pain

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?

Knots.jpg

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.

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.

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.

 

 

 

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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

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