Standing Firm - Why it sometimes hurts to stand from sitting?
The sit-to-stand (STS) is a test used to measure lower-limb strength in older people or those with significant weakness (1).
It is considered an easy, quick and fairly valid measure, which involves measuring the time taken to stand from a seated position a certain number of times, or recording the number of repetitions you can do in a given period (2).
The findings of recent studies suggest performance in this test is influenced not just by factors associated with strength, but also balance and mobility, and a vast array of psychological factors (1).
But what about when sit-to-stand hurts?
Low back pain can reduce spine, hip and pelvic floor motion due to conscious or unconscious guarding associated with pain (3).
Multiple studies have shown there are changes in how energy is transferred between bone and soft tissue in the spine, pelvis, and legs associated with pain (4). And that inefficient energy flow or transfer then places more demand from everything. A cycle of back pain-altered biomechanics can start, creating more back pain. With all the changes in energy transfer and muscle power, everyday activities such as standing up from a sitting position can become difficult.
Muscle coordination, balance and mobility are affected, and psychological factors start to play in and effect our beliefs and so the cycle continues (1).
Stopping the cycle can be easy.
You just bypass your traditional route to standing and try something different altogether.
Try these simple tips. You may not need all of them:
RELAX before you start
WIDER STANCE - think SUMO wrestler
SLOW DOWN (TIMING) - move more slowly
HANDS ON KNEES
BREATHE OUT - this is a big one. The less compression in the container of the torso the better.
Many people are surprised they can suddenly sit-to-stand with no pain after weeks or months experiencing twinges and outright muscle spasms when trying to stand after sitting.
After a few days of pain free sit-to-stand, you can try heading back to your old ways as there is rarely a “right” way to do something. You can get up and down any way you choose, each one of them equally valid.
As a lot of research shows, the way you do something does start to matter. If you always get up and down via your arm on the desk, leaning forward to create momentum, it means the strengths necessary to do it another way are waning.
Can this help if I have pain elsewhere?
This can also break the cycle if you experience pain in hips, knees and feet.
references
1. J Gerontol A Biol Sci Med Sci. 2002 Aug;57(8):M539-43. Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people. Lord SR1, Murray SM, Chapman K, Munro B, Tiedemann A.
2. Exp Gerontol. 2018 Oct 2;112:38-43. doi: 10.1016/j.exger.2018.08.006. Epub 2018 Sep 1. The sit-to-stand muscle power test: An easy, inexpensive and portable procedure to assess muscle power in older people. Alcazar J1, Losa-Reyna J2, Rodriguez-Lopez C1, Alfaro-Acha A3, Rodriguez-Mañas L4, Ara I1, García-García FJ5, Alegre LM6.
3. Explain Pain Supercharged G. Lorimer Moseley and David S.
Butler. Adelaide City West: NOI Group Publishers, 2017. ISBN: 978-0-6480227-0-1
4. Gary L. Shum, PhD, et al. Energy Transfer Across the Lumbosacral and Lower-Extremity Joints in Patients with Low Back Pain During Sit-to-Stand. In Archives of Physical Medicine and Rehabilitation. January 2009. Vol. 90. No. 1. Pp. 127-135.
Is that a knot in my muscle?
54 year old Barbara has pain extending across the top of the shoulders, frequently extending into the neck. Is it a muscle? Is it a trapped nerve? Or is there something more complex going on? Why didn’t it hurt six months ago?
Surely, the muscles are tight?
They may actually be a bit wound up actually, especially with a little bit of stress in your life. Most of us have experienced a rush of adrenaline in the work place, at home or even crossing the road. Adrenaline is great; it prepares your body to get moving by increasing your heart rate and your breathing so you can send more oxygen to your muscles. The free-floating adrenaline also binds to your muscle spindles, increasing the resting tension so your muscles can burst into action.
Most of the time though, we’re left not bursting into action but taking a deep breath and getting on with not moving.
But is all that tension going to make a knot?
One study specifically found there is no clear evidence of a strong relationship between increased electrical activity of muscles and the development of musculoskeletal disorders (2). Keep in mind this was one study, and the definition of a musculoskeletal disorder might not include Barbara and her sore muscles across the top of her shoulders.
I can definitely feel a knot in there.
There is zero consensus about what that hard lump in the muscle actually is and ‘knot’ seems like a fairly innocuous word to all those other than knitters and sailors. And just like knots in the real world, most are amenable to unwinding given the right intervention.
Bio (Body) Psycho (Brain) Social (Environment/Interaction)
Like many things in the body and pain, the pathophysiological mechanisms remain unclear. We are always more than the sum of our parts and if we look at the risk factors above, you need to find out whether Barbara has stress in the workplace, disappointment in her job, her relationship, whether she has a cold, whether her dog just died and she’s stopped walking, whether her children left her with five grandchildren on the weekend? And then what is her ability to control any or all of these aspects of her professional and personal life?
See the problem? This is why a medical history is important, why Osteopaths ask a lot of questions, why we need to spend more than seven minutes with you to grasp how to help you out of pain. We need to find out what’s tipped you from not even noticing that you’re a bit tight, to not being able to tolerate your shoulder discomfort a moment longer.
Hopefully, it’s as simple as softening off the muscles, turning a computer to a better angle, taking some micro breaks in the workplace and heading out for a daily walk.
Let’s get back to Barbara...
Step One:
take a slow deep breath
drop your shoulders
release the tension
Step Two:
get up from your desk occasionally
wave your arms around or run them quickly on the spot for ten seconds
smile at your colleagues and let them know you’re not crazy
Step Three:
Find some daily exercise that you love
Step Four:
Advise your children you can no longer care for all five grandchildren at once for an entire weekend.
