Osteopathy

T4 / Rib 4 Problems

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I have recently been thinking about the connections between the ribcage and shoulder pain. From this, I have noticed a couple of connections.
The main one is dysfunction around rib 4 either side leading to pain in the same side shoulder and arm. This has typically presented as pain next to the scapula, tension in trapezius and radiating pain down the triceps into the forearm. The patient typically has a history of desk based work or driving, with the pain often coming on waking or after coughing / sneezing. Examination shows restricted thoracic spine and tenderness on the ribs, both sternally and on the spine. Having tried to research this, I struggled to uncover much that enlightened me, other than a chiropractic diagnosis of T4 syndrome, which doesn’t really match and often seems rather vague.
My view is that the symptoms are actually caused by fascial tension and pain related muscular spasm, so fascial release, gentle manipulation and soft tissue treatment can have an apparently miraculous effects on some people. I also do some cranial / functional work anteriorly to re-centre and balance the ribs / fascia.
From this, it has been useful to be able to rapidly assess the motion of the spine. Although a detailed examination is always important, it is useful to be able to have a rough guide as to where you should be looking.

Supine, where the patient lies passively and you use their bent knee to create rotation in the spine, blocking at the pelvis, ribs and shoulder to isolate the main sectors. This is following a simple standing active examination, where the patient attempts the main spinal movements of flexion, rotation and sidebending.As an extension of that, I started getting patients to attempt “monkey”. This is an Alexander technique standing posture, which is meant to demonstrate balance within the spine (my perspective). The most important thing to know about Alexander technique (other than it is really rather good and a couple of lessons from a good teacher is worthwhile, I recommend a number of patients to my local teacher) is that it is all about intention and the mind being in charge of the body, so speed is always controlled.To move into a version of monkey posture ask the patient to do the following:

1) Get them to stand comfortably, feet parallel (check, lots externally rotate to minimise loading in the glutes)
2) Bend the knees slightly
3) Bend forward at the waist, spine straight
4) Let the arms hang loose
This is a german video of a man sitting down, but if you stop half way, its monkey.
What I noticed is that most cannot bend solely at the hips without looking down and treating any thoracic restrictions allows them to move much better.
The reason for all of this is to demonstrate treatment further away from the area of complaint and to look for other areas of compromise in their movement patterns. They may also find cervical and lower limb problems start to surface. Once this has been physically demonstrated, it is easier to achieve compliance in terms of future treatments, exercise pescription and general understanding of their body.
And for a positive patient outcome, this can be used as part of their ongoing exercise plan.

Tonight we dance: Lower back pain, tango and movement

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My friends recently bought a wii for their family and watching them play a dancing game, I noticed something that had been slowly dawning on me for a while.

One of them seemed a little more fluid than the other but as they are all very fit and active, at first I couldn’t understand why.

The answer appears to  lie in the lumbar vertebrae and their apparent lordosis. One of them had a slightly more lordotic spine, with more resulting anteriorisation in the pelvis than the other.

From that, the pieces fell into place. Shortening in the quadriceps and psoas had led to a slight increase in the anterior tilt of the pelvis, in turn reducing the available motion in the lumbar spine.

This pattern can commonly be seen in the wider population, especially those presenting clinically. On examination, we will generally find tight glutes, shortened psoas, a slight medial rotation to the thigh, hypertonicity in the superior insertion of quadratis lumborum, an anterior tilt to the pelvis and restriction motion in one or more planes in the lower lumbar spine. If active, they may also report hamstring problems.

Clinically, resolving this can have several approaches, depending on the level you wish to work. Posteriorise the pelvis (one colleague uses MET of the hamstrings, another does it manually side lying), lengthen the quadriceps, stretch or release any psoas restricitons and work on any QL points. Other, more distal, areas can then be incorporated to address the underlying issues that the body was adapting around. This is where it becomes interesting and the individual practitioners preferences come to the fore.

Once treated, this can often be prevented from returning by regular stretching and, interestingly, regular dancing or hoola-hooping! Both of these activities help keep the spine mobile and fluid, encouraging good movement patterns and core integration. And Tango? Particularly for the ladies, this elegant form of dance requires excellent upper body posture, with the ability to stabilise and extend the pelvis and leg smoothly.

As ever, all problems are individual and should be investigated professionally. None of the information above is a diagnosis or treatment plan.

Blood pressure and treatment

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An article in New Scientist in November 2010 noted that a group of researchers had successfully managed to lower a group of patients blood pressure by 10mmHg. This is significant because, as they stated, this reduces their risk of stroke and earlier death by approximately 30%.

It seems to work by affecting the nerve supplying the kidneys. Which got me thinking that, if they were able to reduce the pressure via the nerves, surely maximising the health of the nervous system would also have the same effect.

This is not a random and unsubstantiated claim that Osteopathy can do this directly but we do know that treatment affects the nervous system and therefore if we can maximise patient health, then maybe this would have a knock on effect, helping the neural supply to the kidney as well. In fact, whilst at college, I was aware of a fellow student who was measuring the effect of cervical manipulation  on the blood pressure of the patient, but I am unaware of her outcomes.

Of course, the best thing to do would be conduct a nice randomised controlled trial but as with many things osteopathic, this would be difficult to do, if for no other reason than the funding.

However, it is something to bear in mind as we treat.

We should, of course, always bear the patients blood pressure in mind when we are treating, since it is a risk factor in cervical manipulations and, as potential primary care practitioners, we may be the first person the patient has been to see for years.

Out with the syphg and onwards to better health!