back pain

On: Bowls

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Imagine, if you will, 3 bowls. These bowls are inside you, one stacked above the other.

The first is your pelvis. Already described as a bowl, it supports and holds all above it.

The second is your diaphragm. Separating the organs in your chest from the organs in your abdomen, it forms the top of the abdominal cylinder and should move gently as you breathe.

The third is in your upper chest, at the top of your lungs and about the same level as your collarbones.

This being a conceptual experiment, fill them with water. Then, think about the way you are standing or sitting. Are those bowls going to overflow? Is the water going to run out of the front, the back, even the sides?

Stand easily if you can, weight distributed in the centre of your feet. Soften your knees and ankles.

Then, come up to the pelvic bowl. Tilt it forwards and backwards, until you find the centre, neutral position.

For the diaphragm, you can feel if it is forward or backward and correct.

Ditto the shoulders. Allow them to open, don’t force, allow. A subtle external rotation and lengthening of the clavicle.

Once reflected and considered individually, check in again with all three.

This is probably one of the quickest ways of achieving optimal posture smoothly, balance the bowls, check how they move when you breathe and then, get on with the business in hand.

Of course, if you need help balancing the bowls, can’t find a neutral position or are struggling to fix it in any other way, please book in, we are happy to help.

On: Advocacy

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I don’t have your best interests at heart. Why would I? I have my own stuff to deal with once our interaction is over. The criticism, fear of failure, and self doubt in my mind. Administration, other patients, personal and family concerns, my own health issues, background noise, the passing comment from a colleague that got stuck in my head and keeps rattling around, the alerts and distractions on the screen in front of me. That’s not even counting the 30 or 40 other interactions I will have today, another 8 patient appointments and the meetings related to those.

As a medical professional I try my best to push those aside, to silence them and focus on you. To give you the time and attention you need and deserve, to bring the years of training and experience to bear on your behalf. To know when to treat, when to advise and when to refer. And hopefully at the end of our consultation together, as we conclude our interaction, you will feel listened to, reassured and aware of the next steps.

But I don’t have the time to advocate for you, to have your long term best interests at heart and ensure a life plan is laid out before you. You simply get the time slices I can afford, amongst all the other pressures.

Thats your responsibility. It has to be. This is a 2 way relationship. Come to me for treatment, support, advice and reassurance. Then take control of the other elements yourself, to make sure everyone is working towards the overall goal of longevity and optimal health.

Be your own advocate.

On: Rehabilitation / Prehabilitation

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The best way to recover from an injury is to not have an injury.

Other than the sort you simply cannot predict, the majority of injuries are caused by poor preparation or the inability to adapt dynamically to the situation.

Rehabilitation goes through three main stages.

  • Pain management
  • Ranging
  • Loading

First, control the pain. This is both passively and actively. Once the pain is a under control, it is a return of function, within that pain free zone. Optimise the range of motion, or activity that is available without causing excessive complaint. Finally, the loading phase, where we return to activity, initially graded and then competition.

This is, of course, a gross simplification of the tasks at hand, offers no insight into the variety of techniques considered, but is offered as a thought guide for the observer.

As stated at the beginning, the best rehab is prevention, through prehab. Prepare better, prevent problems.

Everybody has a weakness, a compromise point, or an area that appears to be less effective, so train those out to become more capable.

Seek professional input if you are prone to niggles, seek professional input for coaching if required and build steadily. Social media is not your coach, a search engine doesn’t replace a doctor.

You are what you do.

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They presented with a long history of shoulder and back pain, with occasional headaches, particularly in the evening. No other significant complaints, simply a tight and painful upper back, and shoulders, with a stiff neck.

After taking a thorough history and checking pertinent red flags, I carried out a suitable examination, looking at how they used their body, how it wanted to respond passively and actively.

And the thing was, other than the presenting complaint, there wasn’t much to be found. An anteriorised head posture and slightly kyphotic thoracic spine, but nothing much more than you might expect for a modern lifestyle. They exercised frequently, were not obese and tried to optimise their working posture when at a desk.

I treated what I found, and we addressed a few issues, but I was unhappy with their progress, as the complaint didn’t feel like it was resolving along the curve I expected.

Then it clicked. Whenever I went through to reception to collect them, they were playing with their phone. Head slumped forwards on the chest, looking down at the tiny screen and typing or scrolling away.

The problem is, modern expectations are that we are constantly connected, with rewards and punishments meted out by both the device and other people if we do not respond to its electronic siren call. I am as guilty as the next person, at instinctively checking and wasting hours.

It was this small, but frequent behaviour that was causing, in this case, the shoulder pain. Looking down was loading the back of their neck, the shoulders were coming in to support the arms holding close and everything matched when I mimicked them.

However, other than taking the phone away from them, there wasn’t a direct intervention I could do, so instead we discussed possible mitigation strategies, to reduce the automatic reaction, shorten the time spent interacting and change the posture, things that have been shown to work.

Following the rules of three, I suggested:

  • Switching on greyscale. This, interestingly, makes the device far less stimulating, but still allows you to work effectively. It also helps increase battery life on some devices.
  • Clean up the home screen and put apps that distract in a folder so you don’t see them first
  • Turn off notifications for social media applications

The point was simply to create a brain pause that allowed for a moment more reflection before the action, rather than create a wholesale change that would more likely fail.