References:
Ratey, John J.,Hagerman, Eric. (2008) Spark :the revolutionary new science of exercise and the brain. New York : Little, Brown,
Westad C, Westgaard RH, De Luca CJ. J Physiol. 2003 Oct 15;552(Pt 2):645-56. Motor unit recruitment and derecruitment induced by brief increase in contraction amplitude of the human trapezius muscle.
Morning, I'm Broken!
We all know we feel better physically, emotionally and psychologically if we’ve taken the time to exercise in the morning but how do we reduce the general ache and stiffness that many of us feel before we even get out of bed?
The main thing people consult an osteopath for is pain. Pain in their low back, between their shoulder blades and in their neck.
But a frequent complaint in practice is people reporting a general feeling of stiffness or ache in all sorts of places when they try to leave their beds of a morning. So while the good news is you aren’t woken with pain in the night, the moans and groans start when you haul yourself out of bed. And it can be enough to wake your partner, or the dog.
Is there any research on this?
There was nothing focused in the literature about whether stiffness improves with exercise, and certainly nothing as specific as morning stiffness. Although this may be because no one asked the question in an original study (i.e. it wasn’t set as a specific outcome for the population being studied).
An educated guess…
Waking with stiffness would be due mostly to your body trying to adapt to new behaviours or resting postures you’d get out of given the chance if you were awake.
Examples of the types of things that might cause stiffness in your neck:
Stomach sleeping
Bingeing on Netflix in bed with a laptop
Long long hours at a computer
Long drives on straight roads
Examples of the types of things that might cause stiffness in your low back:
See above
Examples of the types of things that might cause stiffness in your feet and achilles:
Standing for long periods (cooking, ironing, gallery walking)
New exercises or an increase to new exercises (skipping, golfing, new shoes)
Or just good old DOMS the day or two after a workout at the gym
What exactly will you be mobilising?
There is no exactly about it….you’ll be mobilising nerves, muscles, tubes, connective tissue, all manner of fluids including sparking up your brain juices.
A word of caution in the mornings.
Your nervous system is a bit protective of itself when we first wake up, as anyone who has ever done yoga before 6am will attest. That burning tightness behind your knees is not your hamstrings it’s actually your sciatic nerve letting you know it does not appreciate being pulled quite so aggressively before the sun has even risen.
Give it a fortnight.
It might take a while to tell if your body is going to love a new regime but in the meantime you can reward your mornings with these mobilisations:
ACHILLES and FEET stiff when you stand on them in the mornings?
Prancing with straight legs
Heel to toe
Holding onto the door frame squat
If your low back stiff in the mornings?
Try this series of movements:
LB twist
Knees to chest
Cat/Camel
Child Pose with Lateral Flexion
UPPER BACK and NECK stiffness in the mornings?
Sidelying bow and arrow
Neck slider/shoulder shrugs
All our mobilisations will be available on our BLOG this month.
So make yourself a morning routine that suits you.
Share these tips and tricks to put some spring in someone else’s step this August.
Get Your Body Moving - 30 mobilisations for everybody
Let’s be honest people. We can’t always be as active as we want.
We find it inconvenient and at times impossible to answer the call for natural movement*. It’s hard to run across the grassy plains when we’ve only got a concrete path or it takes a two-hour train ride to get to a wilderness trek up the side of a mountain. And we have to be dedicated in searching out opportunities to squat, throw something, wrestle, dance, run, leap, climb or hang upside down off a branch.
We need to do these things, but when we can’t, you can offer something else to your beautiful body. Something to nourish, so it can flourish! And so comes the concept of 30 ideas to mobilise your body.
WHAT THE HECK ARE MOBILISATIONS?
Mobilisations are like dynamic stretching. They sit somewhere in between rehab and lifting weights. It’s difficult to get any specific research to support this kind of movement but we can draw some conclusions based on evidence supporting early movement after surgery for hip and knee replacement (1) daily movement for acute low back pain rather than bed rest (2) safe movement following a car accident instead of a neck brace (3) and a long history of committed movement in multiple cultures (tai chi, qi gong, ceremonial dancing, prayer and worship).
We might even want to throw it out there that mobilisations might be useful for:
- pain relief
- early healing
- micro breaks
- preventing pain
- preventing injury (I said maybe!!)
the dip in the couch
We can get attached to not moving. You know the feeling when you’ve succumbed to the dip in the couch or you’ve shaped your body to the back of your ‘ergonomic’ chair. Our bodies sometimes try to get us to move out of desperation before the thinking part of our brain even gets a say. We crack our neck, stretch our back over the back of the chair or twist forcefully to one side. Take charge of your runaway body and acknowledge that alarm bell for what it is.
Convert that animal instinct into something to nourish your cells in all your tissues, including your brain. Pump and stretch those clumping cells and provide them with the nutrition they need via blood supply using the mechanics of your own body. Help juice up your joints, tendons, skin, brain cells, muscles, nerves, ligaments, organs and move those tubes that string them all together.
we've put together 30 great ideas to inspire the modern human to combat physical stagnation.
