“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.
Millions of people take opioids for chronic back pain, but many of them get limited relief while experiencing side effects and worrying about the stigma associated with taking them.
More than 100 million people in the United States suffer from chronic pain, and those with chronic low back pain are more likely than patients with other types of pain to be prescribed opioids. Unfortunately, these medications are addictive and can cause side effects, ranging from drowsiness to breathing problems.
“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Asokumar Buvanendran, M.D., lead author of the study, director of orthopedic anesthesia and vice chair for research at Rush University, Chicago, and vice chair of the American Society of Anesthesiologists (ASA) Committee on Pain Medicine. “While some patients may benefit from opioids for severe pain for a few days after an injury, physicians need to wean their patients off them and use multi-modal therapies instead.”
In the study, 2,030 people with low back pain completed a survey about treatment. Nearly half (941) were currently taking opioids. When asked how successful the opioids were at relieving their pain, only 13 percent said “very successful.” The most common answer — given by 44 percent — was “somewhat successful” and 31 percent said “moderately successful.” Twelve percent said “not successful.”
Seventy-five percent said they experienced side effects including constipation (65 percent), sleepiness (37 percent), cognitive issues (32 percent) and dependence (29 percent).
Respondents also had concerns about the stigma associated with taking opioids. Forty-one percent said they felt judged by using opioids. While 68 percent of the patients had also been treated with antidepressants, only 19 percent felt a stigma from using those.
A major pharmaceutical company recently agreed to disclose in its promotional material that narcotic painkillers carry serious risk of addiction and not to promote opioids for unapproved, “off-label” uses such as long-term back pain. Researchers also note a lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.
Patients with chronic low back pain, persistent pain lasting more than three months, should see a pain medicine specialist who uses an approach that combines a variety of treatments that may be more beneficial, said Dr. Buvanendran. These treatments include physical therapy, bracing, interventional procedures such as nerve blocks, nerve ablation techniques or implantable devices, other medications such as anti-inflammatories and alternative therapies such as biofeedback and massage, he said.
American Society of Anesthesiologists (ASA). “Many back pain patients get limited relief from opioids and worry about taking them, survey shows.” ScienceDaily. ScienceDaily, 23 October 2016.
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.