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PrintYearning for a Good ‘Neck’ Sleep?
Have you ever woken up with a stiff and/or painful neck or shoulder, and wonder if it is because of the pillow that is causing the problem?
If the answer is most likely a yes, continue to read on.
A pillow that fails to support the neck probably will cause the neck to end up in a wrong position for a long period of time, which inevitably causes excessive stress to the neck and leads to pain. The question here is, how do we choose a good pillow?
A GOOD pillow is one that could help preserve the natural curvature of the neck, and the position in which the neck has its normal curvature is called the neutral position of the neck. This is important because the muscles at the neck can be supported so that they can relax and not overwork throughout the night. Just like a good back support could help us maintain a good back posture and prevent overworking of the back muscles, a good pillow could help us maintain a good neck posture at night.
Before we talk about how to choose the most suitable pillow for yourself, we must look at the sleeping positions. The reason is that with different sleeping positions, different support is required to maintain a neutral neck postion.
Back sleeper
When someone lies on his/ her back without a pillow, the head usually falls downwards and the chin tilts upwards. This puts a lot of stress on the neck as it aggravates the reversed “C-shape” of the neck. The situation would be worse if he / she has a stiff / hunched upper back.
A good pillow for back sleeper is one that could fill the gap between the back of the head and the upper back, so the natural curve of the neck can be maintained. There are many contour pillows that could help achieve this.
When using a contour pillow, the higher end should be inserted underneath the hollow of the neck closer to your shoulder.
What to look out for:
- Place your hands around your neck to feel for any muscle tightness/tension. If you are in the correct position, your neck muscles will be relaxed.
- Get someone to take a look at your neck posture from the side view. He/she should be able to draw a straight line from the ear lobe to the shoulder joint and the hip joint.
Modification:
If your pillow is too low for you, you could use towels and pile them on top of a regular pillow (the towel is the modified higher end of the contour pillow, and works to fill the gap between the back of the head and the upper back). Do not use a regular pillow that is too high or too low, which either bends the neck too much forward or allow too much backward arching of the neck.
Side sleeper
A contour pillow may best serve the purpose of maintaining a neutral neck.
The higher end of the pillow again needs to be underneath the hollow of the neck. It is also important to pull the pillow as close as possible to the top of your shoulder. The height of the contour is usually equal to the width measured from the base of the neck to the tip of the shoulder of the same side.
What to look out for:
- As shown in the picture above, the spine should form a straight horizontal line, parallel to the floor.
Modifiation:
Again, an extra pile of towels on top of a regular pillow may be used as a modification of a contour pillow.
Tummy sleeper
Though this is not a sleeping position recommended as it forces the neck to be turned to one side and also arch backwards excessively, some people do sleep this way. For people who sleep on their tummies, it is the best to choose a regular pillow that is soft and low.
The pillow also needs to be pulled lower so that it supports the top part of the chest. Those could help prevent excessive neck rotation and backward arching.
Treatment Options for Chronic Pain- What Does the Research say?
As discussed in the previous article, chronic pain can manifest through very complex thought processes, as result of a wide variety of factors stemming from physical, psychological and cultural influences.
For this reason, there is not one single fix for chronic pain, but its treatment is very much defendant on a combined approach.
This article will focus on the conservative management of chronic back pain whilst not negating the importance of appropriate pharmaceutical and other interventions.
So what does the research say?
- Exercise therapy -the first line treatment
The current evidence suggests exercise is more effective than “GP care” for the reduction of pain, disability and return to work . No one form of exercise (e.g. Aerobic, Mckenzie, conditioning exercise) appears to be superior to the other, although an supervised and individualised exercise programme is recommended over general exercise conducted individually. This is something that can be discussed and provided by a qualified physiotherapist following a thorough assessment of your back.
Studies comparing the effect of pilates based exercises and usual back care, has shown pilates to significantly reduce low back symptoms and disability over long term basis.
There is strong evidence showing that exercise therapy alone is not more effective than conventional physiotherapeutic techniques (e.g joint mobilisations) and therefore exercise therapy must be prescribed along side other treatment adjuncts.
