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PrintExercise therapy: Coping with pregnancy related discomforts
Introduction
Most of the musculoskeletal problems that arise during pregnancy can be prevented and treated by physiotherapy. Individualized physical therapy programs have been found more effective than group sessions for the reduction of pain and sick leave due to back pain in pregnancy.
Pregnancy related problems: Physiotherapy and exercises
The most common, pregnancy related problems which benefit from physiotherapy are musculoskeletal problems like back pain; pelvic girdle pain (approx. 50% prevalence in pregnancy(Britt et al)), thoracic pain, nerve compression syndromes (e.g. carpel tunnel), stress incontinence and diastasis rectus abdominus.
Pelvic girdle pain and back pain
According to an article published by Artal et al most of the musculoskeletal problems that pregnant women experience are related to the altered postures with women getting heavier, while ligaments and muscles relax and stretch respectively. Whilst it may not be possible to stop this process from occurring, it is possible to minimize these maladaptive postures. With posture advise and through strengthening the core muscles the weakened structural integrity can be somewhat restored. This can help reduce or eliminate many of the common discomforts associated with pregnancy and improve postpartum recovery, particularly those associated with back problems (Artal et a and Hammer et al).
In addition to changes in posture, development of abnormal movement patterns is also very commonly seen, in particular during the second and third trimester. The resultant effect of abnormal movement will be pain during bed and car transfers, sit-stands and with walking. Gentle exercises to strengthen the core muscles, hamstrings and deep gluteal muscles combined with soft tissue release of the overactive piriformis, and advice of normal movements is often all that is required to reduce or completely eliminate pain.
Nerve Pathologies
Exercises to mobilize the nerves within nervous system can also be advised for women with nerve compression.
Incontinence
Incontinence (urine more so but faecal too) is a very common problem that may affect women during pregnancy. Neglecting the importance of pelvic floor muscles may result in women going on to develop incontinence during the pregnancy and at a later stage in life. Strengthening these muscles during pregnancy can also help develop the ability to relax and control the muscles in preparation for labor and delivery.
Ongoing strengthening post-delivery is highly recommended to promote the healing of perineal tissues, increase the strength of the pelvic floor muscles, and help these muscles return to a healthy state, including increased urinary control. Incontinence at any stage, can also be affected by a person’s lifestyle, occupation and diet and therefore advise must be provided in addition to exercise for such women.
Diastasis rectus abdominus
Traditional stomach crunches and sit-ups have actually been found to do more harm than good by increasing the separation of the rectus abdominus sheath. This is due to excessive exertion of tummy muscles that are stretching during the natural course of pregnancy. A study done by C. Cynthia et al at the Columbia University School of Physical Therapy showed that pregnant women who did not exercise had a 90% incidence of diastasis recti as compared with 12.5% in the exercising group who used their transverse abdominis during exercise. What this study highlights is the importance of exercise, but that too the correct form of exercise.
Not only antenatally but pilates based exercises to reduce the separation of these muscles postnatally is also often prescribed.
Additional benefits of exercise
Exercise also helps to ease the process of labor by training breathing control and strengthening the muscles required for labor. Exercise helps combat pregnancy related depression by improving body image and increasing self-esteem. It also aids in a faster recovery following delivery.
Considerations for Exercise prescription and physiotherapy intervention
Prior to exercise prescription knowledge regarding potential risks, awareness of baseline norms (e.g. in BP) and the assessment of the physical ability of the individual to engage in various activities is required. Given the potential risks, albeit rare, thorough physical evaluation of each pregnant woman should be conducted before any exercise programme is recommended. Individualized evaluation and exercise prescription by physiotherapists which includes intensity, frequency, and duration of the exercise seem to be important determinants of its beneficial effects. A women’s health physiotherapist specializing in issues associated with pregnancy can recommend exercises for pregnant and post-partum women after an assessment which generally consists of an analysis of the following:
- Joint mobility and symmetry
- Muscle imbalances and strengths
- Neurological evaluation
- Evaluation of functional limitations
Physiotherapy treatment techniques in addition to exercise commonly include:
- Pain management.
Techniques to aid joint and soft tissue flexibility.
Stress relief and relaxation training.
