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PrintShoulder 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.
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!
Anti-Aging Exercise for your Lower Back – Good Nourishment is the Key
The discs in the spine age and degenerate just like all of the other structures in the body. However, today’s sedentary lifestyles often speeds up this process. We cannot apply anti-aging creams or lotions to our discs, but certain exercises can help to maximize the discs nourishment.
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
- 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.
How do I know if I have scoliosis?
What is scoliosis?
Scoliosis refers to a medical condition in which the spine curves sideways. On an X-ray film, the normal spine looks straight, but the scoliosis spine will look like a “C” or “S”.
I suspect that I have scoliosis, how do I tell?
Besides looking at X-rays, one can look at his or her posture in order to look for possible signs of scoliosis.
Signs that may indicate scoliosis are:
- Head not centered to the body Uneven shoulders (either one is in front of the other or one’s higher than the other)
- Uneven shoulder blades: one is more prominent or higher
- Uneven waist angle: the gap between arm to trunk is wider on one side
- One hip is more prominent than the other or the hips are not leveled
- The spine line is not straight
One can use the picture below for a quick self test of scoliosis:
You can also perform a Forward Bend test (also called “Adam’s test”) to detect for possible scoliosis.
- Standing with the feet together, then bend forward as far as you can with your palms together, fingers pointing at between your toes.
- Look at the back, one side of the back (either upper or lower back region) will be higher than the other side
Introduction to SpineCor Scoliosis Brace
This video introduces the SpineCor brace, a flexible dynamic brace for idiopathic scoliosis.
SpineCor®‘s unique dynamic action treatment approach offers improvement over traditional static braces. Research indicates that a significant dynamic action is required on the spine (vertebral growth plates) to alter the abnormal growth progressing the deformity in scoliosis patients.1
Thoracic Outlet Syndrome
What is Thoracic Outlet Syndrome?
Thoracic outlet syndrome refers to a condition whereby blood vessels and/or nerves that pass into the arms from the neck are compressed, due to narrowing of the thoracic outlet which is the space between the collarbone (clavicle) and the first rib. This can lead to pain, tingling or numbness along your neck, shoulder, arm and hand.
Scheuermann’s Kyphosis
Scheuermann’s Kyphosis is a developmental disorder that causes patients to have a stooped posture due to an excessive curve in the thoracic spine. The thoracic spine normally has a slight contour called kyphosis which is exaggerated in Scheuermann’s disease. It is a self-limiting condition that presents in the adolescent years, usually at the end of the growth spurt. It affects between 0.5% and 0.8% of the population and is more prevalent in males.