- Cognitive behavioral therapy
This form of psychosocial therapy assumes that maladaptive, or faulty, thinking patterns cause maladaptive behavior and “negative” emotions (Maladaptive behavior is behavior that is counter – productive or interferes with everyday living).This treatment focuses on changing an individual's thoughts (cognitive patterns) in order to change his or her behavior and emotional state, allowing them to partake in exercise and all activities of daily living.
- Manual therapy
Joint mobilizations should be considered as treatment in the short term management for chronic pain sufferers to increase function and decrease pain.
The research shows that joint mobilizations carried out in physiotherapy treatments is of equal effectiveness to analgesia, normal "GP care" and physiotherapy exercises in reducing symptoms.
- Massage
Massage is not considered as an effective treatment option for chronic pain sufferers, but may be useful to treat the symptoms of muscle tightness post exercise.
- Education
This is vital in in helping people understand that beliefs can alter and affect their recovery from pain. Pain should not been taken for granted, and a person should seek medical advice to decrease the amount of pain as soon as possible.
Education regarding pain, and understanding that pain is an unpleasant but subjective emotional experience, and therefore should not be used as a tool to measure the amount of tissue damage is vital.
Having less fear and anxiety will make a person more willing to return to functional activities and exercise allowing for recovery.
References:
O. Airaksinen, J. I. Brox, C. Cedraschi, J. Hildebrandt, J. Klaber-Moffett, F. Kovacs, A. F. Mannion, S. Reis, J. B. Staal and H. Ursin, et al (2006) European guidelines for the management of chronic nonspecific low back pain, European spine journal, vol 15: 193-300
Rydeard,R., Legar, A., Smith, D (2006) Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability : A randomized controlled trial, The Journal of orthopaedic and sports physical therapy, vol 36:474-484
TMJ dysfunction- The possible origin of severe referred pain
The temporomandibular joint (TMJ) refers to the jaw joint. When dysfunction occurs in the jaw joint, it may cause symptoms that people could not associate to the jaw. This is because the pain caused by the TMJ dysfunction may refer pain to the other structures surrounding or away from the TMJ. However, early diagnosis with physiotherapy will prevent TMJ dysfunction from becoming chronic.
TMJ is the most frequently used joint in our body as it allows us to open and close the mouth at least 2000 times a day. Therefore, a dysfunction in the TMJ can cause pain that can debilitate our daily activities.
So what the common symptoms from TMJ?
- Severe headaches
- Dizziness
- Pain in the eyes or in the back of the eyes
- Earaches
- Ringing in the ears
- Pressure in the ears
- Hearing problems
- Stiff shoulder and neck muscles
- Tooth ache
- Difficultly swallowing
- Frequent sore throats
When the TMJ is injured, muscles, ligaments, tendons, nerves and blood vessels can get injured simultaneously. The nerves send out and receive information from these structures. Irritation of the nerve can cause pain felt far from the originating problem. This phenomenon is also known as “referred pain”.
Another cause of referred pain from the jaw is the “trigger point”. A trigger point is an irritable spot in a muscle that is locked into a painful spasm. Normally, when a muscle is working, its fibers act like little pumps, contracting and relaxing to circulate blood through the muscle. In a trigger point, the muscle fibers hold their contraction, which leads to blood flow decrease. This causes the tissue to have lesser oxygen intake and more accumulation of muscle waste products. The trigger point responds to this, sending out more pain signals in the affected area and connected areas leading to a no ending cycle of continuous muscle contraction and lack of blood flow.
The main goal of the physiotherapy is to identify the source of the symptoms, aiming to reduce the pain and regaining normal function of the TMJ with manual therapy and exercises.
Jaw pain? Physiotherapy can help.
Although physiotherapists are getting more referrals from dentists, many people are not aware that physiotherapy is capable of treating a wide range of symptoms caused by a dysfunction of the Temporoandibular Joint (TMJ). Common symptoms are local jaw pain, clicking jaw, and muscle tension around the jaw.
