervates the clavicular head of the pectoralis major and weakness indicates lateral cord injury (5).

The Posterior Cord (in the middle):
The posterior divisions of all three trunks unite to form the posterior cord which means that they receive input from all levels of the brachial plexus (C5 to TI). The posterior cord gives rise to three branches before it terminates as the axillary nerve and the radial nerve; namely, the upper subscapular nerve, the thoracodorsal nerve and the lower subscapular nerve (figure 2 (and 3)).

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

Injuries:

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

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

The Brachial Plexus Nerve Branches (From Rami to Cords) and Muscular Supply

The neural branches from nerve roots to cords to cords can be seen to supply the following muscles.

Phrenic nerve ( Rami C3 to C5): Diaphragm (keeps the diaphragm alive)
Dorsal Scapular Nerve (C5 Rami): rhomboid minor and rhomboid major , Levator scapulae
Long thoracic nerve (C5, C6 & C7 Rami): Serratus Anterior
Suprascapular nerve (C5 & C6 upper trunk): Supraspinatus & infraspinatus
Nerve to subclavius (C5 & C6 upper trunk): Subclavius muscle (clavicle stabiliser)
Lateral pectoral nerve (lateral cords): Sternocostal head of the pectoralis major muscle (5)
Upper subscapular nerve (Posterior cord C5, C6): Superior portion of the Subscapularis
Thoracodorsal Nerve (Posterior Cord: C5, C6, C7 and C8): Latissimus Dorsi
Lower subscapular nerve (Posterior Cord; C5 and C6): I nferior portion of the subscapularis and the teres major .
Medial Pectoral Nerve (Medial cord; C8 & T1): pectoralis major and pectoralis minor muscles.
Medial Cutaneous Nerve of the arm (Medial cord; C8 & T1): [smallest branch of the Brachial Plexus] Supplies the skin on the medial brachial side of the arm
Medial Cutaneous Nerve of the Forearm (Medial cord; C8 & T1): supplies the anterior and medial aspects of the forearm and the distal wrist.

Upper Brachial Plexus Injury; Erb-Duchenne Palsy

Also known as 'waiter's tip deformity' and named after the neurologists Wilhelm Erb and Duchenne de Boulogne who first described this condition that commonly occurs during an excessive increased angle between the neck and shoulder. Anatomically, the cephalic portion of the brachial plexus C5, C6 and occasionally C7 is either stretched and or at worse torn which can happen during child birth or shoulder trauma (e.g. motor bike accidents or sports, for example, a rugby scrum or horse riding) (12).

Typically, the presentation of an affected limb is to hang limply and be held in adduction with internal rotation at the shoulder joint from the unopposed action of the pectoralis major muscle (12). At the elbow joint, there is extension and pronation caused by atrophic muscle changes within biceps brachii and spasticity of the wrist flexors along with flexion of the fingers (11). This overall presentation has contributed towards the term "waiter's tip deformity". The typical symptom is numbness (anaesthesia) along the lateral aspect of the arm.

The most commonly involved nerves include suprascapular nerve, musculocutaneous nerve, axillary nerve and nerve to subclavius. The muscles that are affected include deltoid, supraspinatus, teres minor, subclavius, infraspinatus, biceps, supinator, coracobrachialis, and brachioradialis muscles of the upper limb (12).

From an incident post birth, the neurological examination is characterized by the absence of Moro’s, biceps, and triceps reflexes of the affected upper limb with the presence of grasp reflexes as interossei muscles are not affected (9). Sometimes diaphragmatic paralysis is also seen if associated paralysis involves C3 and C4. At this age, treatment involves conservative management with performing physiotherapy and exercises to prevent muscle contracture which starts 7-10 days post injury and overall has excellent prognosis with good neurological outcome (10).

Lower Brachial Plexus Injury: Klumpke Palsy

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

The injury is usually caused via traction on an abducted arm in circumstances from e.g. an infant being pulled from the birth canal by an extended arm above the head or with someone catching themselves by a branch as they fall from a tree (12). Another cause could be from a compression injury and cause similar signs and symptoms via an apex lung tumor which may press on the cervical sympathetic ganglia of C8 to T1 nerve roots and sympathetic involvement can cause a Horner's syndrome presentation (8).

