These pains are real. Pain in the arm can be referred from the neck and similarly the source of pain in the leg can be from the lower back.

Types of referred pain from the spine 
 

1. The most common is a deep dull ache in certain parts of the affected limb. See image below. These areas of pain correspond to where the nerves in the spine supply sensation to. There are 7 vertebrae in the neck. Depending on the level, nerves exit from the vertebra and travel to specific areas of the scalp, shoulder, arm, forearm and hand. Similarly nerves exiting between the 5 vertebra of the lower back travel to the bottom, thighs, legs and feet. These nerves supply sensation to these particular areas and are called dermatomes.  So if the exiting nerves are mildly irritated, it can refer pain to its specific dermatome. Therefore, if the structures surrounding the nerves are inflamed, immobile, strained or somehow affect the exiting nerves, pain can develop in the extremities.
2. The second type of referred pain is sharper, more acute and often described as pulling, stabbing and severe pain.  However, the site of pain remains the same. In these cases, the nerves exiting the vertebra are not only irritated but usually impinged or compressed.  The cause of the impingement is usually severe degeneration in the vertebrae, disc prolapse and swelling which reduces the canal space, for which the nerves to exit.  These types of pain can be accompanied by loss of strength of muscles in the arm and leg as well as decrease sensation as the compression affects the conduction within the nerve fibres. The impinged nerve essentially is less able to send its usual amount stimuli to the muscles it excites. 

Dermatomes

Treatment of referred pain

The treatment for referred pain is simple.  Find the cause of the irritation or compression and remove or reduce the cause as much as possible within the realm of physiotherapy.
 

1. Type 1 Dull achy pain is usually due to poor posture, excessive mechanical loading on the spine, i.e. tight muscles, stiff and or mal-positioned facet joints.Once the mechanical fault is corrected, the structures offloaded, through manual therapy, the symptoms tend to promptly reduce.
2. Type 2 Pain which is more acute, it is more difficult to treat.  As the source of pain is from the compression /impingement of the nerve, the cause of the impingement is usually structural.  This means that the existing degeneration of the spine and the significant disc protrusion are the main reasons for the impingement.  Therefore unless that is addressed, often the pain is not completely resolved. 

The role of physiotherapy in this intance is to reduce the non structural causes such as excessive vertical loading, the narrowing of the canal and pain reduction. These non structural causes could be the result of swelling, poor posture, muscle spasm. Traction and specific exercises are therefore taught to open the canal space and reduce disc protrusion and impingement.

Arm pain or neck pain…Where is the source? is a post from: Musculoskeletal Consumer Review

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Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.

Background

Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.

Image from Pilates Suffolk click for larger view

Clinical Pilates vs Pilates

Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.

In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.

Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery. 

The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.

Peripheral injuries

When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries. 

Spinal Injuries

Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.

In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.

Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.

In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.

If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt. 

The benefits of Pilates
 
•    General fitness and body awareness greater strength and muscle tone
•    Improved flexibility
•    A flatter stomach
•    Improved efficiency of the respiratory, lymphatic and circulatory systems
•    Better posture and awareness
•    Less incidence of back pain
•    Increased joint mobility
•    Lower stress level

Which clients would benefit from Pilates?

•    Males and females
•    Pregnant: Pre and post natal
•    Athletes and dancers
•    Amputee and stroke rehabilitation clients
•    Elderly
•    Children 12 years-old +

Clinical pilates therefore  targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.

If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!

Pilates and Physiotherapy is a post from: Musculoskeletal Consumer Review

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The Theory: Disc Nutrition

The discs are fluid filled gel like structures that act as shock absorbers in the spine. They are found between each segment of bone throughout the spine. The discs slowly lose some of this fluid through the daytime under the effects of gravity. The fluid is then drawn back into the disc when we sleep at night in an unloaded position. This movement of fluid is critical for disc health as discs nutrition is provided from this exchange, and the volume exchanged must remian balanced. Unfortunately, sedentary individuals may be encouraging a negative fluid balance. It has been shown that sitting or standing statically for as little as 1 to 2 hours significantly increases the outflow of fluid. This process leads to the first step in disc degeneration. The disc becomes ‘dehydrated’ and mechanically ineffective when it tries to distribute the body’s load. This initial change often presents as the mild ache you feel when sitting for long periods.