The rules to follow:
- easy and painless
- lots of repetitions (i can do it i can do it i can do a little bit more) 25-75 repetitions (1-3) sets/day
- joyful, fun, no protocol, no commitment beyond maybe a few days
- if you’ve tried to make it easier and it still feels bad (or pointless) then STOP
INSTA VIDEO SERIES
SEATED ROTATIONS
hip and back tightness/pain, neck stiffness, excessive sitting
STIR THE POT
neck stiffness/pain, upper back pain, shoulder pain
FOREARM MOBILISATIONS
arm and shoulder tightness and pain, desk worker
SIDE RAINBOW
side stiffness, hip and back tightness, shoulder pain
HIP RELEASE - KATY BOWMAN STYLE
hip and buttock tightness/pain
STANDING ROTATIONS
stiffness everywhere, excessive sitting
SEATED GLUTE STRETCH
hip pain , low back pain , improve hip mobility
CHEST OPENING AND CLOSING
upper back, chest and shoulder tension
ALPHABET EXERCISE - ARM SWINGS
thoracic and shoulder tension, low back too
BEAR HUGS
more dynamic than chest openings, more arm wrap around, good for shoulder and upper back tension
ASSISTED SQUATS
low back, hips, knees and ankles
ANKLE TWIRLS
stiff ankles, fluid congestion, motion is lotion
CAT AND CAMEL
good for spinal mobility, ask practitioner if this is right for you
THREAD THE NEEDLE
thoracic and shoulder mobility, low back stiffness
THREAD THE NEEDLE (V.2)
thoracic and shoulder tightness, standing at the desk version
CATH A BUTTERFLY
shoulder, hand, forearm and elbow
HIP DROPS
low back hips and pelvis
LOWER LIMB AND GLUTES
glutes, hips, hamstrings and calf
WAG THE DOG
lower back, hips and pelvis
LEG SWINGS
hip stiffness, low back, balance, positional awareness
DO THE SWIM
shoulders, upper back and neck
LEG SWING V.2
hips and low back
THE LAWNMOWER
Upper back, lower back and shoulders
NECK MOBILISATION
write out no. 1-10 with your nose, for general neck stiffness
SHOULDER SWINGS
good for stiff shoulders - who would have thought!?
BOW AND ARROW STANDING
shoulders, upper back and chest
FOOT AND ANKLE MOBILISATION
foot and ankle mobility
CHEST OPENINGS
chest, shoulders and upper back
THE SHOVEL
general back and shoulder - better without a real shovel!
DISCO TIME
looking good ladies - dance your way to better movement!
THAT'S 30! PHEW!
References
(1) Guerra, Mark L., Parminder J. Singh, and Nicholas F. Taylor. "Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review." Clinical rehabilitation 29.9 (2015): 844-854.
(2) Hagen, Kåre B., et al. "The Cochrane review of bed rest for acute low back pain and sciatica." Spine 25.22 (2000): 2932-2939.
(3) Teasell, Robert W., et al. "A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2–interventions for acute WAD." Pain Research and Management 15.5 (2010): 295-304.
(4) Chan, Roxane Raffin, and Janet L. Larson. "Meditation interventions for chronic disease populations: a systematic review." Journal of Holistic Nursing 33.4 (2015): 351-365.
thank you for your inspiration:
How to do Joint mobility drills - Todd Hargrove
Mobilize! Dynamic joint mobility drills are an alternative to stretching - Paul Ingraham
Therapeutic Stretching - Eyal Lederman
Nutritious Movement - Katy Bowman
Daniel Wolpert - TED talk
There are devoted proponents for natural movement who have wonderful websites. Check them out:
Mark Sisson, Katy Bowman, Phillip Beach
Jaws 42 - The Curse of TMD (Temporomandibular Joint Disorder)
All credit of this image go to Steven Spielberg and novelist Peter Benchley. Also to Zanuck/Brown Productions and Universal Pictures.
It has been nearly 42 years since the legendary movie "Jaws" was released. It was a cinema masterpiece of its time with bucket loads of suspense and horror that managed to scare everyone from swimming in the ocean for years afterward. Well, so I'm told. With the clever use of animatronics, images of bloody big dorsal fins and spooky music it left movie goers nursing tense and sore jaws from clenching their teeth through anxiety and fear. Segue complete. See that? Jaws and jaw pain?
Jaw pain is a pretty common issue affecting 33% of the general population at some time in life (1). Of that population there seems to be more significant spike in the age range of 20-40 year olds, with a significant portion of that number needing to seek treatment from a health professional. Anxiety is a key contributor to jaw pain but it is not the only reason people experience pain in/around the jaw or temporomandibular joint (TMJ). We commonly refer to pain around the TMJ as Temporomandibular Joint Disorder or TMD. It is actually not one single disorder but representative of multiple sub groups of issues. They are typically categorised as muscle problems or joint problems.
WHAT CAN YOUR OSTEOPATH DO?
At Fairfield Osteopathic Clinic we take into account the whole person when dealing with the treatment of TMD. In other words we need to understand the underlying causal factors, which may range from mechanical joint factors, emotional stress or functional overuse issues (think Australian gum-chewing cricketer). There are also direct links between neck pain and TMD and any assessment will recognise the connection. There is plenty of evidence both clinically and through peer reviewed research to suggest that the neck and jaw are pretty tight in their relationship with one another (pardon the pun). One paper suggesting that 70% of TMD sufferers also experience neck pain (2).
A worthy TMD assessment will always encompass an actual physical assessment of the muscles around the jaw and the joint movement itself. This will guide treatment options. As osteopaths we use lots of direct and indirect techniques to modulate pain, but without addressing underlying causal factors that impact the jaw then relief may not last for long. These irritating causal factors might include chewing gum, chewing meals on one side of the mouth, specific dental issues, night time bruxism or teeth grinding and habitual jaw clenching (a lot of people don't realise they clench until they actively relax their jaw muscles). There are simple relaxation exercises for the jaw that are easy to practice and master. Head down to the end of the BLOG for some ideas.