The classic presentation of Klumpke's palsy is the “claw hand”, as all the intrinsic muscles of the hand are affected with a supinated forearm, the wrist becomes extended with the fingers flexed. If Horner syndrome is present, there is miosis (constriction of the pupils) in the affected eye (12). Thus, the ulnar and medain nerves are affected and a loss of sensation along the medial side of the arm is usually reported (11).

For an open related injury i.e. there is an open fracture, obvious break through the skin or severe vascular compromise, emergency surgery in this instance would required. For closed injuries, conservative treatment via physiotherapy may includes strengthening and stretching exercises the supportive and affected surrounding muscles to help maintain the range of motion and aid a full recovery (8).

If there is no improvement post 3 to 6 months of injury, surgery would be a requirement which would involve nerve grafting. In cases of injuries proximal to the dorsal root ganglion, neurotization or nerve transfer is most recommended which can be defined as 'the transfer of a healthy but less valuable nerve or its proximal stump reinnervating a more important sensory or motor territory that has lost its innervation through irreparable damage to its nerve' (7). Merryman and Varacallo (2018) note that in most cases, the nerves will eventually heal and spontaneous recovery from nerve palsy is possible, but most C8-T1 nerve palsies do not recover without intervention.

References

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

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

3. Keet, L., Louw, G. (2018) Superficial location of the brachial plexus and axillary artery in relation to pectoralis minor: a case report , Southern African Journal of Anaesthesia and Analgesia; 24(4):114–117.

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

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

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

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

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

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

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

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

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

Hand Pain & Carpal Tunnel Syndrome (CTS)

Sun, 09 Aug 2020 12:08:41 GMT

Symptoms, Cause, Anatomy & Testing

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

Symptoms & Clinical Features

Most patients may complain of aching, tingling, burning or numbness within the hand localised to the first three digits and sensory distribution of the median nerve (3, 5). Symptoms are typically worse in the morning and night and often made worse by strenuous wrist movements which becomes more persistent as the entrapment worsens (3, 5).

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

Aetiology & Cause

Activities that often implicate the symptoms in individuals are those who perform and create repetitive movements of the surrounding tendons and thus cause compression of the median nerve within the carpal tunnel.
Such activities may include (3):

Typing
Knitting
Scrubbing
Dishwashing
Driving
Painting
Gardening
Lifting
DIY

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

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

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

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

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

Anatomy

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

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

Figure 2: Sight of compression of the median nerve within the carpal tunnel

Course of the Median Nerve

The median nerve originates from the lateral and medial cords of the brachial plexus and has contributions from ventral cervical nerve roots C5 to C7 (lateral cord) and C8 and T1 (medial cord) (3, 8). McNamara (2003) interestingly reports that the nerve only sometimes receives fibres from C5 and mainly originates from C6-T1 nerve fibres.

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

Below shows a labelled picture for the path of the median nerve and its branches. Your practitioner learnt and practised painting with acrylics during this year's 2020 spring lockdown (figure 1):

Sensory Distribution of the Median Nerve

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

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

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

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

Figure 3. Showing the sensory distribution of the median nerve.

Clinical Testing

Physical examination of the CTS involves studying the motor and sensory functions of the affected nerve in comparison to those of the ipsilateral ulnar nerve. Provocative tests to study entrapment of the median nerve.

Tinel's Sign
The Tinel’s sign is the percussion of the median nerve at the level of the carpal bones to reproduce paraesthesia in the median nerve dermatome

Phalen’s Sign
Involves holding the wrist at maximum flexion for 30 to 60 seconds to reproduce paraesthesiae in an already compromised nerve.

The severity and specificity of the clinical picture and provocative testing differ from one study to another.
However, it is considered by many that sensory symptoms, signs, and history are more important and reliable than Phalen’s and Tinnel’s signs in the diagnosis of CTS.