Anatomy
The TMJ is a more complex structure compared to our other joints in our body because of the interaction among the disc and a good amount of muscles, ligaments, the jaw and skull bones. Furthermore it is supplied by blood vessels and a large number of nerves, which makes it sensitive to pain.
What can cause a TMJ problem?
Disorders in this joint rarely occur as single symptom, but more often as multiple problems with overlapping symptoms. Usually, the pain, tension and degeneration are caused by anatomical features. But pain can also occur after a period of teeth grinding, bite problems or even having to open the mouth for a long period of time at the dentist. A history of trauma, such as at hit on the face or head can also have aneffect on the jaw.
How can physiotherapy help?
The TMJ can be affected by several factors – the position of our head, the cervical spine, the hyoid bone and our posture are often responsible for a TMJ dysfunction. A specialized therapist will assess the TMJ together with it's surrounding structures, the cervical spine, the shoulder girdle and will analyze the posture of patient. The tongue, mouth and facial functions will also be assessed to get a clear view of the actual cause of the jaw pain or referred pain.
Depending on the diagnosis a physiotherapist have several treatment options. Treatment options include soft tissue release and trigger point therapy to decrease the tension of the jaw, facial and neck muscles, mobilization techniques to decrease pain and help the TMJ joint to move correctly.
Advice on the right posture and home exercises are essential to strengthening of the weakened muscles and to assist on the right alignment. Most patients will experience an improvement with TMJ physiotherapy. Lasting improvement however will depend on staying in the right posture, and being discplined in doing the home exercises.
Sling bag vs. back pack vs. luggage bag, which one should I pick?
Have you ever wondered why your shoulder or back is painful after carrying a bag? Or do you ever wonder if your children are getting the most suitable bags for their posture and growing body? Let’s now look at how each type of bag should be carried, and what the common problems may be when carrying a bag wrongly.
Sling bag
As we all use our shoulders to carry a bag, let’s start by looking at the normal structure of the shoulder. The shape of the shoulders is that the part that is near the base of neck is usually higher than the tip of the shoulder, so it creates a natural “down slope”. Therefore, when a sling bag is carried only on one shoulder, the tendency is for the bag to slide off the shoulder. In order to stop the bag from sliding, one usually needs to lift up the shoulder on the same side to level the “down slope”. This can eventually leads to overuse of the shoulder and neck muscles, and causes pain and stiffness.
The correct way to carry a sling bag is to carry it with its strap across the chest. By doing so, the weight of the bag pulls the strap towards the base of the neck (the “cross” effect), instead of slipping off the shoulder. Thus there wouldn’t be a need for the shoulder to elevate excessively. Another benefit of carrying a sling bag across the chest is that the weight of the bag can be supported by the hip or back, the downward pull on the shoulder is also lesser, which helps reduce the risk of over-using the neck and shoulder muscles.
Back pack
There are many different designs of back pack, but they all share one thing in common: there are 2 straps and one on each shoulder. Hence, there won’t be any tendency for the bag to slip off the shoulder (as compared to the sling bag), so there will be less risk of shoulder / neck overuse injury. Speaking of which, that is provided the bag is indeed carried by the defaulted way: carried on 2 shoulders. If the back pack is carried on one shoulder with only one strap being used, it turns out to be another “modified sling bag”, and of course may lead to problems as mentioned above too.
Let’s say now we do carry the bag on both shoulders, does it mean one will definitely have a correct way of carrying it? The answer is “no”. Have you ever wondered why many parents complain that their school-going kids have terrible posture when they carry their school bags? So, what went wrong here?
When carrying a back pack, the length of the strap is most crucial: if too long, the back pack will “lean backward” instead of pulling straight “downward”; the backward “leaning” would encourage a body “forward leaning” or in some people “forward hunching”. This eventually leads to either a much hunched spine, or elevated shoulders, or both, giving rise to many back and shoulder problems such as back / shoulder pain or poor posture.
So the key is to adjust the length of the strap so that the back pack stays closely in contact with the back. If possible, look for bags that have front straps that cross the chest / abdomen, as those straps can hold the bag closely to the body. The closer and more firmly the bag is to the body, the less movement of the bags, and the less the body needs to work to carry it with you.