SELF MANAGEMENT
Self management strategies are essential in dealing with any long term TMD. A large study published in November 2016 attempted to collate as much data on self management strategies and form a best practice management strategy for longterm TMD. These strategies include:
1. Education - a bit of positivity is a good start as pain is usually self-limiting. Understanding the anatomy and usual function of the TMJ complex and associated musculature can be helpful too. Other ideas include improved sleep hygiene (don't watch Jaws before bed), sensible and time-limited use of analgesia, avoidance of OTC splints bought without consultation with a dentist, limit caffeine usage, ‘doctor shopping’ won't help.
2. Self exercise therapy - gentle stretches for the jaw muscles and relaxation exercises, which are best explained by your osteopath.
3. Heat treatment - usually heat for sore jaw muscles is best. Ice treatment is best avoided due to the sensitivity of the nerves that innervate the area (remember ice-cream headaches)
4. Self massage therapy - there are very simple self massage techniques for the main jaw muscles and upper neck muscles. Again these are best explained in person as a little goes a long way.
5. Diet and Nutrition - it's important to establish a pain-free diet for at least three weeks. That means avoiding excessive chewing or hard-to-chew foods. In other words TMD sufferers may need to establish a "soft diet" until sensitivity decreases.
6. Parafunctional behaviour - this is the tricky one. There are often habits that irritate the jaw that we seem to not have as much control over e.g. grinding teeth or jaw clenching during sleep, which is called nocturnal bruxism. This may require some other modalities of therapy or medication to help. Reflecting on coping strategies for stress and anxiety may be pivotal to changing some of these nocturnal habits (3).
EASY EXERCISE
Stand in front of a mirror.
Hold your palms gently on the side of your face - covering your cheeks.
Let your lower jaw fall into your hands. In other words relax it and let it go all loose.
Now practice that again without using yours hands on your face. Make as long a face as possible.
If you are having trouble mouth the sound "Bah". It lets your lower jaw fall open. Repeat that until you get a sense of your jaw relaxing.
If you practice this in the mirror then when you are at work throughout the day you can put your hands on your face and use that as a trigger for your face and jaw to relax. You are creating awareness around the difference between tension and ease.
Good luck and don't hesitate to make a booking to see us if things are a bit out of control.
References
1. Wright, Edward F., and Sarah L. North. "Management and treatment of temporomandibular disorders: a clinical perspective." Journal of Manual & Manipulative Therapy 17.4 (2009): 247-254.
2. Silveira, A., et al. "Jaw dysfunction is associated with neck disability and muscle tenderness in subjects with and without chronic temporomandibular disorders." BioMed research international 2015 (2015).
3. Durham, Justin, et al. "Self‐management programmes in temporomandibular disorders: results from an international Delphi process." Journal of Oral Rehabilitation 43.12 (2016): 929-936.
Slow and steady wins the race
The simple solution for the complex problem
When pain hangs around for longer than expected this can be immensely frustrating for patients. But when problems are complex and recalcitrant they can also be frustrating for practitioners.
A complex problem requires patience from both parties. If a patient has a story of brokenness, then it takes the right information, at the right time provided in the right way for that person to help turn that story into one of hope.
So many of us are pressed for time and aren't we all searching for the simple, immediate solution to any problem?
Often a simple and effective solution can be manual therapy. Good practitioners can be really good at providing an immediate relief for pain. Whether it lasts is another story and the transient relief for patients can be at once addictive and ultimately frustrating.
A good practitioner will combine manual therapy and education. Education comes in multiple forms, knowledge about why it hurts, and information about pain can help redirect the assumption of brokenness.
Education can also be advice about unhelpful behaviours, thoughts or beliefs. And it most certainly should involve having a discussion about the true
A good clinician will help find your baseline for activities and armed with good knowledge, your brain and body will know you're safe even if you experience some discomfort.
A fair amount of frustration exists around trying to increase physical activity, which as we know from the literature (and the media) is a magic bullet (1). But many people have the experience that simply increasing the amount they move increases their pain. Often, they'll take the weekend warrior approach. They join a gym and do a body balance class and end up crawling in for pain relief as their low back and neck are screaming at them. If the alarm bells are ringing and you're getting negative feedback from every part of you it's hard to make the connection that it's a) good for you, and b) we need to do more of it and finally c) do it forever.
A good clinician will help find your baseline for activities and armed with good knowledge, your brain and body will know you're safe even if you experience some discomfort.
I listened recently to a great podcast with Neil Pearson, who is a physical therapist in Canada, who uses graded exposure to therapeutic yoga to help people with complex pain problems. But it doesn't have to be yoga that gets you there. The simple and free option is walking.
What is graded exposure?
Graded exposure is a fancy way of saying that you need to start with a small amount of something that threatens you and as your brain and body tolerate it, add in a bit more the next day until you can participate in an activity you enjoy without a backlash.
So what does a graded exposure program to walking look like?
Start with a baseline of 10 minutes per day at around 65% of your maximum heart rate. In the range of comfortably carrying on a conversation. Up the benefits and go with a friend.
You need to assess how you feel afterward. If you have any adverse effects, ask yourself, do they last five minutes, five hours or five days? Depending on the answer, you need to increase or decrease the amount of time and effort you are making with walking. As a guide, anything more than a three hour increase in discomfort means you're overdoing it. Remember though to pay attention to your response AFTER your walk, not during, as this is a better indicator of how irritable your body and brain is.
If you don't overdo it, you'll improve so rapidly that after only a week you'll want to start increasing the amount of time, slowly now, to get to the point where you can walk for 45-60 minutes. It might take eight weeks or it might take six months, depending on how your body responds.
When you reach the 60 minute range, you'll be improving brain health, fighting Alzheimers, etc, you'll definitely be burning fat, if that's your extra goal achieved.
