Some common spinal injuries and conditions we treat:
Acute lower back (lumbar) pain due to spinal disc and/or facet joint injuries
Chronic low back (lumbar) pain
Sciatica – referred pain and symptoms into the lower limb
Pelvic dysfunction syndromes . Often diagnosed in patients who feel ‘out’.
Childbirth related instability and acute pain syndromes of the lower back and pelvis.
Spondylolisthesis (forward slip of one vertebrae on the vertebrae directly below it)
Spondylosis (disc space narrowing combined with degenerative changes in the facet joints common with age)
Acute neck pain due to facet joint and/or spinal disc injury
Chronic neck pain
Brachialgia-referred pain and symptoms into the arm, ‘pinched nerve’ pain and/or pins and needles/numbness (known as paraesthesia)
Mid-back (thoracic) and rib (costovertebral joint) pain (which, in some cases, refer pain around the chest wall)
Acute/chronic (myofascial) trigger point conditions. (These are tender and hypersensitive coin sized zones within the muscle tissue that can cause local pain and tightness and can also refer to distant sites.)
Muscle and joint stiffness
Causes of Spinal Pain
Acute and chronic spinal pain is experienced due to the stimulation, via mechanical or chemical irritation, of small nerve endings, nerve root or spinal cord sheaths, nerve cords, complex pain mechanisms in the central nervous system or a combination of the above.
Acute Spinal Pain
This can involve findings of bulging disc, disc protrusion or disc prolapse/rupture. Disc problems are very common in the lower back (lumbar spine). They are often associated with episodes of bending, bend with twist or prolonged sitting /driving which distorts the rim of the disc causing acute pain. In addition it can produce pressure on the spinal nerves in the lower back which produce symptoms known as sciatica. This is felt as pain, pins and needles sensation, numbness and/or weakness in the leg(s). In the neck (cervical spine), disc injuries can cause debilitating pain into the neck and commonly severe pain into the arm called brachialgia due to compression of the spinal nerves in the neck. This is commonly referred to as ‘pinched nerve’.
These joints are small joints which flank the disc on either side and behind the spinal discs. They are like a finger joint in their structure and when injured swell and inflame and cause acute pain and restriction of movement. They can be sprained in an injury or activities involving twisting, arching and reaching upward movements. In the neck they can become overstrained by an awkward night’s sleep leading to a condition known as ‘Acute Wry Neck’. They can cause local pain and also refer pain to neighbouring and even distant sites.
The joints of the pelvis can suffer acute injuries through high force trauma such as motor vehicle/bicycle accidents, contact sports, slips and falls on to the ground/floor, landing from a height, or when the female pelvis is vulnerable before and after childbirth. Injury and acute instability syndromes can occur which involve the sacroiliac and pubic joints. Lumbo-pelvic dysfunction conditions are common in the sporting population. Muscle imbalance, asymmetrical posture and structural alignment, as well as poor activation and stabilising strength (core control) can create syndromes such as chronic back pain, Osteitis Pubis (OP), recurrent hamstring strains, and contribute to a range of soft tissue injuries/conditions in the lower body.
This refers to the soft tissue layer involving the muscles, tendons and fascial tissues. This can be injured acutely and cause local pain at the site of injury but can also be responsible for ache and pain at distant sites. Myofascial pain is often associated with damage to deeper joint structures, namely disc and facet joints as either a primary (injured tissue) and/or secondary (protective spasm) component of the acute injury.
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 vertebra, 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.
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.