Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. They are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints at the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each verteba, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or bowling at cricket.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
PROGNOSIS OF BACK PAIN
Physiotherapy for back pain can provide outstanding results but it is a process, not magic. The damage which produces pain in a back takes time to develop and also time to repair and heal. You will understand there are often several interacting factors to deal with and patient compliance is necessary.
“Tension headaches” are often talked about and we see a lot of patients with these headaches. In our diagnosis of these conditions, about eighty five percent of all headaches arise from the neck, or cervical spine, which refers pain into the head through the nerves which go to both areas. Neck problems cause head pain because some of the nerves which come from the spinal cord have branches which go to the upper neck joints and other branches which spread over the back of the head, with still others going to the front of the head. When one area is sore the brain interprets the pain as coming from all the areas the nerve branches go to.
CAUSES OF TENSION HEADACHES
Patients who have “Tension Headaches” or “stress headaches’’, are often very busy and have work related problems, a tough boss, urgent deadlines, problems with managing work flow and they often have trouble sleeping because of work problems and their worries. This causes the patient to be mentally and emotionally stressed and their relationships at work and with their families suffer.
They develop a headache which they cannot shake and they feel helpless, tired, tense, anxious and in pain. We have seen many cases where the headaches have continued for weeks and frequently kept recurring, sometimes over many years.
It is important to understand that a Tension Headache is due to “physical tension” in the tissues, often from a poor working position and the damage it has caused, not the other mental “tensions” listed above. Once full neck movement has been restored with treatment, the tissues have healed and the postural strains have been removed, patients often cope better with the other aspects of their lives. This is where Physiotherapy can help by breaking the vicious “Physical Tension” cycle. It is better to think of these as “structural headaches”.
Our neck is made of seven vertebrae stacked one above another. They support the head and they are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints which join the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. The junction of the first vertebra and the head does not have a disc and the joints there are particularly susceptible to leaning forward which causes the weight of the head to strain the joints, ligaments and muscles as gravity causes a shearing force as the head slides downward.
The neck muscles are often blamed as the cause of pain but this is rarely the whole story. Muscle pain often develops as the muscles contract to prevent further damage, as they protect the primary underlying structures. This pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture, etc, there is temporary relief but the pain will always comes back as the muscles resume their protective bracing. The most common sources of primary pain are the facet joints and their ligaments in the upper neck and the discs in the lower levels of the neck.
A facet joint strain is much like an ankle sprain, strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged.
In the upper neck, facet joint strains typically occur during excessive bending or twisting movements and may follow trauma such as a car accident causing whiplash but generally, Tension Headaches occur with prolonged forces such as slouching, keying and reading.
There is often a previous history of pain coming and going as the damaged area became inflamed, was treated and settled for a while but as the underlying problem still remained, the pain flared up repeatedly every time it was strained. This type of injury, although often chronic, responds very well to specific Physiotherapy treatment.
There are many other sources of headaches and neck pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will advise you should a more serious condition be suspected.
SYMPTOMS OF TENSION HEADACHES
Symptoms of “Tension Headaches” arising in the neck, are always affected by movement of the head and neck. This is important to understand. Symptoms are sometimes severe and may be sudden in onset but also may be mild and of gradual onset. There are other serious conditions which can produce headaches. If you have severe headache symptoms which are not affected by movement and a recent history of fever or nausea, you must consult a doctor urgently.
Facet joints, discs, muscles and other structures are affected by our neck positions and movements and when damaged, will respond very well to Physiotherapy treatment.
DIAGNOSIS OF TENSION HEADACHES
“Tension Headaches” often appear complex and require a full understanding of the history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues and these coexisting pathologies are treated individually as each is identified. Where the Physiotherapist requires further information or management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
TENSION HEADACHE RELIEF
Some of these cases will temporarily respond to a general non-specific treatment such as bed rest, ice and anti-inflammatories, however Musculoskeletal Physiotherapists have developed diagnostic skills and treatment techniques, targeted to stopping “Tension Headaches”. We will identify the reasons for the development of the pain and advise strategies to promote healing and to prevent further damage.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education.
When normal function has been achieved, the inflammation and pain has settled and the structures have healed, using your new strategies will reduce the possibility of the headaches ever recurring. We use this approach to reduce or stop chronic pain. While we have the choice to manipulate or “click” joints, those with ongoing pain will seldom benefit from repeated “adjustment”. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost as the tissues tighten up again. Potentially dangerous “adjustments” of this type have little long term benefit and can lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safe and appropriate treatment for you.
PROGNOSIS OF TENSION HEADACHES
Physiotherapy for “Tension Headaches” can provide outstanding results but it is a process, not magic. The damage which produces “Tension Headaches” takes time to develop and time to repair and heal. You will understand there are often several interacting factors to deal with and your compliance is necessary.
Ok so your shoulder has been hurting for a while and your Physio has diagnosed you with a Rotator Cuff injury. What the hell is a rotator cuff? How do I get rid of this pain!?