Luggage bag
Pulling a luggage bag is probably easier for the back as the load now is on the ground. It has less impact on back posture (either good or bad to start with). But not to forget, if the length of the handle is not correctly adjusted, for example, if it’s too short, one needs to turn and bend to the side to pull the bag which may lead to back strain. On the other hand, if the length of the handle is too long, one would need to excessively lift the shoulder to accommodate the position of the handle, which is also not ideal for the posture.
The key here is to ensure appropriate length of the handle so that when you pull the bag, you shoulder should remain down and relaxed with elbow bent slightly. There shouldn’t be any turning or side-bending of the trunk too. Last but not least, the weight of the bag also should not be too heavy to cause possible arm muscle strain, especially when the travel time required is long.
Exercise with Brace
What are some of the facts about exercising with scoliosis brace?
If you are wearing a hard brace:
- Due to the weight and movement restriction, you will have to change the way you do sports or exercises. For example, if you used to run, you probably will have to run for a shorter distance or run at a slower speed;
- Exercises that require many trunk movements will likely to be difficult;
- You may tired out sooner too because of the pressure on the rib cage which affects chest expansion during breathing;
- You may need to exercise at a cooler time of the day as it will be hotter to exercise with the brace;
- You need to be careful with the skin condition at which the pressure is applied to control the curve; this too may affect how much and the kind of exercise you can participate in.
So…most likely, if you need to exercise like before, you need to keep the brace off.
If you are wearing soft brace:
There will be minimum movement restriction. It is less hot and less likely to cause skin problems. All kinds of land exercises (such as cycling, badminton, and dance) are encouraged as exercising with the brace on speeds up the curve correction. Soft brace also allows much better muscle retaining and joint mobilization, which has a great impact on curve correction retention after the brace treatment is over.
How do I know what exercises are good?
- Exercises that are designed to work specifically on muscle imbalance, posture faults are more beneficial than general exercises like swimming, jogging, generic yoga & back stretching exercise; the reason is that general exercises usually fail to stress the “imbalance” in scoliosis, either for strength or flexibility;
- Swimming is good to unload the spine and improve the breathing function; it may also help to reduce back pain that results from excessive loading or tension;
- Correct breathing techniques are important as rib cage deformity is common in scoliosis;
- In order to specifically work on the muscles affected, the curve of the scoliosis needs to be assessed, the posture changes need to be analyzed in details;
- After the study of the curve type and the posture changes, specific movement can be taught and implemented to work on the faulty muscle and posture development;
- The exercised then can be progressed with resistance or more repetitions;
- Do not perform general weight training for scoliosis, as those usually only works on the muscles that are being used all the time and are already strong, and the weak ones will still remain un-used and weak!
Surgery: The Machine Analogy Misconception
Surgery as a treatment option brings up a lot of mixed emotions amongst patients. Often it is seen as the last resort. Something that carries with its risks and pain but should definitely work. This ties in with our sense that something complicated and riskier should be better than something simpler and risk-free. This creates an unrealistic expectation of surgical procedures to deliver miracles. Recently, Spine discuss several articles on how back surgeries fail.
Of course, as with most things, there are always two sides of the story. There will be surgical cases where too much was promised, too little delivered. But often too, there is a case of the patient simply expecting too much either refusing to understand the risks and possible outcomes or simply (which often I believe is the case) the patient not having a firm enough grasp of the situation and implications.
As this is a musculoskeletal site, lets focus on orthopaedic surgeries as an example.
First of all, what do surgeries generally achieve.
Most of the surgeries, do one of the four things below.
- The removal of some part that causes an obstruction, impediment or impingement – for example – disc bulges (Removal)
- The replacement of some part that has failed or deteriorated for examples spinal discs (Adding)
- The strengthen of the some part, for example – adding cement into vertebral body. (Enhancing)
- The weakening of a part, for example tight muscles or severing inflammed tendons in the wrist (Weakening)
Complicated surgeries will combine two or more of these things. All of this seems simple enough. So where do we go wrong? Our tendency to over simplify the situation.