Recommendations for sleeping and birth positions
Posture correction and ergonomic advice
Postpartum rehabilitation
It is also very important to provide women with knowledge of instances where exercise is detrimental to their health and the babies.
EXERCISES
Aerobic activities and activities that promote musculoskeletal fitness are part of an overall exercise prescription. Typically, aerobic exercise can consist of any activities that use large muscle groups in a continuous rhythmic manner and the intensity veryimportantly should be based on scales which measure rate of perceived exertion. Exercises for musculoskeletal fitness include strength training and ?exibility exercises.
The 2003 Canadian clinical practice guidelines for exercise in pregnancy and the postpartum period, issued jointly by the Society of Obstetricians and Gynecologists of Canada and the Canadian Society for Exercise Physiology, provide more speci?c recommendation. Previously sedentary women should be counseled to begin with 15 mins of continuous exercise three times per week and work toward a goal of 30 mins four times per week.
SPECIFIC STABILITY EXERCISES
- Kegel Exercises
Kegel exercises, also called pelvic floor exercises, help strengthen the muscles especially the levator ani that support the bladder, uterus, and bowels
Intensive training of the pelvic floor muscles during pregnancy seems to facilitate rather than to obstruct labour. It could prevent a prolonged second stage in one in eight women. (7)A Cochrane review of 43 randomized trials concluded that PFM exercise was consistently better than no treatment or placebo and should be offered as first-line treatment for women with stress incontinence.
- Abdominal bracing exercise
This exercise requires the co-contraction of the transversus abdominis and multifidus that wrap right around the abdomen like a corset. It helps protect the spine which is under constant stress of the growing uterus, postural changes and reduced ligamentous stability. A study was done to compare the effects of the contraction of the transversus abdominis, independently of the other abdominals; with the bracing action that used all the lateral abdominal muscles on sacroiliac joint laxity. Joint laxity values decreased significantly in all individuals during both muscle patterns (P < 0.001). However interestingly isolating transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stability) to a significantly greater degree than the general abdominal exercise pattern (P < 0.0260) Richardson et al)
Pelvic titling combined with abdominal bracing are essential exercises for maintaining good posture and to prevent back ache that is due to bad posture.
MOBILITY EXERCISES
- Pelvic tilt
Pelvic tilts strengthen the muscles of the abdomen and lower back, increase hip mobility. Pelvic tilts are particularly effective in relieving lumbar pain.(J. Sabino et al)
- Stretching
Sub occipital extensors, pectorals, hip flexors and back extensors are tight due to an increased kyphosis, cervical and lumbar lordosis in pregnancy and can be the source of thoracic and posterior pelvic pain. In a study by Yeo et al that compared walking and stretching exercise, it was found that regular stretching exercises may promote endogenous antioxidants among women at risk for preeclampsia. The incidence of preeclampsia was 14.6% (95% CI, 5.6 to 29.2) among the walkers and 2.6% (95% CI; 0.07 to 13.8) among the stretchers
Warning signs to terminate exercise while pregnant
• Vaginal bleeding
• Dyspnoea before exertion
• Dizziness
• Headache
• Chest painMuscle weakness
• Calf pain or swelling (need to rule
out thrombophlebitis)
• Preterm labour
• Decreased fetal movement
• Amniotic fluid leakage
SUMMARY
Pregnancy should not be a state of confinement, and pregnant women with uncomplicated pregnancies should be encouraged to continue and engage in physical activities. Despite the fact that pregnancy is associated with profound anatomical and physiological changes, exercise can help prevent and combat many of the complications.
If your suffering from any of the above problems, or wish to seek further advice about excerise, consult a womens health physiotherapist
REFRENCES
- S. Snyder, B. Pendergraph. Exercise During Pregnancy: What do we really know? American Family Physician 2004;69(5)
- Borg-Stein J, Dugan S, Gruber J: Musculoskeletal aspects of pregnancy. Am J Phys Med Rehabil 2005;84:180 –192.