Having created this awareness and put in some simple measures, we were both very happy to see that the treatment was then far more effective and the presenting issues resolved.

After they had left, I reflected in how the simple actions we do can have profound impacts and that, as practitioners of every discipline, we need to continue to look at the whole person, not just the complaint.

What Physios don’t want you to know

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And osteopaths, chiropractors or any other manual therapist.

Unless they are making special claims for their technique,  which they can back up with evidence,  the truth of the matter is that all manual therapies are doing one of three things-

  • Breaking down adhesions, scar tissue and restrictions, whether in fascia, muscle or connective tissue
  • Resetting the joint position sense and neural signalling around the affected area
  • Improving fluid flow and drainage of the tissue.

That’s it, that’s all we do. However, the reason you need to keep a good osteopath or physiotherapist on speed dial is because the real trick is knowing which one needs to be done, what tools and techniques should be used when, how and where, as the true cause of the problem may not be at the place it hurts.

One classic example of this, that many have suffered from and lots fail to treat effectively,  is plantar fasciitis. The too familiar pain lancing into the sole of your foot when you first stand up, it is caused by inflammation and microtearing in the fibrous tissue running along the foot, generally near the heel. Traditional treatment is to brace, stretch and possibly inject cortisone, all of which take time and often fail to address the question why it failed in the first place.

A better complete approach, using the above concept,  is to not just treat the foot locally,  but look away for restrictions and signalling issues elsewhere as well. Only then,  once the underlying issue is addressed,  can real recovery and progress be made.

Gym free exercise of the day.

2 minutes breathing practice while swinging arms and legs to open the joints.

3 X 30 seconds skipping on the spot, imagining a rope if space / equipment restricts.

5 x 1 minute Burpee superman interupt. 30 secs recovery between sets.

Squat down, thrust legs back to pressup position,  lower your chest to the floor then take hands up above the head to full extension. Raise opposite hand and leg off the floor. Repeat for the other side, then hands to chest, push up, legs back in to squat position and jump up.

2 minute breathing practice, with stretching.

Notes-

The objective of the warmup is to check and prepare joints for range of motion,  followed by getting the cardiorespiratory system ready.

The core of the workout is to get every muscle in the body firing to stimulate a high level of intensity. By lifting the arms and legs off the ground,  you break the fascial tension that can be used as a spring rebound mechanism,  so it becomes harder.

Scaling if you are unable to do burpees or pressups would be 3 standing air squats with a pause at the bottom, followed by 3 kneeling pressups with hand / leg lift. If the pressups are still too challenging,  wall pressups (pushing off the wall) followed by arm / leg extensions. If in doubt, try the one you think you might fail at to push yourself.

Why walking in their shoes will give you new insights.

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To understand someone better, it is said that we need to walk a mile in their shoes.

This is perhaps a little extreme but as with many statements, there is a lot of truth buried in there.

Walking in their shoes, or at least picking them up and looking closely at the wear patterns, both inside and out, will tell you much about the person’s interaction with the world. Do they currently have a prescription orthotic, or some form of insole? How has the outsole worn? Are both sides worn in the same way? Can you see the way the foot turns and loads inside the shoe?

By observing and considering the information provided, it can be possible to start gaining a better insight into how the person moves and hence any potential issues they may be adapting for.

If necessary, stand up and attempt to physically mimic their movement, and what leads them to that positioning.

Feeling it in your own body can be an eye opening experience and one that may hugely enhance your own practice.

Running it off does not work

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Each week, we see a number of runners and increasingly gym based athletes, who have had an injury for a while and have tried to train through it.

This never works for a number of simple reasons:

  • Unless it was a non traumatic injury, it will have happened due to a chronic issue somewhere, which needs to be addressed before the problem resolves fully
  • If it was traumatic, there will be a knock on effect, which can get worse if you attempt to train through in any way that loads the injured area
  • Training through, even if it does not dynamically load the injured place, demands modifications in your form and movement patterns, which can cause injury later on

The best approach instead is to use the PRICE principles and book in to get it checked by a professional, who is used to working with athletes.

PRICE:

  • Protect: Avoid loading the injured area and strap or support it if you do need to move
  • Rest: Cut back on your workload and give it some time to heal properly
  • Ice: If acutely injured, cold treatment can help reduce the swelling and pain
  • Compression: A simple bandage may help reduce the swelling and pain, particularly in joints
  • Elevate: By raising the effected area to level or higher than the heart, the chance of swelling is reduced, helping the body heal more effectively

Whether you’ve tweaked an achilles, strained your knee or have a chronic lower back problem whenever you run over a certain distance, don’t just ignore it, pop a pill and carry on, call in and get it resolved quickly and effectively.

Whats the difference?

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As a practitioner, I get asked this every week…

“So whats the difference between osteopathy, chiropractic and physiotherapy”

Once we’ve got the jokes out of the way (The spelling, 50 grand a year and a Porsche etc), I try to explain, which is far harder than you initially think, as there are a huge number of cross over points between each discipline.