The Degeneration Cycle

Over time the disc reduces in height and becomes less compliant. Globally the spine loses flexibility and therefore cannot create enough pressure on the disc to effectively and sufficiently move the fluid in and out. The disc receives less nutrition and has difficulty removing waste products. The cycle continues and may cause a break down of the structure of the disc. This stage relates to when back pain becomes more chronic in nature, and additional disc damage and pain can occur from minor activities.

The good news

Traction exercise completed on a daily basis can halt and even reverse this process. The overall aim is to improve the fluid flow mechanism in the disc and ultimately increase disc height and health as it rehydrates.

Where to start?

Any exercise to ‘traction’ or ‘decompress’ the lumbar spine can help. An example is shown below using a yoga block (approx. 7cm height), placed below the belt line

Spine Decompression exercise on Yoga block
click for larger view

• Spend 1 minute relaxing in this position

• Remove the block and rest for 30 seconds

• Repeat this process 3 times in 1 session

• 1 session should be completed around midday, and a further session prior to sleeping.

Other Important Factors

• The  exercise should be carried out in the evening. This is when the disc has been maximally compressed from daytime activity. Traction allows the discs to take in fluid more efficiently during the night hours when the spine is unweighted.

• If you normally exercise immediately after working at the office all day, use the traction exercise as part of your warm up to ‘decompress’ the discs. This will reduce the stress on the disc during your exercise routine.

• Added benefits This position stretches the muscles and other soft tissues at the front of the spine and hips, which are often tight from many hours spent in working postures.

• The stretch can create better alignment of the upper body making you stand straighter, which is important for maximum recovery following a lower back injury.

Caution Assessment by a Physiotherapist is strongly recommended prior to starting the above exercise. If you already have lower back pain you may also require hands-on treatment from a therapist to physically mobilise a particularly stiff spinal segment for the above exercise to be more effective.

Anti-Aging Exercise for your Lower Back – Good Nourishment is the Key is a post from: Musculoskeletal Consumer Review

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Exercises should be done daily for 3 -4 weeks to see results.

Seated leg lift click for larger view	Seated Leg Lift Sit on a chair with your back flat (do not arch your back) and feet flat on the floor. Resting your hands over the lower abdominal muscles, pull in your lower abdominal muscles and pelvic floor muscles while breathing normally. Do not hold your breath. Keeping the contraction in your lower abdominals and pelvic floor, gently raise one knee so that the foot is about 5-10 cm off the floor. Hold the position for 5 seconds, making sure the pelvis and the spine remain level. Make sure you are still sitting firmly on your buttocks and not shifting your weight to one side, neither should you shift your upper body in any other directions. The upper body should be still with the pelvis level while doing the exercise. Repeat 10 times with each leg. Gradually increase the hold to 10 seconds or more for future sessions.
Lower abdominal strengthening click for larger view	Lower abdominal Strengthening Lying on a mat or firm surface, flatten the small of your lower back into the mat. This movement will tilt your pelvis back, putting it in a neutral position, thus protecting your back. You should not feel any gap between your lower back and the mat. Next, bend your knees and raise your feet of the floor till the thighs are perpendicular to the mat and the lower legs are parallel to the mat. Then, while keeping the lower back flat and breathing normally, pull in your lower abdominal muscles and slowly extend the legs until you feel your back is about to unflatten or arch. Hold your legs in that position, feel the lower abdominals drawing into your spine while keeping your lower back flat for 5 seconds, then bring your legs back to the starting position. Be sure all movements are slow and controlled, and that you are not holding your breath. Repeat 10 times. Gradually increase the holding time to 10seconds and the repetitions to 20 times.
Prone hip extension click for larger view	Prone Hip Extension Lie face down with your lower abdominals pulled in. you may put a pillow under your hip for comfort. Place fingers between hip bone and the floor. Feel pressure on each side. Keep the leg straight and slowly float the leg up 5-10 cm. Ensure the pressure on your fingers remains exactly the same, side to side when you move your leg. Hold position for 5 seconds. Return leg to starting position and repeat with other leg. Repeat 10 times for each leg. Gradually increase holding time to 10seconds.