One of our most common tool we reach for to understand something is comprehension through analogy. We use somewhat similar alternative to explain key concepts. Like the human heart is the "engine" for the human body. The eyes are like video cameras. This helps narrows the gap in our understanding of new complex idea or concept. Unfortunately, analogies can sometime mislead us.
One common area is spinal disc replacement (Removal and Adding). Patients are often surprised that the new hi-tech disc doesn't work as well as their original human discs. Unlike, cars or computers where parts are easily replaceable. In fact with very specific numbered replacements parts. Parts in machine are relatively simple and have very precise functions and operated within a very specific range of conditions. Not so for the human body. In our human body, each part usually have several functions and interacts with the rest of the body in very unique ways. This helps us to be adaptable to our surroundings. Currently no replacement spinal disc has the same degree of freedom movement as a real human spinal disc. This implies a slight impairment to your body's actual biomechanics. Something and somewhere else will adapt to compensate for the slightly reduced degree of movement.
Also often fixing the faulty part does fix the underlying problem. In a machine when a part fails, it is usually because of poor quality rather than the machine operating beyond its specifications (thought that does happen. In fact, some machines are designed with some parts to be the designated failure points so that it is easily replaced and cheaply). Replacing a poor quality part if easy and usually eliminates the problem. But in the human body, parts fail not because of poor quality but often somehow it is not being used in the correct manner. Like sitting a poor posture leading to back pain. Solving the pain is only a short term solution if the external cause – poor posture is not corrected. This situation occurs less frequently for machine. Machines are usually used for the purposes they are designed for. If your coffee maker is crushed because you used it as a door stopper is not something covered under the manufacturer's warranty.
While some machines are large and more difficult to build (not something you can hammer out at your workbench) doesn't mean they are complex by any means. At least not relative to human body. Complex machines are far more difficult to repair and a point of failure can have far reaching and heavy consequences. Something that is beginning to show up in complex systems that we are building. So use analogies carefully. They help us understand a new complex topic but remember it is no substitute to actual understanding. Take you time and find out as much as you can about your pain and condition, and especially the solutions proposed.
Bracing for Scoliosis
How many types of braces are available for scoliosis?
In general, there are 2 main types of braces: hard brace and soft brace.
Hard braces are made of thermoplastic. It has been the main brace prescribed over the last a few decades. Common types of hard braces are Boston’s, Charleston’s, and Milwaukie’s etc.
| Hard Brace | Soft Brace |
Like what its name suggests, it is hard and non-flexible, and wearing which limits movements of the spine. Hence it greatly affects one’s sports participation and causes significant comfort and tolerance issues. Additionally, hard brace is usually bulky and heavy, and shows under the clothes, it is not easily accepted by image-conscious teenage girls. Besides, it also creates much stiffness of the spine, weakness and tightness of the spine muscles.
Soft brace on the other hand, allows movement of the spine when worn. Therefore, the spine is much more mobile during and after the treatment, there is also much less muscle imbalance and joint stiffness of the spine.
Currently the only available soft brace for scoliosis is SpineCor brace. You can get more information on SpineCor brace by following this link: http://www.spinecorporation.com.
How different are the two types of braces? Is one definitely better than the other?
It’s hard to say which brace is definitely better than the other, they work on different principles. Hard braces are designed to hold against spine deformity statically, soft brace on the other hand, is designed to use dynamic force to target on bone deformity and muscle re-training and balancing.
Both hard and soft braces can be effective before the bones of the spine reach maturity, which is usually between 13-15 years old for girls and 15-17 years old for boys. Hard braces can be used for any types of scoliosis such as neuromuscular scoliosis, congenital scoliosis, and idiopathic scoliosis. SpineCor brace is designed for idiopathic scoliosis only.
Both braces need to be worn regularly throughout the day (16 hours per day). Soft braces are lighter and more comfortable to wear; it is more cosmetically acceptable as it can be well hidden under the clothes. It also allows better posture & muscle development, and is able to promote good mobility of the spine while correcting the curve. Hard braces are usually much heavier and hotter to wear and may result in a poorer compliance compared to soft braces.