Firstly, the rotator cuff is a group of four muscles which help to stabilise the shoulder. The shoulder is a ball and socket joint, similar to the hip, however the shoulder has a shallow socket in comparison. What the shoulder lacks in stability it makes up for in mobility, generally speaking, a healthy shoulder has almost 360 degrees of movement so it needs help from the surrounding muscles to maintain stability through movement. There is also another structure inside the shoulder joint called the labrum, which helps to deepen the joint and provide stability.
How does my Rotator Cuff get injured?
Rotator cuff injuries usually occur either acutely (immediate sharp pain) or over time (gradual increasing dull ache). Acute rotator cuff injuries can often involve a tearing of the rotator cuff tendons and leads to pain and weakness of the shoulder. Gradual onset of shoulder pain can be associated with repetitive overhead movements, which can lead to smaller tears in the tendon and inflammation around this area.
One of the main factors which can influence shoulder pain is the position of the shoulder. The further forward the humeral head (the ball) sits in the socket, the more compression of the tendon occurs and leads to injury.
How can I fix it?
Having your shoulder properly assessed by a qualified Physiotherapist is the first step in diagnosing a Rotator Cuff injury. Investigations such as Ultrasound or MRI may be relevant if the Physiotherapist feels there is significant injury. For acute rotator cuff tears, a small period of immobilisation in a sling or in some cases, just with some tape, will help settle the pain. Once pain and inflammation are under control then you need to get the shoulder moving and gradually strengthen the rotator cuff tendons and surrounding muscles.
For the gradual onset type shoulder pain there is usually a biomechanical cause for the loading of the tendons. Thorough assessment by a qualified Physiotherapist is a must to get to the bottom of your shoulder pain. Initially settling down the pain and inflammation around the tendons and encouraging gentle pain free movement is the first step. Then gradually increasing the load in the shoulder until the strength is back to normal
How can I prevent this from happening in the future?
Continuation of the strength and flexibility exercises prescribed by your Physiotherapist will help decrease the likelihood of re-occurrence. Identifying aggravating positions i.e. overhead movements or reaching in awkward positions will also decrease the likelihood of re-injury. If your job is a relatively sedentary and requires hours of sitting at a time, trying to break up your day with standing/walking will help, also an ergonomic assessment to ensure your workspace is properly set up to suit you will help ease the stress on your shoulders/neck.
Feeling dizzy? You Could Have a Vestibular Disorder
Do you experience dizziness? Perhaps when rolling into or over in bed, or turning your head to one side?
Dizziness can be more than dehydration, a big night out, or a compulsion to spin in circles on your office chair. It can be a symptom of asymmetry in your body’s sensory systems.
The most common condition that causes dizziness is benign paroxysmal positional vertigo, or BPPV. The brain has three main mechanisms for perceiving how we interact with the environment around us. These are the visual, proprioceptive, and vestibular systems.
The visual system is self-explanatory. The proprioceptive system is a network of nerves in all of your muscles and joints that relay information about the position of those muscles and joints back to the brain. It is how you can close your eyes and still accurately position your arms and legs in different poses.
The vestibular system is located in your inner ear and is used to identify the position and movement of the head in space. This is the system commonly linked to dizziness and vertigo.
The vestibular system is made up of three perpendicular fluid filled canals in each ear, which relate roughly to the planes of movement.
These canals each have sensory nerves at one end that are made up of crystals resting on fine hairs. When you turn your head, the fluid moves through the canals and pushes on the crystals. This causes the hairs to move and stimulates the nerves.
Your response in each ear should be equal and opposite, and work in tandem with your visual and proprioceptive systems. If things are not working in tandem, then dizziness, vertigo (room spinning), or nausea may result.
Have you ever felt nauseated in a car, or on a boat? This is because your vestibular system recognises that your head is moving but according to your eyes, you are still or moving a different way.
Someone may have suggested looking out the window or finding the horizon. This is great advice as fixating on something which the car or boat is moving relative to, provides a visual reference point and reduces or eliminates the disagreement between the visual and vestibular system.
In patients suffering BPPV, a similar disagreement occurs but it is completely internal. It occurs when crystals in one ear canal become dislodged from the hairs and drift down into the canal. This can happen as a result of trauma but is just as frequently unrelated to any incident.
When the head is turned, the nerve stimulation in one ear is different to the other and a combination of dizziness, vertigo, and nausea can result.
Generally, this resolves in seconds, or in more severe cases last up to two minutes. Usually only one canal will be affected at a time so symptoms are commonly worse to one side, and occur most severely in a single plane of movement.
If you are dizzy due to asymmetry, then your physiotherapist can assess and treat it. Assessment of specific movements can isolate which ear and which canal is causing the problem and treatment involves techniques designed to use gravity and inertia to relocate the crystals back to where they belong at the end of the canal.
NOTE: If you are suffering from severe, sudden onset headache, or persistent dizziness, double vision or nausea that seem unrelated to any particular movement then consult a medical doctor immediately.