Hard Core Muscles for Mummies (Part 2) is a post from: Musculoskeletal Consumer Review

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Do you have neck and back aches during pregnancy or after delivery? Do you really think it is part and parcel of parenthood? Think again.

Source: Merendi
click for larger view

What are the core muscles and why are they important?

Core muscles stabilize your body and the pelvis during dynamic movements, such as walking and running. The core muscles include the transverses abdominis (TA), multifidus, pelvic floor muscles and the obliques. These muscles are attached to the inner portion of your thorax, (the trunk region below your ribs to your pelvis), allowing them better control of your spine and pelvis while you move. Imagine a tree trunk that has been cut into half. The rings of the tree represent the layers of your core strength. The transverses abdominis (TA) is the innermost ring, acting as a thick corset around your spine. It gives stability to the trunk and support your spine to help maintain a correct upright position.

All movements of the trunk activates the core muscles, so even when you are lifting your hand, the core muscles in your back and abdominals are recruited to assist the movement. Hence, it is crucial that your core muscles are activated before movement occurs, in offer to offer support and strength to your spine, as failure to do so will result in excessive or faulty loading to your spine, leading to low back strains and pelvic dysfunctions. Fortunately, our core muscles are normally already activated when we are in good posture, the problem comes when we deviate from good posture or sustain back injuries, thus deactivating the normal auto-recruitment of the core muscles.

How are they related to persistent back and neck pains?

Weak or inefficient core muscles are one of the contributing factors to persistent back and neck pains. We are constantly loading our spine with our activities of daily living, such as, working at the desk or computers prolonged, and carrying laptop bags or groceries. These activities stress the spine and the muscles that worked to support it may strain and get injured. This results in faulty postures which either avoid or aggravates the pain, hence, changing the normal activation of the core muscles, thereby reducing the protective function of these muscles. This may eventually set in motion a vicious cycle, in which faulty posture lead to incorrect muscle activation and less protection of spine, which lead to pain, and eventual muscular weakness , which lead to more faulty postures and pain and eventual degeneration of the spine, with persistent and recurring back and neck pains.

What are the negative effects weak core muscles can have on pregnant women and parents (who spend a lot of time bending over to take care of the baby, carrying children etc.)?

During pregnancy, your core requires greater stabilization due to changes in your weight, posture and centre of gravity. As your pregnancy progresses, the muscles that make up your core, plus the muscles that support you and your growing baby become stressed and extremely challenged. In addition, relaxin, a hormone emitted during pregnancy, ‘loosens’ your joints and ligaments in preparation for birth; as a result your supporting muscles have to work harder to achieve adequate stability. This in turn may lead to overstraining of your core and supportive muscles. A weak core will then result in higher probability of back and pelvic strains, which can be debilitating. Hence, strong core muscles play an important role in supporting your spine during pregnancy and also in assisting recovery from child birth.

The same goes to parents who spend a large portion of their time nursing and doing other back-breaking tasks, such as carrying children, lifting heavy cradles or large bags. Since such tasks are repetitive, the stress in the back accumulates over time and may eventually lead to fatigue of the supporting back muscles, resulting in back sprains. Again, having strong core muscles will help in better supporting the spine and back, thus reducing the likelihood of injury.

Hard Core Muscles for Mummies (Part 1) is a post from: Musculoskeletal Consumer Review

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And after months of hard work at the gym with weights and cable machines, you feel slightly better but you still slouch now and then. Why didn't it work fully for perfect posture ALL the time?