When you can comfortably walk in this time range with no negative repercussions, you can add in some moderate intensity exercise, like a 30 second jog, and then another 30 second jog later in the walk around 75% of your maximum heart rate. Once you've worked up to 6 x one minute jogs, then you're ready to add in some additional activities that take your fancy.
Strength work, flexibility and high intensity exercise come after all this preparation. You'll be so much more connected to what your body might want to achieve and what you might enjoy. If you enjoy being out in the sunshine, then there are myriad options at your disposal. Do something you like, do it with a friend and do it for your mental health, as well as to improve your pain.
1. http://www.canberratimes.com.au/act-news/exercise-could-be-the-answer-to-solving-one-of-australias-biggest-health-burdens-20160809-gqo8bi.html
HOW LONG UNTIL THIS STOPS HURTING?
Not all pain is caused by tissue damage but there are many occasions when an ‘event' has caused someone to present with pain. Pulling off a tight and sweaty crop top, lifting a heavy pot plant on a weekend clean-out, twisting an ankle during a netball match or landing awkwardly while trying to double bounce your kids on the trampoline.
Four weeks ago, a lovely mid-50s patient kicked a heavy box (that wasn't there before) on a night time bathroom break. She had an x-ray the next day and there was no indication of a fracture and now she is presenting with pain in her toe joint one month later. She is worried the toe may be fractured and the x-ray missed it and now her pain seems to expanding into other areas of her foot.
As students we all learn about how long a tissue injury may take to heal. But this information is infrequently passed on to the patients and I don't think we should underestimate the benefit in learning how long something might take to feel better. It is one of the active ingredients in therapeutic care that we can provide to patients with pain, along with reassurance. Sometimes people don't want to hear that healing and resolution will take 'time' but I'm afraid that's one of the first things we need to accept.
As an absolute minimum these are some common timelines for Tissue Healing:
Muscle Tear: between 2-12 weeks depending on the severity
Acute Tendinopathy: 4+ weeks
Degenerative Tendinopathy: 8+ weeks
Ligament: Between 2-12 weeks depending on the severity (and 12+ weeks if you've had surgical repair)
Internal Disc Derangement: 8+ weeks depending on severity and location
Bone fracture: 8+ weeks (depending on severity)
Bone bruising: 8+ weeks
Most Cartilage injuries: 4+ weeks
Bursa: 2-6 weeks (or on and on and on) depending on severity
Things that will impact tissue healing times (for better or for worse):
- Underlying bony change (age related or previous injury)
- Anti-inflammatories
- Progressing exercise too fast
- No exercise
- Sitting on your butt 9 hours per day
- Eating great or crap food
- Drinking alcohol
- Drinking caffeine
- Drinking sugary drinks
- Age
- Occupation
- Values (have you got a big game to play?)
- Beliefs (your father thinks you're weak)
- Sleep or lack of...
- Stress
Keep in mind we are talking about tissue healing times here and this is something completely different from whether you are experiencing pain or whether you have terrific or terrible function (read this entry here for more on the complexity of pain).
Back to our lovely mid-50s lady with sore toe. Potentially, when she kicked her toe into the heavy box, she didn't fracture the long bone but compressed the ends of two bones into each other essentially bruising the bone. This bruised bone takes a lot longer to heal than a bruise to the skin and the soft tissue just below it and this means it may also hurt for longer.
Finally, walking around with that sore toe can mean you may start to move through your foot differently avoiding the sore joint. You might weight bear more on the foot that doesn't hurt. Your whole body is invested in reducing the pain in your foot and so adapts to give your poor old toe the time and space to heal and recover. Learning about this can help your anxiety around your sore toe and even reduce pain levels. And of course manual and physical therapy provided by the Osteopaths at Fairfield Osteopathic Clinic can certainly diagnose, treat and provide education and advice to help reduce your pain and your anxiety about 'how long until this stops hurting'.
To make an appointment book online or call 9489 0981
Sitting at the desk can be a real pain in the %$*&
It's one of the most common questions we get in the clinic - what is the best sitting posture?
To be honest, it would be ideal if we didn't sit as much of the day as we do, but given the society we live in it's going to be a while before we all get to go primal.
We have all had a think about it and the overwhelming advice we give revolves around optimal sitting postures and reducing the amount of time you sit altogether.
So what can you do?
We all need to become big softies. Softening your neck, shoulders and upper back will go a long way to reducing pain and dysfunction around that area.
Start by dropping those shoulders.
Whether you sit, stand or kneel you're still going to get a sore neck and shoulders if those upper back, neck and shoulder muscles are working hard for hours on end. They have to work hard any time you have your arms out in front of you for long periods of time. For instance, when you are tapping at the keyboard, driving the car, crocheting, and then throw in the added tension that stress creates. A neat trick that seems to help is to tuck your elbows to your sides, this lets the shoulders relax a little more and keeps you mindful. Always try and rest the weight of your forearms on the desk or chair if you are sitting.
Some other good ideas to help you soften through your upper back neck and shoulders include:
1) Breathe and Release - most people find it easier to drop the shoulders, soften and release on an exhale.
2) Driving - hold the wheel on the two lower quarters and let your shoulders rest when you are in a more relaxed stage of a drive.
3) A Trigger - find a trigger during the work day to consciously soften through the trapezius and drop the shoulders, e.g. hanging up a phone call, sending an email, etc.
I'm sure you've noticed the recurring theme is 'letting the shoulders drop'.
If you are quite conscious of this over a period of three weeks, there is a sense of 'retraining' your brain to release your shoulders and neck tension automatically.
There are definitely more optimal sitting posture than others.
We have included some photos of the good, the bad and the plain ugly. Some sitting positions are extremely sloth-like but extremely comfortable, and that's ok. But always remember the more comfortable you are in the position the longer you can hold it - and that can be the problem.