- Kramer MS. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2004;(1):CD000180
- W Brown .The benefits of physical activity during pregnancy Journal of Science and Medicine in Sport2002;5(1):37-45
- Gavard, Jeffrey A; Artal, Raul.Effect of Exercise on Pregnancy Outcome; Clinical Obstetrics & Gynecology: 2008;5( 2)467-480
- Britt Stuge, Even Lærum, Gitle Kirkesola, Nina Vøllestad. The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy-A Randomized Controlled Trial; Spine 2004;29:351–359
- R Artal, M O’Toole.Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period Br. J. Sports Med.2003;37;6-12
- R. L. Hammer, J. Perkins, R. Parr. Exercise During the Childbearing Year; The Journal of Perinatal Education2000:9(1)
- Chiarello Cynthia, Falzone Laura A., McCaslin Kristin, Patel Mita N, Ulery Kristen R. The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women;Journal of Women’s Health Physical Therapy 2005:29 (1)11–16
- Kjell Å Salvesen, Siv Mørkved. Randomised controlled trial of pelvic floor muscle training during pregnancy:BMJ 2004;329:378–803
- Hay-Smith EJ, Bo K, Berghmans LC, Hendriks HJ, de Bie RA, van Waalwijk van Doorm ES. Pelvic floor muscle training for urinary incontinence in women. The Cochrane Library,Issue 1, 2001.
- Richardson, Carolyn A.; Snijders, Chris J.; Hides, Julie A.; Damen, Léonie; Pas, Martij; Storm, Joop. The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain: Spine 2002; 27(4) 399-405
- SeonAe Yeo, Sandra Davidge, David L. Ronis, Cathy L. Antonakos, Robert Hayashi, Sharon O’Leary A Comparison of Walking versus Stretching Exercises to Reduce the Incidence of Preeclampsia: A Randomized Clinical Trial: Hypertension in Pregnancy 2008; Vol. 27, No. 2 , 113-130
Your arm itches all the time but your dermatologist says there is nothing wrong with you. You might want to see a physiotherapist for a neck problem instead.
There is a chronic condition of itchy arms called brachioradial pruritus. A new study reported in the October issue of the Journal of the American Academy of Dermatology suggests a strong link between the itch and a compressed nerve in the neck which physiotherapists can help relieve.
While it seems that dermatologists are just finding more about this condition (See Is A Compressed Spinal Nerve Causing Itchy Arms?), it is not a new concept to musculoskeletal rehabilitation specialists like physiotherapists. It combines two concepts that we have discussed before in the past in MCR.
- Dermatome patterns (see Dermatome Patterns)
- Referred Pains (see Arm pain or neck pain…Where is the source?)
It is not un-reasonable for us to look at or around the problem area for the source of the problem. But it early diagnosis and treatment based on this narrow scope of analysis does not yield results, we have to expand the scope of our search.
A hypothesis: Why Singaporean Kids are more likely to develop neck pain than their counterparts in South East Asia?
As a physiotherapist working in private practice, I am starting to see an increasing trend of younger clients with neck pain. The youngest has been 8, but the majority are between 13-16 years of age. I believe that this is a trend that we will continue to see with potential for even younger clients.
My thoughts: Some possible factors unique to Singapore, that may be contributing to this trend:
1. IT/ phones
Singapore is one of the most wired up countries in the world, having one of the highest IT penetration rates. Despites Singapore’s 4 million population, it has 402,992 iPhones, 76575 iPod Touch and 1,453 iPad’s totaling 480,950 iOS devices. Singapore has the highest iOS penetration , in comparison to neighbouring Indonesia which has the lowest. http://e27.sg/2010/06/10/highest-ios-pen…).
According to iDA Singapore, in the fourth quarter of 2010, Singapore’s household broadband penetration rate was 191%. This percentage suggests that almost every household had 2 broadband subscriptions.
The mobile phone penetration rate is 143%, and 3G mobile subscription totals is an overwhelming 4.7 million.
The statistics alone indicate that the Singaporean lifestyle has changed over the last 10 years. It can be inferred that almost every household will have access to a computer, a 3G mobile phone and possibly a tablet.
Most children in Singapore have access to some IT and are exposed and taught to use computers in schools. This fact, combined with the popularity of social networks like Facebook and Twitter for the older kids and Club Penguin for the younger kids, as well as the myriad of free games available on the iphone and ipads, children in Singapore spend more time in potential poor postures whilst attending to these IT tasks; and more time indoors than outdoors.
