“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.
Okay. So you’ve decided to embark on a fitness regime in order to shed some kilo’s, get fit or just for fun. New gym membership. Check. New sparkling runners. Check. Gym gear (a bit tight at the moment). Check. Alright, let me at that treadmill/rower/crosstrainer/zumba class!
“Hold on a second – what about your warm-up!”
“Warm-up” you scoff, “you’ve got to be kidding. No time to waste on that”.
Sorry folks, but the warm-up is an important part of your exercise routine and plays a crucial role in preparing your body for exercise. Skimp on the warm-up and you run the risk of injury during exercise or sport, as well as reduced performance levels.
“But what’s so important about doing a few stretches?” I hear you ask.
A proper warm-up involves more than just standing around stretching and talking. It prepares your body for the exercise/sport it is about to undertake and should simulate the actions involved.
The benefits of a warm-up are:
1) Increase in core body temperature
2) Preparation of muscles, tendons and joints for the stresses/strains of activity
3) Increase in nerve impulse conduction to muscles
4) Increase in blood flow to muscles
5) Increase in respiratory (breathing) rate
Let’s have a closer look at each of these benefits.
1. Increased core body temperature – this is important as it prepares the body for the change in activity level from being sedentary to exercising and gets the body into a ‘ready’ state. This also results in an increase in muscle temperature which makes them more pliable, supple and loose.
2. Prepares muscles, tendons and joints for activity – each sporting activity stresses the body in different ways so it is vital to prepare in a way that simulates these activities. For example, if you are a basketballer you need to include in your warm-up the jumping, running and change of direction that occurs during the game. If you pump weights at the gym, it is vital to perform a warm-up set of each exercise at a lower weight to allow your body to adjust to each specific movement.
3. Increased nerve conduction – muscles that are in a ready or aroused state react quicker and more efficiently than muscles that aren’t prepared for activity.
4. Increased blood flow to muscles – through increased blood flow there is an increase in oxygen flow to muscles as well as nutrient flow. This increased flow allows for improved performance
5. Increased respiratory rate – prepares the lungs for an increase in activity level and improves oxygenation of the blood flowing to the muscles.
Okay, so now that we know why we are performing a warm-up, what should it involve?
One common misconception out there these days is the importance of stretching as part of a warm-up. Note I said part of a warm-up.
Stretching on its own does not constitute a warm-up – rather it forms a critical part of one.
An effective warm-up has a number of very important key elements, which work together to minimize the likelihood of sports injury and prepare the individual for physical activity.
These key elements are:
1) The general warm-up
2) Static stretching
3) Sport specific warm-up
4) Dynamic stretching
1. The general warm-up
This consists of light physical activity such as walking, jogging, easy swimming, stationary bike, skipping or easy aerobics. The intensity and duration of the general warm-up is dictated by the fitness level of the participating athlete. For the average person, this part of the warm-up should last between 5 and 10 minutes and result in a light sweat.
2. Static stretching
Yes! Static stretching. This is a very safe and effective form of basic stretching. There is a limited threat of injury and is beneficial for overall flexibility. All the major muscle groups should be included for a period of 5 to 10 minutes.
Debate has raged about whether static stretching should be part of a warm-up and some studies have shown that static stretching can have an adverse effect on muscle contraction speed and therefore performance. It is for this reason that static stretching is performed early in the warm-up and always followed by sports specific drills and dynamic stretching. It is important these first two elements are completed properly as it allows the more vigorous and specific activities of elements three and four to then be performed.
3. Sport specific warm-up
In this part, you are specifically preparing the body for the demands of your particular sport or activity. During this part of the warm-up, more vigorous activities should be employed. Activities should reflect the type of movements and actions which will be required during the activity.
4. Dynamic stretching
Finally the warm-up should finish with a series of dynamic stretches. Caution should be taken with this form of stretching as it involves controlled, soft bouncing or swinging motions to take a particular body part past it’s normal range of motion. The force or the bounce of the swing is gradually increased but should never become radical or uncontrolled. These exercises should also be specific to the sport or activity.
Another important factor to keep in mind when undertaking any new exercise regime, is the time it takes for the body to adapt to training. If you have had a period of time away from sport or activity, then your body won’t be used to the stresses and strains put on it from exercise. It can take up to 4 to 6 weeks for your muscles, tendons and joints to become adjusted to the movements involved in your sport or activity.
During this period it is advisable to start with low to moderate intensity exercise which gradually builds over time. Heading straight up the red or blue arrow as your first exercise session in 3 or 4 months isn’t a great idea. Starting out with flat walks or jogging and gradually increasing time and intensity is a better way to start. After 4 to 6 weeks you will be at the stage where you can tackle more intense sessions.
The same goes for weight training. Starting with lighter weights and more repetitions will allow your tendons and joints in particular, to adapt to lifting load. Going too heavy too soon can lead to tendon injuries or severe muscle and joint soreness.
Lateral epicondylalgia or tennis elbow is the most common cause of musculoskeletal
pain located near the elbow. It is commonly known as tennis elbow as it can be a significant problem amongst tennis players. However, you do not need to play tennis to have experienced this injury. It is reported that approximately 40% of people will experience this type of pain at some point in their life and it usually presents in males or females aged between 35 and 54. Lateral epicondylalgia is an injury to the forearm muscles that act to extend the wrist and fingers. The point of injury occurs at the site where the muscle attaches to the bone near the elbow.
What causes tennis elbow?
Lateral epicondylalgia is usually caused by an overload of the forearm extensor muscles where the load is more than what normal muscle tissue can handle. Associated neck or shoulder pain may also contribute to the presentation. Common causes or activities can include:
Poor technique during sports or other activities i.e. racquet sports
Manual workers with jobs involving repetitive gripping and hand tasks
Office workers with jobs involving repetitive use of the keyboard and mouse
Symptoms of lateral epicondylalgia include tenderness over the side of the elbow and pain with activities involving gripping or wrist extension. There may also be areas of tightness through the forearms and pain when the involved muscles are stretched. Your physiotherapist will be able to diagnose this condition based on physical examination and gathering a complete history of your injury. Your physiotherapist may also send you for medical imaging scans to assist in ruling out other causes of elbow pain including muscle tears, ligament injury and elbow instability or pain that is originating from the neck.
The goals of treatment are to reduce pain, promote healing and decrease the amount of stress applied to the elbow. Also, to restore full strength and movement of the elbow and wrist. Early treatment may include:
Rest from aggravating activities
Exercise programs involving gradual strengthening and stretching
Massage and other soft tissue techniques
Taping to reduce load on the muscle and tendon
Acupuncture or dry needling
Once pain levels have decreased, physiotherapy will involve prescription of more difficult or specific strengthening exercises and correction of any predisposing biomechanical or technique problems. These are essential to prevent future aggravation and shorten recovery time.
Braces are available which are designed to assist in alleviating pain by reducing the amount of stress on the tendon. However, not all people will benefit from using a brace. Your physiotherapist will be able to guide you through all stages of rehabilitation.
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.