Grip Strength
Motor deficit from CTS is gauged by strength assessment of the abductor pollicis brevis which is innervated by the recurrent branch of the median nerve. Clinically, patients with advanced carpal tunnel syndrome will have thenar atrophy.

Treatment For Carpal Tunnel Syndrome

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

Treatment Modalities Offered at the Leagrave Therapy Clinic

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

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

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

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

Rocktape/ Kinesiology Tape

Medical acupuncture

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

References

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

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

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

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

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

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

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

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

Sciatica, Lower Back Pain & the Sciatic Nerve

Wed, 17 Jun 2020 14:24:00 GMT

Ideology, Anatomy, Pathology & Management

Sciatica, Sciatic Nerve & Anatomy

The sciatic nerve (SN) is a Greek work derived from "Ischiadichus" and also known as the ischiadic nerve (18). Renowned for being the longest, widest and largest peripheral nerve in the human body in the medical world, the sciatic nerve supplies most muscles of the leg, skin of the posterior compartment of the thigh, leg and foot. It consists of two components; the tibial nerve (TN) and common peroneal nerve (CPN) component of the sciatic nerve. The union of five spinal nerve roots from the lower lumbar spine and the sacrum form the sciatic nerve and are derived by the joining of the ventral rami L4-S3 (18).

Non specific lower back pain (NSLBP) places a substantial economic burden on private and public healthcare providers and direct costs for the provision of care to address NSLBP in the UK has previously been estimated at £11 billion, 51% of which was attributed to costs in primary care, physiotherapy and allied health professions (7).

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

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

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

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

Figure 1. Upper posterior view of the Sciatic Nerve (4, 6)

Risk Factors

Age: commonly between 45 - 64 years
Height
Mental Stress
Cigarette smoking
Exposure to vibration from vehicles
Obesity / being overweight
Heavy labor / strenous physical activity
Full time desk jobs
Occupation factors
Poor posture (although not proven)

Occupational Factors

Strenuous physical activity e.g. frequent lifting, bending and rotating the body.
Driving, vibration of the whole body.

Cigarette Smoking: Studies have shown that current and past smokers have an increased risk of nonspecific lower back pain with 10-30% for past smokers and between 20-60% for current smokers (19).

Smokers have a slower healing rate and recovery process than nonsmokers and have a higher risk of recurrent lumbar disc herniation than nonsmokers (19). Smoking increases the production and release of inflammatory cytokines in the intervertebral discs which interferes with the healing process.

Symptoms

Sciatica is characterised by neuropathic pain radiating from the lower back into the leg that follows the path of the sciatic nerve, often experienced down one or both legs and can sometimes also cause numbness or tingling (paraesthesia). It is often caused when the sciatic nerve (which runs from the back of the pelvis through the buttocks and down to the feet) is irritated, causing pain (16).

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

Many people can present with clinical symptoms of sciatica, but have no lumbar disc herniations shown in their scans (10).

Figure 2. Lower anterior view of the Sciatic Nerve (4, 14, 16)

Causes

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

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

Figure 3. Lower lateral view of the Sciatic Nerve (15, 21)

Neural Course, Cutaneous & Motor Innervation of the Sciatic Nerve

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

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

Common Peroneal Nerve
The common fibula (peroneal) nerve contains posterior fibres L4 and L5 of the lumbosacral trunk and lumbar sacral roots S1 and S2. It then crosses over plantaris and the lateral head of the gastrocnemius to gain access of the anterior leg before wrapping around the neck of the fibula and passing through the peroneus longus, where it bifurcates and divides into two terminal branches; the superficial and deep fibula (peroneal) nerve (figure 2 and 3)(4).

Superficial Peroneal Nerve

Provides motor innervation to the following muscles (4):

Peroneus longus
Peroneus brevis

& cutaneously supplied:

Cutaneous (skin) supply to the dorsum of the foot.
Cutaneous (skin) inferior 1/3 of the leg on its medial and lateral aspects.