2. Decrease outdoor play
Apart from the reasons mentioned above, other factors that may influence outdoor play are:
The oppressive heat and humidity, With a constant daily humidity of 99% and a temperature of 33 degree Celsius it is understandable the kids prefer to stay indoors. Possibly aggravating the problem are the parents who also may not be as willing to accompany the younger ones to the park for the same reason.
Secondly, the lack of open spaces available for free play. Approximately 80% of the population lives in apartments, and the majority of those living in landed properties have little garden space. The physical environment in itself is not conducive to outdoor play.
It is commendable that in most housing estates, there are playgrounds for young children to play, but not much for the older kids. You will often see signs that say “no soccer allowed” in the void decks and even some open fields. With such restrictions, it is no wonder outdoor play is reduced.
Thirdly, perhaps the majority of households are dual income, parents are not able to supervise outdoor play and may not want their children to play outdoors on their own.
3. Great emphasis of academic results and sport is not seen as a priority.
There is a greater emphasis on academic performance in Singapore, compared to anywhere else in South East Asia. With no natural resource, human resource remains its main driving force leaving Singaporeans no choice but to be ahead of the game.
This translates to lots of pressure to do well in school as that is seen to lead to a good job with a good income, and thus growth for the economy.
As a result, outdoor play or pursuing ambitions of an elite sport athlete is not a priority or possibly encouraged in a practical Singapore. Such mindsets are subsequently ingrained in a young children, and is unlikely to change anytime soon in the future.
4. Parents awareness of ergonomics
As children spend increasingly longer time studying or and at the computer, it is imperative that as parents, we realize that good ergonomics is paramount in reducing the incidence of neck and back pain in this population.
The study table and chair must therefore be of the right height. The child’s back must be fully rested against the back of the chair; and feet completely supported on the floor. The table height should be lowered such that the child’s elbow can be at 90’ angle when rested on the table. When reading, the table should be inclined so that the child need not to drop their head forward to read. Investing in an ergonomic table and chair is a worthwhile investment for your child’s spinal health.
If the child has to spend a fair bit of time on the laptop, buy a laptop riser, a separate key board and mouse. Using a laptop without ergonomic modification will result in excessive loading in the neck joints leading to pain.
If your child is complaining of neck or back pain, consult your nearest Core concepts branch for advise and treatment.
Neck Pain: The truth on Traction
The amount of people working in a desk bound jobs is increasing worldwide. Unfortunately, these jobs tend to go, hand in hand with a greater chance of suffering from prolonged neck and back pain. Maybe for this very reason, currently the most common source of musculoskeletal disability is chronic neck pain.
According to a recent study, 34% of the general population experiences neck pain at some time in their life, of which 14% having symptoms lasting longer than six months.
Due to the number of health care visits, work absenteeism, decreased productivity and disability, neck pain has huge consequences on peoples well being, and their health care expenses.
There are many methods that clinicians use to treat neck pain. A traditional and conservative method commonly used by physiotherapists, is cervical traction. Despite its clinical popularity, previous and current studies, looking at the effectiveness of cervical traction, remain inconclusive.
In theory, applying a controlled pulling force on the spine causes a number of physiological effects:
- It enlarges the intervertebral foramen
- It releases pressure on intervertebral discs
- It releases pressure on nerve roots and blood vessels
- Ligaments and paravertebral muscles of the neck region are being stretched
- Effects of abnormalities of the cervical facet joints are reduced
These effects are believed to release muscle tension, nerve tension and increase blood circulation in the cervical region, which ultimately should result in decrease neck pain.
In a more recent study done by the Hong Kong Polytechnic University, intermittent cervical traction on 79 patients (aged between 20 to 70 years old) with chronic neck pain, was investigated. The patients were randomly assigned into two groups. For a period of six weeks, one group received cervical traction twice a week, adminsistered by a experienced senior physiotherapist. The second group recieved placebo- infra-red (heat therapy) treatment twice a week.
At baseline, after 6 weeks, and after 3 months, the patients were asked to complete a disability questionnaire, score their pain on a pain scale, and range of motion of the cervical spine was measured.