The thing about maintaining good "posture" or sitting more upright is that the "better" your posture the more energy intensive and the harder it is to hold so then you move away from that position - therefore it’s better for you. Moving more is better for you - it is that simple.
Other simple tricks for the desk jockey:
1. Stand to talk on the phone wherever possible
2. Look out the window at something small and distant (like a bird in the tree) - this is good for your eyes.
3. Have walking meetings outside wherever possible. Who said a meeting had to be sitting down?
Blurred Lines of Health Care
I felt the need to share the case of a patient I had recently. The issue is not with the patient themselves but with the care they received from another practitioner.
The mature gentleman in question had presented to me with a long history of knee pain. Due to that long history he had also developed some compensatory pain in the hip and low back as his overall function had diminished. Some treatment helped with the presenting complaint but the knee was still pretty bad. A quick consultation with the GP and it was agreed a specialist referral would be necessary. Turns out the knee was severely degenerated and he was a strong candidate for knee replacement surgery.
The patient was not keen on surgery, which is fair enough. The recommendation is always to hold out for replacement surgery as long as possible and I support that wherever possible. He decided to get a second opinion from another manual therapist, a Chiropractor, that had been strongly recommended by a friend of his. This opinion was meant to see if any more could be done to prevent surgery. I would always encourage a client to seek further advice if they have any doubts at all.
A COUPLE OF WEEKS LATER....
The patient returned to my practice a couple of weeks later with a full spinal X-ray series - from head to bum basically. They wanted my opinion on this series of X-rays that the Chiropractor had ordered. The patient was particularly interested in my opinion of their neck X-ray. There was a little bit going on in the neck but nothing too sinister at all. I asked whether they currently had neck pain. The answer was a resounding "No". Turns out they hadn't had any neck pain at the time of the X-rays either. However the Chiropractor had pointed out a lot of areas of 'concern' that would need to be addressed in a series of treatments over the next YEAR!
I'm sorry, but there was no pain and no clinical indication to X-ray anything above the knee in the first place. The Chiropractor may have valid reasoning in their own mind for pursuing a course of treatment on an asymptomatic neck but it's not good health care.
THE BUSINESS OF HEALTH CARE
A big problem with private practice health care is that it is about the practitioner's livelihood. There are mortgages, living costs and often large educational debts to pay for, as well as their own health care needs, and the list goes on. Many get into health care professions with the most noble of intentions only to find it is not that easy to make a living - not as easy or lucrative as many would think. There are numerous health care business coaches out there who wax lyrical about the money that can be made in private practice. Unfortunately, it is completely driven by increasing treatment for patients and this means they aren't always selling good health care in order to build those numbers. They are selling over treatment and dis-empowerment of the patient and that's not an equation we like too much.
A multitude of practitioners sign people onto treatments they don't need. In fact Four Corners did an hour long expose of the billions wasted in unnecessary investigations and treatments within the medical system.
http://www.abc.net.au/4corners/stories/2015/09/28/4318883.htm
Instead of the public purse paying for treatments it is the patient's personal income that pays for unnecessary treatments and for what end?
Practitioners may unknowingly prescribe snake oil. They have invested a lot in their careers and they may be dissatisfied with their earning potential or they may have chosen to ignore the evidence to everyone's peril.
HCF PROFILE
HCF is a private health fund that sends us the data comparing the number of treatments we provide to their members compared to other Osteopaths in the area. Providers at Fairfield Osteopathic Clinic provide 30% less treatment per person. I don't think it's limited to clients who are members of HCF!
And don't get me wrong, I don't think it's because we're more talented. I think it's because we take time to explain the complexities of pain, encourage clients to be insightful about their condition, and encourage an active care approach and more than anything empower our patients with the confidence and knowledge to help themselves on a daily basis.
Another thing we do is to ask what your goal is? Most of the time it's simple things; to get a better sleep, to be able to run with no pain, etc. Not many people are aiming for one hundred percent. There is no finish line or silver bullet. Reducing pain and improving function is maddeningly provisional and a lot of the time we are just there to give you a better chance of doing it better the next day.
This is not something that works for every patient. Some people benefit hugely from therapeutic touch for lots of different reasons and they seek hands-on treatment much more often than others. As long as patient and practitioner have a clear understanding of the care plan going forward then that is entirely appropriate.
OUTCOMES NOT OUTPUTS
All practitioners at Fairfield Osteopathic Clinic look at the outcomes for our patients, not at the outputs on the books. It's a terrible business model of course. So please, unless it's an exercise program, don't sign on for anything that's going to take twelve months.
* For interest of privacy many details have been changed.
The Massage "Affect" on Anxiety and Depression
JUST GET A MASSAGE
I know many people feel that booking in for a massage is an indulgence. They wait for a gift voucher from a loved one, or save up once a year for their birthday.
Many benefits of massage are still disconcertingly uncertain but while everyone is discussing those, a somewhat proven benefit is its positive effects on mood (1).
Massage has been shown to:
1. reduce depression
2. reduce anxiety
ANXIETY AND PAIN
How often have you noticed your neck pain is at it's worst when you're under a lot of stress? It will build up and up until you finally lean over to pick up your toothbrush and 'bam' you can't move your neck.
Anxiety is a potent factor in all types of pain. And in the case of lower grade anxiety and depression, the kind we all seem to be living with every day, massage can make a valuable contribution to your well being.
MASSAGE TO INTERRUPT THE CYCLE OF PAIN AND IT'S EFFECT ON MOOD
Although the neurophysiological effects are complex, the simple negative cycle that emerges when people are depressed or anxious, is that it's hard for them to do anything when they feel miserable. As you continue to feel miserable, this leads to doing less, which in turn, leads to feeling worse.