Muscles Types

The reason gym workouts fail to completely correct and support your posture all the time, is that it simply did not target all the relevant muscles – the stability muscles. And it was the wrong type of training for some of the muscles – gym works targets the power muscles. And muscles exercises alone isn't enough – postural awareness is also required.

What are the different types of muscles and why does the differences matter?

We tend to think of muscles as simply muscles but in fact, there are broadly two basic muscle types - striated muscles (that includes those postural muscles) and smooth muscles.

• Striated muscles are your skeletal muscles. Muscles that you usually think of such as your bicep muscle or calf muscle.Your heart muscle is also a type of striated muscle but stands distinct from the rest of the skeletal muscle.
   
• Smooth muscles are usually involuntary muscle that blends in other tissue type to form say your bladder or intestines.

Longer weaker, Shorter stronger

One key difference between striated and smooth muscles is that the strength of the striated muscle weakens the further it is stretched apart. So the same muscle, at say, 10cm length will exert a lot of more force at both ends as it contracts then if the same muscle is stretch to, say, 20cm. More specifically the strength of the muscle is a function of the area of its cross-section – the fatter, the strong the muscle.

Smooth muscle is different is this respect. It doesn't lose its strength as it gets stretched out. An important feature to have with a full bladder or stomach.

So now we know that skeletal muscle, a type of striated muscle, is weaker when it is stretched and stronger when it is shortened. What does this mean to people with bad posture?

It means that one of the key things to do to strengthen weak posture muscles it to shorten the lengthened ones and lengthen the shortened ones. That is get your posture right to strengthen the key postural muscles and to release to the overly tight/strong muscles that is pulling you out of the right posture.

Sustaining good posture and strengthening the postural muscles is further confused by how we think about muscle strengthening programmes. To build strong muscles, we generally think about more repetitions, heavier weights and repeat as required. This works if we are talking about big power muscles such as your biceps and thigh muscles. Postural muscles have a higher percentage of Type I (slow twitch) fibres. These are fibres that are designed for endurance, not power.

This means for slow twitch fibres, a better type of exercises is one where we use lower load threshold and holding it for longer periods of time. Again, it sounds exactly like holding the right posture for prolonged periods of time (with proper rest periods in between) will improve your posture over time.

When a movement is loaded with too heavy a load, the fast twitch (Type II) muscle fibres take over.This is one of the reason why lower load exercises like pilates and yoga are better for people with low back problems than heavy workouts at the gym.

Weak muscles lead to bad posture. So why doesn’t a gym workout help? is a post from: Musculoskeletal Consumer Review

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There are no sure answers depending on your condition and the competency and experience of the yoga instructor. But here are four simple questions that you can ask yourself. If the answers to the questions suggest that you should not do yoga, seek advice from your therapist.

4 signs that you may not be ready for Yoga is a post from: Musculoskeletal Consumer Review

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Source: Flickr a4gpa

According to Sylvia Ho, a principal physiotherapist with Core Concepts, "We often recommend our clients take up some form of exercise, including yoga and pilates. But not before they are ready." "Back pains and neck pains are complex problems. Just because they are quite common doesn’t mean that they are simple or all have the same underlying cause.", adds Sylvia.

Core Concepts recently revamped their core stability programme to further break down the initial stages of training to include sessions with Real-Time Ultrasound Imaging (RTUI). Sylvia explains, "with RTUI, our clients can get a better grasp of the fundamentals before progressing on to the group classes."

The concepts of prevention and treatment often get jumbled up. The average person thinks that if something helps prevent a problem, it must also be helpful in treating or fixing the problem. For example, if we have a fever, we might take paracetamol (Panadol) to bring the fever down. But we don’t take paracetamol on a daily basis to prevent fever. In fact, you are more likely to suffer side-effects from over consumption of it.

Given the rise in the number of injuries, there are increasing concerns about the qualification of these yoga instructors as was recently reported in Channel News Asia ("Hong Kong’s yoga boom sparks injury surge") . Sylvia  feels that is only half of the equation. "You can’t only depend on someone else to advise you on what’s appropriate. You have take some proactive action on your own to better understand your conditions and needs," she adds. While it can be daunting to dig through all the available information, Sylvia feels that some knowledge is better than none.