My take is:

  • The philosophy behind each practice. Having evolved from similar roots, each form has taken on a different theoretical approach to treatment.
  • An Osteopath tends to look globally as well as locally, use soft tissue techniques in conjunction with appropriate manipulation and applies the osteopathic principles to diagnosis and treatment.
  • Chiropractors traditionally look at adjusting the spine to improve the health of the body, manipulate (or adjust) more often, use x ray and other interventional tests to aid a diagnostic process and feel able to treat far more frequently.
  • Physiotherapists use a range of soft tissue techniques and electrotherapy as well as some manipulations and tend to practice in a hospital environment, as well as having special areas of interest, for example pre and post operative, respiratory etc.

However, these days there are far more areas of commonality. All practices are protected by law (you are not able to call yourself any of the above unless on a legally defined register), have to regularly train and update their skill base, use palpation, active and passive movements for diagnosis and have access to a combination of techniques to achieve their therapeutic goal.

In the end, it comes down to personal preference and personal recommendation. A good practitioner of any discipline should be able to take the time to talk you through your presentation, give you the treatment options, the space to come to your own conclusions and help map out a treatment pathway.

Whoever you choose to help manage your health, consider it as a lifetime investment in yourself.

5 easy ways to stop back pain

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1

Over 70% of adults will suffer from back pain at some point and this number is rising every year. We all use our backs every day without thinking about it until they hurt.

Whether its from acute discs to muscle spasms, trapped nerves to torn ligaments, there are lots of ways for them to go and some easy ones to prevent it, without resorting to pills and surgery. Techniques doctors don’t always have time to tell you but save you time, money and worry.

  1. Move regularly. Your back is often painful if you sit for too long. The muscles go weak, the ligaments holding the bones together stretch and pain is the end result. Instead, walk a bit more, sit a bit less and use those muscles. Exercise doesn’t have to be gyms and furious sweating, simple moves at home will do it.
  2. Lift Properly. Whether it is a bag of shopping, a suitcase out of the car or a small child, we often lift very heavy objects without thinking and without doing it properly. Even if you can only manage a few of these items, they will massively reduce the risk. There is a simple way to remember lifting:
    1. Stop: Stop and think about the lift. Is it too heavy, too bulky?
    2. Face: Move to face the object. Twisting, bending and using the spine is the fastest way to cause lots of damage quickly.
    3. Brace: Pull your tummy muscles in. They are orientated so that they help support the spine safely but we often neglect to use them.
    4. Legs: Bend your knees, back straight and lift by pushing your heels into the ground and driving through your bottom.
  3. Stretch. If we spend too long sitting down, all the muscles at the front of us shorten, all the muscles at the back lengthen and we develop imbalances that cause pain when we try and stand up. Simple stretches can make an enormous difference to how you stand and move.
  4. Lose weight. If you are overweight, every step you take creates excess load on all your joints, even the ones in the spine. Your back has to take more force in the wrong directions, increasing the risk of it hurting.
  5. See an Osteopath. If in doubt, see an expert. Preferably before it starts hurting and you need the emergency appointment. Osteopaths are able to see where it might go and help free you up, allowing you to enjoy life without worrying.

Try these before its too late and you’re laid up.

Wobbly sticks and string

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Most people have seen a tensegrity model. These are clever constructions of sticks and elastic that use balanced tension and compression to created self supporting shapes.

(Image taken from http://dotensegrity.blogspot.co.uk/2011/01/make-your-own-tensegrity-model.html)

It is possible to consider the body as a tensegrity model, where the bones, muscles and ligaments all act together to support, articulate and move.

Although simplistic and missing huge elements of the effects of fascia, organs, inflammation and so forth, it is a useful analogy to hold, especially when trying to educate patients.

Recently, I have been considering the lumbar spine and the need for good abdominal support around it. The metaphor I use it that of a wobbly stick attempting to link upper and lower halves of the body. The pelvis is a fairly stable, solid object and the thoracic spine is well held with the ribs. This leaves the cervical spine (a wobbly stick with a block on top) and Lumbar spine to do a lot of work. Therefore, we need plenty of active muscles recruited to provide stability, support and movement.

So, no matter how much we may train that six pack and work to get well toned abs, if we cannot recruit them during activity, its fairly pointless.

I have 3 basic exercises I start with for every patient and, if they can do those, move to the next level. These are:

Pelvic control: The patient lies supine, slides one heel up the couch or floor, whilst attempting to maintain a level pelvis, the ASIS not deviating significantly posteriorly. Recruitment of the TA is particularly useful in this.

Cat crunches: On all 4s, the patient pulls their navel towards the spine, attempting to keep everything else still. A count of 5 and release slowly. This helps recruit deep obliques and the thoracolumbar fascia attachments.

Gluteal raises (trendelenburg drops). The patient stands sideways on a step and allows one leg to drop. They raise it back up again, using the opposite glutes, minimising recruitment of QL or lumbar erector spinae if possible.

Once they’ve got these, then the neuromuscular paths are working better and we can progress to more dynamic tests.

No more wobbly stick, less back pain.