There is a boatload of evidence to support enjoyable movement and exercise to improve mood but how about not getting to the point of feeling miserable or trying to find someone to help you crawl out of that hole?
Most massage therapists are pretty nurturing types of humans. They can provide a therapeutic support role through 'recovery' and encourage paced activity to incorporate self-management.
IS MORE MASSAGE BETTER?
A leading researcher in this field is Christopher Moyer PhD who is a behavioural scientist primarily interested in the role of massage therapy on anxiety and depression or the human affect.
I'll let him speak about the research he has accumulated on the subject about whether more massage is better:
"We made an interesting discovery concerning the effect of the treatment on the state of anxiety. When a series of massage therapy sessions was administered, the first session in the series provided significant reductions in anxiety, but the last session in the same series provided reductions that were almost twice as large. This pattern was consistent across every study we were able to examine, which strongly suggests that experience with massage therapy is an important predictor of its success, at least where anxiety is concerned. To put it another way, it is possible that the greatest benefits come about only when a person has learned how to receive massage therapy." (2)
SO STOP FEELING GUILTY
You can all stop feeling guilty. If you enjoy getting a massage then book one now and do something good for your mental health. Give yourself a pat on the back for being proactive about your wellbeing. Well done you!
(1) Christopher A. Moyer, PhD, Research Section Editor, IJTMB, Assistant Professor, Int Journal Therapeutic Massage and Bodywork. 2008; 1(2): 3–5. Published online 2008 Dec 15.
(2) Moyer CA, Rounds J, Hannum JW. A meta-analysis of massage therapy research. Psychol Bull. 2004;130(1):3–18.
What is Osteopathy?
The word Osteopathy, along with the concept, was developed well over a hundred years ago. "Osteo" is clearly a derivation relating to "bone", but an Osteopath is much more than just treating bones. I'm pretty sure if it was developed now, a whole team of branding and marketing specialists might come up with a better name. It does have a fair bit to do with bones (as part of the overall musculo-skeletal system), but I don’t think there are many Osteopaths still out there who think we can use joint manipulation to cure serious disease. So whilst many theories have been culled from the original concept, the manual side of Osteopathy has evolved to help people with pain and provide professional advice in their recovery from injury or surgery.
A foundational principle, or perhaps the philosophy of Osteopathy, remains sound. Historically, Osteopaths were trained to treat the body, mind and spirit. In today’s speak, Osteopaths are trained to take a bio-psycho-social approach. Bio (body) pscyhological (mind) social (spirit) is at the very foundation of how Osteopaths think.
BIOLOGY (BODY)
We work with the body because we are manual therapists. This means we use our hands, our eyes and our brain to assess your body and use a broad range of hands-on techniques and movement therapies in order to modulate your pain and help you move better. Modulate in this context means to modify, hopefully in a positive direction, with the result being, you have less pain and movement is easier.
PSYCHOLOGICAL (MIND)
But where would we be without your brain, or ours for that matter. Our brain works with your brain. This doesn't mean we’re psychologists but it does mean we’re good listeners and we recognise the person standing in our room has a brain, a mind, a long history of lived experience; possibly trauma, happiness, an education. We work together with your brain, in countless ways, listening, discussing, educating and providing advice. We might challenge your default or resting postures, and significantly, we will educate you about pain and this might challenge the way you think about your pain.
SOCIAL (SPIRIT)
Osteopaths have historically also worked with your ‘spirit’. This is the part that can make people feel we’re a bit ‘out there’, a bit ‘crystal healing’, a bit ‘woo’. Once again, this aspect has an historical context. Osteopathy was developed when Science and Medicine didn't have answers for many horrible afflictions. Using leeches and ‘bleeding’ people was common practice.
Like medicine and the manual and physical therapy realm, Osteopathy has benefited from great leaps of understandings in Science over the last 100 years and especially research into neuroscience in the last 20 years.
Most people’s experience of pain improves when you are provided with nurturing environments, good education about pain and why it’s there, empowering explanations, and the knowledge of how to change their pain. This isn't pandering to the concept of a ‘spirit’ but it does recognise that people are complex creatures and appreciate being treated as humans.
TODAY
Many practitioners, whether medical or manual, still practice within a biomedical model in which they tend to treat just the anatomical aspects of a problem. “Here take some ibuprofen”, “You need to see me forever every four weeks to be truly healthy”, “Let’s strengthen your core to really solve the problem”, “Stand up straight”. They often ignore the other human aspects that might be contributing to the problem, including the most important part that runs every single aspect of our mind and body, our brain.
And we don’t forget the basics either. We are very qualified to rehabilitate post-surgical or post-injury movement dilemmas. That's our bread and butter.
At Fairfield Osteopathic Clinic, our Osteopaths meet with you for up to an hour the first time you come in, in order to grasp the whole picture.
Pillow, pillow on the bed, which is the best one for my head?
Which pillow shall be crowned in glory?
I am frequently asked about pillows. Most people who ask me ‘Should I get a new pillow?’ have arrived seeking treatment for a sore neck, insomnia or morning headaches. They don’t like their current pillow and have at some point flung it across the room in frustration. They may have paid a lot of money for one or many different kinds of pillows.
What is the perfect pillow?
I’m sorry, but I’m here to disappoint you, there is no perfect pillow. On a good day or given enough time, you can adapt to nearly anything. Over the last hundred years or so humans used rocks, horse hair and straw to help us sleep comfortably through the night. Before that we slept mostly on the ground, bereft of any pillow.