If you have a back problem, first seek a health professional’s advice. Even if you have been given the green light to go ahead with yoga or pilates, ease into it slowly. Remember that it has taken your instructor years of training and practice to be able to do what she or he is doing up in front of the class.

Is Yoga Bad For You? is a post from: Musculoskeletal Consumer Review

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 "Hi, I am suffering from pain in my lower back. It has been going on for some time now, about 6 weeks of so. Hot packs and heat rubs don’t seem to be working as before. And it seems to be getting worse. I heard that Pilates and Tai Chi is great for preventing back pain, so I was thinking one of them.  Which would you recommend? Thanks!" – Pauline Shi

Hi Pauline,

Sorry to hear about your back but first things first – prevention is not cure. Prevention is great before your have your problem. When you have a problem, what you need is a cure, not prevention.  If you are injured in a car accident, you don’t try to heal your self by wearing a seat-belt in bed. Nor will drinking more milk help your bone fracture heal right.

Flickr: Steve Rhodes

So the first thing I would recommend is that you seek proper medical advice for your low back pain. Doing Pilates or any other form of exercises at this stage is not likely to help and may even aggravate it.

Once the pain is gone or properly managed, you can then look at either Pilates or Tai Chi to prevent the pain from coming back. As to which is better, both have a great foundation in core stability and strength. If done right, these exercises can go a long way in helping you strengthen the right muscles that’s required to support your spine. Yoga is another exercise you might want to consider.

But do look for a reputable instructor, these muscles are located deep within your abdominal area and are hard to activate. More so, for people with a history of back pain. Good instructors will know if you are doing the exercises right.

Here are some past MCR articles that you might find useful.

1. Confused Over Core
2. Multifidus – Smallest Yet Most Powerful Muscle
3. Why does my back hurt?

Good luck.

Prevention is not Cure is a post from: Musculoskeletal Consumer Review

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The two most important criteria in picking the right Swiss ball (also known as Gym Balls, Fit Balls and Exercise Balls) are the Size and the ball Material.

Size Matters

First on Size, Swiss balls often come in several standard sizes – 45cm, 55cm, 65cm and 75cm in diameters. The most common method of choosing the right-sized ball to fit a person is the ‘Sit on the Ball’ test. Sit on a properly inflated Swiss ball with your feet flat on the ground and your knees should end up just below your thigh. If your knees are at a level higher than your thigh, the ball is too small for you.

It is possible to inflate or deflate the ball a little more or less than its recommended size but not too much. Because,

• If over inflated, you run the risk of the ball bursting at the worse possible moment.
• If under inflated, it becomes less wobbly, losing its ‘unstable surface’ properties that make the ball a great stability exercise tool. An under inflated ball also presses against the back of your thigh when sitting down. This can restrict blood circulation during prolonged sitting.

If you intend to use the ball for other exercises other than sitting, you should test the ball size to see if your posture or form is right performing those particular exercises.

Substance Counts Too

One thing that you will notice almost immediately is that the cheaper Swiss ball tends to be quite stretchy. Avoid these materials if possible as their stretchy properties make it harder to properly size a ball to fit you. Sitting on a 65-cm ball can quickly squish it down to a height of a regular 55cm ball. Stretchy materials also tend not to be anti-burst.

Anti-burst will be a common selling feature when you shop for Swiss balls. But what does it mean? Well, it doesn’t mean that your ball will never break or puncture. What it does mean is that when you get a puncture and if you happen to be sitting on it, it will deflate slowly giving you time to get off or if not, fall more gently to the floor.  When a regular Swiss ball is punctured, they pop like balloons – that is very quick, leading to injuries. Anti-burst Swiss ball material tends to be more rigid but not all rigid material is anti-burst. If unsure, ask your therapist or personal fitness trainer for advice. A good Swiss ball should last you for several years.

How to choose a Swiss-Ball is a post from: Musculoskeletal Consumer Review

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