Deep Peroneal Nerve

Travels inferolaterally towards the interosseus membrane and innervates the muscles below (4):

Extensor digitorum longus
Extensor hallucis longus
Fibularis tertius
Tibialis anterior
Extensor digitorum brevis
Cutaneous innervation to the first interdigital cleft of the foot.
Cutaneous sensation between the first and second toes.

Figure 4. Lower posterior view of the Sciatic Nerve (4, 6, 15)

Tibial Nerve

The tibial nerve is known as the medial terminal branch of the sciatic nerve and contains anterior nerve fibres of the ventral rami L4 and L5 from the lumbosacral trunk and the first three sacral nerves S1, S2 and S3 (4).

The tibial nerve crosses medially over the tibial vein to rest between the tibial vein and tibial artery on the superficial surface of the popliteus muscle and enters the leg under the tendon of the soleus. After the bifurcation of the sciatic nerve at the apex of the popliteal fossa, the tibial nerve travels inferiorly straight through the fossa and gives off muscular branches to the following muscles:

Soleus
Plantaris
Popliteus
Gastrocnemius (medial and lateral heads)
Tibialis posterior
Flexor Hallucis longus
Flexor Digitorum longus

And also supplies:

superior tibiofibular joint , tibia bone, interosseous membrane of leg , and the inferior tibiofibular joint .

The tibial nerve further divides into the medial and lateral plantar nerves, which are responsible for the sensation of the sole (Figure 4).

As the tibial nerve travels inferiorly accompanied by the tibial vessels, it pierces the tendinous arch of the soleus to continues between and innervate the muscles:

· Flexor digitorum longus

· Tibialis posterior

· Flexor hallucis longus

Medial Sural Cutaneous Nerve (Figure 4)

From the middle of the popliteal fossa, the medial sural cutaneous nerve branches from the tibial nerve and travels between the two heads of the gastrocnemius muscle before descending inferiorly to the posterior lateral aspect of the malleolus and terminate at the lateral 5th metatarsal bone (4).
Muscles supplied: triceps surae , plantaris , popliteus , tibialis posterior , flexor digitorum longus and flexor hallucis longus muscles .

The medial and lateral sural nerves are made up of collateral branches from both the tibial and common peroneal nerves and provide sensation to the calf and a small lateral portion of the foot (4, 7).

Conditions Related To An Injured Sciatic Nerve

Tarsal Tunnel Syndrome

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

Injury to the Deep Fibular Nerve

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

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

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

Injury to the Common Fibular Nerve

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

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

Foot drop

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

Video 1. Foot drop presentation. We are very grateful and thank the individual's consent to display their walking gait.

Diagnsosis & Imaging

Diagnostic imaging such as an MRI is only useful for if the results influence an individual’s further management. It may also be required for if patients fail respond to conservative care (i.e. physical therapy) for 6 to 8 weeks (9).

The straight leg raise (SLR) is one of the most commonly performed physical tests during clinical examinations to test for sensitivity and impairment of mechanical function of the sciatic nerve and the lumbosacral nerve roots in individuals with low back or lower extremity pain (3). The test is designed to apply tension to the sciatic nerve and lumbosacral nerve roots to evoke a physiological response such as reported pain, neural involvement and/ or altered sensations (3).

Treatment

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

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

Surgery

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

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

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

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

Conservative Management

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

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

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

How Could Osteopathy Help You?

Osteopaths are providers of manual therapy, exercise, self-management and lifestyle advice, which are interventions recommended in the most recent NICE Non-Specific Low Back Pain (NSLBP) and sciatica guidelines (7). Practitioners are frequently consulted for management of spinal symptoms, with NSLBP; the most common symptom presented to osteopaths in the UK (7).

There is debate regarding the most effective treatment of NSLBP as no one treatment modality is considered to demonstrate significant benefits over others. However, treatment following NSLBP guide-line recommendations has shown clinical and economical benefit compared with non-standardised treatment (7).