For people who participate in sports like dancing, gymnast, running or badminton, soft brace is of a much more practical choice. Soft brace is also recommended for individuals who are more prone to skin problems or who are likely to have compliance issues.
What can be done for Scoliosis?
Must I have surgery if I have scoliosis?
No. Surgery is usually only indicated when the curve is bigger than 50 degrees, or is severely affecting one’s everyday activities or his / her quality of life. Majority of scoliosis cases do not require surgery. Surgery will only be considered when the curve continues to worsen in spite of bracing or exercises, and is progressing near or beyond 50 degrees.
The degrees of scoliosis curves are measured by Cobb’s angle.
One must be aware that there are complications with scoliosis surgery, such as stiff spine, spine muscle weakness and possible rods breakage. The spine will no longer grow again after scoliosis surgery, so if it is to be performed in growing children, it should be delayed as much as possible in order to preserve the growth of the developing spine.
What else can help control scoliosis besides surgery?
Besides surgery, the most common treatment is bracing and physiotherapy.
The purpose of using a brace is to control the progression of a curve, but not to eliminate it. Bracing is indicated when the scoliosis curve is between 25-40 degrees, and when the spine has not yet reached full maturity, which is usually between 13-15 years of age in girls, and 15-17 years in boys. In the case that though the curve is smaller than 25 degrees, but worsens more than 5 degrees within a period of 6 months, a brace is also recommended. To ensure the effectiveness of the brace, it needs to be worn 18-20 hours a day through the growing years.
Physiotherapy works to strengthen the weak muscles, to improve the flexibility of the shortened & tight tissues. It helps slow down the development of muscle imbalance and joint stiffness, and helps reduce back pain. It benefits individuals with scoliosis either are or are not on braces. The stiffer the curves are, the more strongly physiotherapy is recommended. Furthermore, physiotherapy enhances the correction achieved by braces during the bracing and after the brace is weaned off.
Exercise and Scoliosis
We often hear people say that if one has scoliosis, they can’t participate in exercises, is that true?
The answer is no. One can usually participate in any type of exercises with scoliosis. Note we are only talking about participation here, not being GOOD at it. Due to the posture and muscle changes in scoliosis, some movements will be harder to achieve, and some will be restricted due to poor flexibility or poor muscle control. For example, one can still play golf, but turning of the trunk may be slightly restricted and that makes a swing slightly harder to perform. Another example is when someone with scoliosis runs, his/ her running pattern may be different due to the posture change.
Exercise endurance sometimes can be affected by reduced lung capacities but this is rare in individuals with idiopathic scoliosis. The main reason for reduced exercise endurance is believed to be a result of lack of regular sports participation. For those who hesitate to participate in sports because they worry about their curves may be worsened by exercises, they can be well assured that it is unlikely that exercises would have any adverse effects on the curve. The reason is that in order for the spine’s growth to change, one needs to exercise continuously for up to 18 hours a day, which is almost impossible for any sports.
If exercises that did not hurt before are now giving you pain, please tune down on the intensity of exercises for a few days. If the pain does not go away, you may need to consult a Dr. or a physiotherapist. Most likely the cause of the pain is that the exercises you are doing has aggravated the muscle imbalance too much, which creates too much joint compression on one side, and too much joint traction on the other side.
Can swimming help reduce the curve of scoliosis?
Swimming is frequently recommended for patients with back problems because the spine is less loaded in the pool with the help of buoyancy. That makes it a natural question “is swimming also recommended for patients with scoliosis?”
The answer is people with scoliosis do benefit from swimming. Besides the fact that swimming is good for general strengthening of the back muscles, it is also good for breathing function. This makes swimming exceptionally suitable for scoliosis as lung capacity and exercise endurance are likely to be affected among the individuals with scoliosis.
Scoliosis involves uneven development of the spine and the back muscles, as swimming targets generally on the whole back, it would not be able to specifically help reduce back pain caused by muscle imbalance. It does not help reduce the curvature too.