From this study they concluded that there was no significant difference in disability, pain and range of motion between the group that received traction, and the group receiving the placebo infrared treatment. The researchers did state that there were several limitations to the study.
Several other studies in the past have found similar findings that as a treatment method in soltaion, traction does not show significant improvements. Research supporting its benefits and use is somewhat flawed or inconclusive and therefore more methodological randomised control studies should be carried out.
In order to maximize the benefit of treatment for patients with chronic neck pain, it is important for clinicians to consider giving a combined and individualized treatment to them instead, of intermittent cervical traction alone. Studies of late are generally leaning to a combined approach of exercise therapy, education, joint mobilisation and manipulations as being the most effective method of treating neck pain
References:
Chiu, T.T., Ng, J.K., Walther-Zhang, B., Lin, R.J.H., Ortelli, L., Kuan, S (2011) A randomized controlled trial on the efficacy of intermittent cervical traction for patients with chronic neck pain; Clinical Rehabilitation:1–9
Gym Users – Are you OVER-working the PECS?
If your gym workout is giving you neck and shoulder pains, you could be over-training your chest muscles. The key is a balanced training program that focuses on several muscle groups to prevent muscle imbalance developing and the consequent dysfunction
The effects of over developing one muscle group i.e. your chest muscles (pectorals) in the gym, whilst neglecting your back muscles, often affect your posture resulting in neck, back, and shoulder pain
To understand why this occurs, you must be familiar with the notion that most joints in our body have two or more separate and opposing sets of muscles acting on the joint. Take the elbow as an example.
When the biceps contracts and shortens, it bends the elbow joint. As the elbow bends, the opposing triceps, must relax and lengthen to allow this movement to occur. And vice-versa, for the elbow to straighten; the triceps contracts and shortens and the biceps must relax and lengthen.
To gain a well rounded physique you must consider strengthening more than just one, if not all the muscle groups. An over developed muscle (group) will create more tension on one side of the joint. Over developed muscles are also often tighter (shorter) than normal. The balance between muscles at the joint is lost, pulling the joint away from its mid-line and changes the angle of rotation at the joint.
The Shoulder
The shoulder is a more complicated joint, however the same principles apply.
From personal experience as a physiotherapist, one of the most common mistakes in the gym is over-training the chest muscles. This causes an imbalance between the muscles at the front of the body and those at the back. The shoulders with time are pulled forwards as the chest muscles get stronger, bigger and shorter, making the posture more rounded, creating pain and potential pathology.
Lateral postural Picture
Why is a rounded posture problematic?
Rounded postures place the shoulder joint in a unbalanced position away from the ideal centred position. This unbalanced position leads to increased compression at the shoulder, resulting in pain and reduced function:
- Compression of muscles and other structures at the front of the shoulder joint, may cause pain in the neck, and or down the front of the shoulder and side of the arm. Pain is usually worse with overhead activities. If the compression of the tendons continues for long enough, tears of the tendons (rotator cuff) may occur.
- Rounded postures often lead to neck pain. A large number of muscle that attach to the shoulder also attach to the neck at the other end. If these muscles are affected (lengthened and weakened by the pull of the shoulders) the neck often tends to rest into a head forward ‘chin-poke’ position. This increases the pressure on the neck joints and also other pain sensitive structures around the neck that can cause symptoms (Szeto, 2005).
- The shoulder’s range of movement is significantly reduced as a result of having less space for the joint to move. (Bullock et al, 2005)
Additional contributing factors leading to rounded shoulders
Modern Lifestyles
Think about all your daily activities; washing your face and hair, driving, sitting at the computer. People are becoming chair-shaped, and this keeps the shoulder in a rounded position.
Pain Response
Your body’s response to pain is another factor. When you have neck and shoulder pain we often adapt a rounded posture. This initially is good protective mechanism to prevent further damage for the first few days post-injury, however in the long term this posture keeps the shoulder in a poor/compressed position and will hinder healing.
How to correct your rounded posture?
As a guide, when looking from a side view your shoulders should be fairly central compared to the trunk, and the head should be central on the shoulders. A ‘plumb line’ from the centre of the ear should fall through the centre of the shoulder.