If we tried that now, out of the blue, then you’d be much like my twenty-four year old osteopathic colleague, Whitney, who recently went camping in Ballarat and slept on the cold hard ground, with only a thin, inadequate mat between her and the dirt. She was complaining this morning of sore shoulders, sore hips and an aching low back. Her whole body was yelling at her to march herself right back home to sleep on her $2000 mattress and contoured feather pillow. Unbelievably, she hadn’t spent any time at all progressively sleeping on less comfortable surfaces over the preceding weeks to get her body prepared for her camping experience. And really who would do that?
Our bodies and the bones, ligaments and muscles that make them up, respond to the activities that we ask of them. If we ask them to sleep on an extremely comfortable, forgiving surface every night then they’re just going to find it a bit of a struggle adjusting to a hard, cold, dirt floor. Your discomfort is not in your imagination.
So back to the person asking me about the perfect pillow. The one who has a sore, tight neck and shoulders and is struggling to adapt to anything. What do I tell them?
Your pillow is a support device.
Your pillow is there to provide support - it’s an orthotic for your head and neck.
A pillow that is unforgiving and asks you to adapt should be pushed to the side. It is meant to provide comfort and adapt to what you need, not the other way around.
This is not a sales pitch but we do sell a pillow at the clinic and it is the one I recommend to people if they’re genuinely in the market for a new pillow. It has a contoured cotton cover stuffed with polyester fill. The reason I like it is simple. It’s adaptable. It has a zip on one end that you can pull out stuffing or put more in as the polyester filling loses it’s ‘lift’. At night, you you can move the stuffing around if you punch it, or shove it into the headboard to make it higher when you roll from your back to your side. And in a couple of years when the filling bunches up and is full of saliva, dead skin and microscopic creatures, you can pull out the stuffing, wash the cover, stuff some new stuffing in and start again.
The Massage (Lacrosse) Ball - Best $8 You Ever Spent
I love these little balls. They’re cheap and they travel well. Recently, I had a client who took one on a bus tour to the Czech Republic. She took it to combat her mid back tightness and by the end of the trip all her travelling companions were impressed with it’s effectiveness.
Most people use it for ongoing tightness or a deep aching discomfort. They rarely like using it for acutely tender, sharp pain and I would not recommend using it for that kind of pain.
People often describe tightness building up over time, weeks or months that has rather suddenly turned into pain, like it has reached some kind of tipping point of tolerance and there is no turning back - not without a beach holiday, some meditation or some hands on therapy. Bring on the ball.
But how does it work? It has a local tissue effect due to the compress and decompress movement and also a nervous effect due to the DNIC approach that Todd Hargrove, a Feldenkrais practitioner from the US, writes about eloquently in this BLOG post from a couple of years ago. Using a massage ball is essentially the same approach:
http://www.bettermovement.org/2013/how-does-foam-rolling-work/
My disclaimers about it’s use are simple:
Use it for a maximum of 90 seconds in one location - nothing much changes after that and you’ll more likely cause injury.
Compress and decompress - that way you’re having a local tissue effect (squeezing and releasing the muscles) and you’re less likely to cause an injury.
Use it only every second day. That way you won’t build up a tolerance to the hard little sucker and start bruising yourself.
I recommend it for the big muscles down either side of the spine, the gluteal (buttock) region and the trapezius muscles.
Here is a little demonstration video we put together to help you get started.
Michael Clarke's Back
Anyone who was watching the cricket yesterday would have seen the incident that led to Michael Clarke leaving the field with severe back pain. For the uninitiated Michael Clarke is the captain of the Australian Cricket team. The last week or so may have been, quite probably, the most traumatic and stressful period of his life so far. Recently there was the tragic injury, while batting, and subsequent death of Australian cricketer Philip Hughes. Phil Hughes happened to be a very close friend of Michael Clarke. A sad event all round and our condolences go to family, friends and the cricketing community at large.
I won't presume through this Blog to know exactly what is happening with Michael Clarke's lower back. I've heard it all from the commentators and journalists - disc degeneration, disc prolapses, sprained sacroiliac joints, pars interarticularis fracture - and the list goes on. No doubt he has a team of specialists giving their two cents on what is wrong and what he can do about it. What interests me is how such an innocuous incident could lead to a flare up of a pre-existing complaint.
The previous week Phil Hughes was felled by a bouncer while batting for NSW. Without going into detail it was a tragic and unfortunate accident that ultimately ended his life. Yesterday, while facing up to the Indian pace attack in the first Test Match of the summer Michael Clarke was travelling along quite well. He has recently altered his batting technique to take pressure off his "niggly" low back and hamstrings and it seemed to be working well. The Indian bowler at the time bowled a bouncer at Michael Clarke (which was a pretty ordinary ball putting the batsman under little pressure at all) to which he flinched to instinctively get out of the way. Wham-Oh! His back went into spasm and he was unable to continue.
Michael Clarke was under pressure - emotionally and physically. He was carrying a "niggly" lower back and hamstring problem. Suddenly a bouncer comes at him at 140km/hr and his brain says "ALERT, ALERT!" There is a reflex tensioning of the body and the messages from the brain to the lower back were greatly exaggerated. Here is a perfect storm for aggravating a pre-existing problem. Stress, anxiety and physical duress can all impact on the DANGER signals to the brain and the way the brain interprets that danger. It is quite likely Michael Clarke has not done any further "damage" to his lower back, and honestly I hope he is not being told how "damaged" his lower back is as it does not directly equate to a persons pain experience one iota.
Michael Clarke is an impressive captain to bravely go out and face that red ball under such stress and I'm sure will bounce back and hopefully be better for it. In fact, I think he just got a century.