Disc herniation has frequently been thought of as a surgical disorder, but opinion in much of the literature is that conservative care should be tried initially, in the absence of indications for immediate surgery such as cauda equina syndrome or rapid and progressive neurological deficits (7). A variety of conservative measures are used including oral medication, epidural injections, bed rest, traction, electrotherapy, exercises, back school or courses, acupuncture and manipulation (7). Many of these approaches are of uncertain efficacy, and manipulation is no exception. Even surgical approaches such as microdiscectomy and laser discectomy have not been shown to be more effective than standard care (7).

References

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

Leagrave Therapy Clinic Blog

Sports Massage & Osteopathy For Upper Middle Back Pain

Understanding the Rhomboid Muscles: Small Muscles,

Big Impact on Posture and Movement & How A Sports

﻿ Deep Tissue Massage Can Help

What Are The Rhomboid Muscles?

﻿

Sciatica - Specific Areas of Pain & Physical Therapies

Sciatica, Specific Areas of Pain, Sport

Massage & Physical Therapy

Breathing Properly for Health

Why so Many of Us Don’t Breathe the Way

﻿ We Should and Why Changing It Matters

What “good” breathing looks like

How many people are “chest breathers”?

Why Learning to Breathe well is A Practice

The Physiology — Why the Lower Diaphragm Matters

1. Vagal tone & the parasympathetic system

2. Blood pressure and autonomic balance

3. Stress hormones (cortisol) and stress symptoms

4. Muscle tension, Jaw Clenching and Pain

What Goes Wrong When We Breathe Poorly (hyperventilation, shallow breathing, chest dominance)

How Many Breaths per Minute Should We Take?

Practical, Evidence-Based Breathing Practices (how to start)

A balanced View & Safety Notes

Conclusion

References

Consanguinity & Genetic Inheritance: Understanding The Link to Connective Tissue & Joint Related Disorders

Consanguinity and Genetic Inheritance: Understanding The Link to Connective Tissue & Joint Related Disorders

1. Hereditary Connective Tissue Disorders (HCTDs)

2. Congenital and Structural Birth Defects

3. Neurological and Developmental Disorders

4. Metabolic and Blood Disorders

5. Reproductive and Perinatal Outcomes

6. Multi-Generational Harm

Good Driving Posture

Driving Posture Awareness ﻿

How Poor Driving Posture Can Cause Neck,

Shoulder & Mid-Back Pain

References

Shoulder Referred Pain Caused by Pancreatic & Heart Pathology

Referred Shoulder Pain Via Underlying Diabetes

﻿ & Heart Conditions

Text Neck

Symptoms of Text Neck

Forces on The Neck

Common Symptoms

Management

Acute Cases

Chin Tuck Exercises Demonstration Video:

References

Heated Stones Massage

Six Ways Heated Stones Can Help Muscular Tension & pain

Six Reasons for A Heated Stone Massage

Overall Effect

Demonstration of Heated Stones Massage Techniques:

References

Plantar Fasciitis: Pathology, Management & Treatment

Plantar Fasciitis, Pathology, Management Tips & Treatment

Contributing Factors and Causes

Neural Contributions

Clinical Presentation

Differential Diagnosis

Treatment Considerations

Four Ways Sports Massage Can Help Sciatica

Four Ways Sports Massage Can

﻿ Help Symptoms of Sciatica

How Sports Massage Can Help With Sciatic-Related Pain

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

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

3. Sports Massage Can Relieve Hamstring Strain and Stiffness

4. Promoting Nervous System Relaxation

References

Five Ways Sports Massage of the Abdomen Can Help Lower Back Pain

Five Ways That Sports Massage of the Abdomen Can Help Lower Back Pain

Possible Mechanisms: How Abdominal Massage Might Help With Lower Back Pain and Sciatica

3 Effective Ways To Reduce Hyperlordosis (Increased Lumbar Spine Lordosis) & Help Lower Back Pain

3 Effective Ways To Reduce Hyperlordosis

(Increased Lumbar Spine Lordosis)

& Help Lower Back Pain

Deep Tissue Massage Can Help

We Should and Why Changing It Matters

Driving Posture Awareness

& Heart Conditions

Six Ways Heated Stones Can Help Muscular
Tension & pain

Help Symptoms of Sciatica