To get into this position roll your shoulders all the way forwards, then all the way back (your shoulder blades should touch), then find the mid-point between these two position. When you have this, gently tuck your chin in, so that your head is positioned on top of your shoulders.
Workout program to prevent the over-training
Weight-training:
If you work the chest 2 x weekly, doing 6-9 sets of 12 repetitions, then do the same amount of work, at the same load and intensity for the opposing muscle groups – the upper back muscles. Most chest exercises involve pushing – therefore to balance this and work the upper back you must include pulling type activity. Some ideas are provided below.
- Lat pull down
- 45 degree angle lat-pull down
- Seated row
- Bent over row
- Pull ups
- Shoulder external rotation
Stretching
As well as strengthening (which contracts and thereby shortens muscles), you should ALWAYS stretch all the muscles you have trained (lengthen the shortened muscles ) at the beginning and end of your workout to reduce tightness of these muscles. In this scenario it is therefore strongly recommended to stretch both the pecs and back muscles.
- Hold 30 seconds
- rest 30 seconds
- repeat x 3 (4 x daily)
References:
- Brukner and Khan. Sports Medicine
- Bullock, M., Foster, N., Wright, C., (2005). Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Manual Therapy 10, 28–37
- Kwok Tung Lau, Ka Yuen Cheung, kwok Bun Chan, Man Him Chan, King Yuen Lo, Thomas Tai Wing Chiu (2010). Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Manual Therapy 15 . p457-462
- Szeto, G., Straker, L., O’Sullivan, P., (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work—2: Neck and shoulder kinematics. Manual Therapy. Vol 10. p 281–291
8 Tips for Back-Care When Flying
1. Lift Your Cabin Luggage in stages. Move slowly when lifting your luggage and break the action into smaller steps. When lifting a bag into an overhead compartment – first lift it to the arm of the seat, then to the top of the seatback, and then into the compartment.
2. Never twist while lifting. This is a common cause of injury to the low back. Turn with your feet so that your whole body moves around instead of just twisting your back.
3. Avoid lifting if possible. Ask for help. If you explain you have back condition, you will be surprised how helpful the airline staff will be. If your bags are small and light, it will be less of a burden to ask someone to do this for you.
4. Pick an aisle seat. Ask for an aisle seat as it is easier to get into and out of an aisle seat, and allows you to get up and move around, throughout the flight with greater ease. Quite a number of airlines now allow you to select your seat when you are making a booking online.
5. Stretch key muscles. Sitting for extended periods can cause stiffness and tension in the hamstrings (the muscles in the back of the thighs) and hip flexor muscles, which in turn puts added stress on the low back. Ask your doctor or physiotherapist to advise you on a few safe stretches you can do whilst traveling.
6. Good posture in sitting. Place a small rolled-up airline pillow, blanket, towel or lumbar pillow between your back and the seat to support the natural inward curve of your lower back. You may also use commercial low back supports if you prefer.
7. Firmly plant your feet. Bottom-up leverage from your feet is also required to support your low back. While seated, your knees should be bent at right angles. If your seat is too high, place your feet on the footrest to keep your knees at a right angle to avoid stressing the low back.
8. Get up and move. Sitting in one position for extended periods of time stiffens the back muscles, which can put stress on the spine. Get up, stretch and move around every 30 minutes if possible. Movement stimulates blood flow, which facilitates the transfer of important nutrients and oxygen to your back, and thus reducing stiff muscles and muscle aches.
Hope these tips help you have a safe journey back!
Shoulder pain in office workers
A shoulder impingement is common amongst athletes involved in overhead sports. Ironically the same condition can happen in someone who leads a more sedentary lifestyle. A common scenario is where someone reaches out for a stack of documents or a heavy object that weighs too much for the shoulder muscles.
A deskbound worker's posture are the main factors that will give rise to such shoulder problem. These factors are similar to those predisposing factors of shoulder pain in overhead activity athletes.
The image below demonstrates a slouched sitting posture with a forward head posture typical of someone who spends long hours at their desk. A few factors to notice in someone with a shoulder pain, is the position of the shoulder blade, rounding of the shoulder, and poking of the chin.
Narrowing of shoulder joint space from a slouched position
Try slouching your upper body and raising up your arm as high as you can, compare this to sitting or standing upright and reaching high up. You will find that it takes more effort in the former scenerio and you may feel a pinch or a block in the shoulder as you go towards the end of range. This is because the shoulder joint space (subacromial joint) is narrower in a slouched position.
Muscle Imbalance
In slouched sitting, the shoulder blade is rested on the rib cage in a forward tilt orientation. Overtime, this develop into a muscle imbalance where the muscles in front (pectoralis minor) are tightened, and the muscles at the bottom of the shoulder blade (lower trapezius) are stretched and thus weakened. As the lower trapezius is one of the vital muscles to stabilise the shoulder blade, weakness will increase instability and poor control of the shoulder joint leading to overuse of the rotator cuff muscles to compensate for the instability.
Long hours in the slouched position also develop stiffness in the joints of the upper back. This means that even if you get away from the desk, the upper back is so stiff that it's "stuck" in this slouched posture, coupled with the muscle imbalance, a person will find it increasingly more difficult to correct their posture even when in an upright standing stance, further increasing the risk of shoulder pain.
Rounded shoulder makes muscles inefficient
In a rounded shoulder, the ball of the shoulder joint will not be able sit well in the socket of the shoulder as there will be a inward rotation of the ball in the socket. Imagine a golf ball balancing on a tee, when the ball joint is not sitting well in the socket, muscles around it will have to work a lot harder to pull the ball into the socket to maintain stability. The excessive efforts from the muscles makes it tires and wears it down faster.
New mums: Pain in the thumb?
Its common knowledge, that pregnant women and new mothers are prone to experience low back pain. Lots have been said to why, and such women have successfully been treated with strengthening exercises to stabilise the pelvis.
However did you know that pregnant women and new born mothers were also prone to wrist and thumb problems?
Carpel tunnel is widely recognised as a problem experienced by women antenatally and postnatally. This condition arises due to an increase in the blood volume circulation and swelling commonly experienced during pregnancy.
The carpel tunnel itself comprises of the bones and ligaments that form a canal at the base of the hand and as the median nerve passes through this, it can be compressed and impinged.
The median nerve gives sensation to the thumb, the index, middle, and half of the ring finger and is responsible for movement of a muscle at the base of the thumb. Pressure on this nerve can therefore cause a loss of either sensation or strength in these areas.
In addition Deqeurvain tendonitis is also seen during the last trimester of pregnancy and in new mothers. In fact some statistics have suggested that 50% of new mothers will experience these symptoms and the older the new mother (40 plus) the more likely. An increase in the incidence of dequervain also relates to the increase in the weight of new born babies over the last 30 years.
This condition involves irritation to 2 muscle tendons that mobilise the thumb causing pain with pinching, grasping, lifting and other movements of the thumb and wrist.
The root cause of this problem in the pregnant clientale is believed to be due to the repetitive and frequent improper lifting and cradling of the child.
Improper lifting and cradling
As a mother bends down to lift her child she often places her thumb under the child’s armpit. In doing so she put a lot of strain on the thumb joint and muscles. This is a movement that is often done repetitively and for a long period and from various heights (floor to standing, cot to standing). As the child continues to grow and gets heavier the strain may potentially worsen, causing inflammation, waekening and scarring to the tendon.
Also whilst cradling the child, some mother will use an L shape index finger and thumb to cradle and support the child’s head. Again overstraining the tendons of the thumb leading to the above problems.
Save your thumbs
New mothers could place their hand around the ribcage of their child and gently squeeze as they lift the child. This will alleviate the pressure exerted on the muscles of the thumb.
Alternatively supporting the child from the bottom and behind the head to lift the child can also reduce the pressure on thumbs.
Have a read of the carpel tunnel and Deqeurvain tendonitis articles for more informarmation about these conditions and physiotherapy treatment options to help your hands.
Arm pain or neck pain…Where is the source?
Have you ever experienced pain in the arm, but the movements of the shoulder and elbow do not seem to aggravate the pain? Or found pain on the side of your thigh or knee, but there is nothing wrong with your knee? Are you imagining the pain? Where is the pain coming from?
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
- 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.
- 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.
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.
- 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.
- 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.
Pilates and Physiotherapy
What is Pilates?
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.
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!
