This article will focus on the conservative management of chronic back pain whilst not negating the importance of appropriate pharmaceutical and other interventions.

source: Image from lifedynamix
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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
 

Treatment Options for Chronic Pain- What Does the Research say? is a post from: Musculoskeletal Consumer Review

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The Problems of this condition

The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.

How do I get rid of it?

External aids:

1. Orthotics

The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.

2. Knee braces

These can help prompt correct alignment of the knee joint, but may create a degree of dependency.

3. Strengthening

A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.

4. Stretching

Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.

Knock Knees – Can I reverse it? (Part 2) is a post from: Musculoskeletal Consumer Review

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Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.

What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?

Source: AAF
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As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).

While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.

Plantar Fasciitis

Plantar fasciitis is an overuse condition of the plantar fascia.

Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.

Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.

Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.

Heel Fat Pad Syndrome

Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.

Contributing factors: Increased age and weight decreases the elasticity of the fat pad.

Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.

Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.

References:

1. Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3^rd edition, Tata McGraw Hill, Australia .
2. Cole, C, Seto, G & Gazewood, J 2005, 'Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy`, American Family Physician, vol. 72, no. 11, pp. 2237-42.
3. Thomas, JL, Christensen,, JC, Kravitz,, SR, Mendicino, RW,  Schuberth, JM, Vanore, JV, Weil, LS, Zlotoff, HJ, Bouche, R & Baker, J 2010, ´ The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010`,The Journal of Foot & Ankle Surgery, vol. 49, pp. 1-19.

Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome is a post from: Musculoskeletal Consumer Review

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If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.

This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.

There are 2 common scenarios that cause pain, making you reach for that heat/ice pack.  One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal).  Each scenario requires a different approach to reducing your pain and speeding up your recovery.

Acute Injuries

It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand.  All these are examples of acute injuries and will show the following signs:

• Sharp, severe pain
• Swelling
• Redness
• Increased warmth
• Restricted joint movement
• Unable to put weight through the structure (e.g. leg, ankle, wrist etc).

Flickr: Kyle May

There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!).  The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.

How does ice work?

1.    Decreasing the pain

There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.

• Decreased nerve transmission in pain fibres
• Cold reduces the activity of free nerve endings
• Cold raises the pain threshold
• Cold causes a release in endorphins
• Cold sensations over-ride the pain sensations

2.    Reducing swelling

Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels.  This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling.  After a few minutes, the blood vessels re-open allowing blood to return to the area.  The narrowing and opening repeat in cycles.

The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury.  Pain is also reduced as pressure from the swelling lessens.  Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.

3.    Decreasing metabolic rate

Ice reduces the metabolic rate and oxygen requirements of the cells.  Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened.  This prevents further injury.

Sub-acute phase

A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury.  However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively.  This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.

How does this work?

Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues.  The increased blood flow to the area provides proteins, nutrients and oxygen for better healing.  It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique.  That means that the area should not be red, and should not be warm to touch.

Chronic Injuries

Flickr: Capture Queen

In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area.  Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.

Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs.  If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns.  The heat should be applied for 15-20 minutes.

How does heat work?

Heat applied on the skin increases the temperature of the skin and the underlying tissues.  This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps  to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.

Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly.  Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.

Heat or Ice? When to use which? is a post from: Musculoskeletal Consumer Review

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Why are females more prone?

There are quite a number of reasons why ladies are more pre-disposed to developing knee pain.  The reasons range from wider hips to increased Q-angle, tighter ilio-tibial band (ITB) to weaker physique. However, what is the most common cause of knee pain? The answer lies in the weakness of the quadriceps or thigh muscles. 

Strong thighs, less pain for ladies.

Though it is well-known that a stronger or well balanced thigh muscles would help decrease knee pain, there has never been much studies to prove this theory. This has all changed in a latest research finding that was released in the USA at the end of Aug 2009. Dr Segal and his team found that ladies with stronger thigh muscles are less likely to develop osteoarthritis (OA). However, this relationship is found only in females and not males. 

They assessed a total of 3000 male and female subjects between the age 50 to 70 years old and measured their thigh muscle strength and took an X-ray of all patients at the start and after the two and a half year study period. Out of the ladies that completed the study, about 10% of them had signs and symptoms of knee pain and degenerative changes on X-ray after the study duration. The main difference between the 10% who developed knee pain was the weakness in the quadriceps muscle. They found that the ladies who had stronger quadriceps muscles did not have any symptoms of knee pain or degenerative X-ray changes.

knee xray

Why is this so?

With a stronger thigh muscle, the thigh muscle would be able to take more of the body’s load and strain therefore reducing wear and tear,  decreasing the strain onto the knee and preventing the knee from hurting . Ladies being structurally at a more disadvantageous position as compared to a man it is all the more important to strengthen the thigh muscles.

Exercises to strengthen thigh muscle

If one can get to the gym, doing exercises like leg presses and knee extensions and hamstring curls would be good. A guide to these weight training exercises is to start off light and aim for high repetitions first. Doing about 3 sets of 10-15 repetitions comfortably is normally advised. As for warm ups, stepping onto the elliptical is a good way to not just warm up but also to build up muscles in the thigh.

However, if you’re not able to get access to any gyms, your home and neighbourhood can also be one’s gym. Doing wall squats, slowly, 3 sets of 10, 3 times a day is beneficial as it aids in strengthening not just the quadriceps but also the calf and hamstring muscles. Doing slow step ups on the stairs can be used to progress the strengthening exercises for the thigh muscles.

Conclusion

Though the study from the USA is the first to have found that the strength of the quadriceps is a good predictor of the development of OA, doing the above exercises has other benefits, other than just strengthening the quadriceps muscle. Those exercises will also slow down the process of osteoporosis. So why wait? Better start now than never. If in doubt, seek help and guidance from your nearest physiotherapy clinic.

Reference:
 http://healthday.com/Article.asp?AID=630…

Picture: www.flickr.com

Ladies! Stronger Thighs, Lesser Knee Pain is a post from: Musculoskeletal Consumer Review

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First 48hrs
Immediate post-injury 

Remember RICER. The ice and compression will prevent severe bruising and swelling. Resting your leg will minimise the strain and prevent further aggravation.

After 48hrs – 4days
Using a compressive bandage would be advised to continue for this period.

1. Ice massage over the area of strain might improve the rate of healing. You may also want to try using contrast treatment (i.e. alternate hot and cold compress).

2. Gentle static stretches for your hamstring should be done. Never stretch into the pain. Stretching at this stage helps to mobilise the scar tissue and prevent it from stiffening.

4. Non-resisted hamstring curl should also be done during this period to speed up rate of recovery.

4 – 8 days
 Start to strengthen your hamstring by doing a resisted hamstring curl. Begin with light resistance for about 15reps for 3 sets. Progress only when you feel the hamstring doesn’t feel achy after completing the 3 sets. Dynamic stretches should be done at least 3x/day. Light jogging can begin at about the 6th day post-injury. Normal activities should be able to be resumed after the 8th day.

Do i need to see a doctor?
Depending on the extent of the strain, one might need to seek a review with either a Sports Physician or a Sports Physiotherapist. The extent of the strain can only be diagnose through a real-time ultrasound imaging (RTUI), which can be done by an experienced Sports Physician. However, in some situation, an MRI might be ordered if the strain cannot be detected through the RTUI.

Moderate to severe hamstring strain will need a more extensive rehab and a longer period of recovery and a referral to a sports physiotherapist is highly recommended to get you back to sports as soon as possible.

Physiotherapy managment
In the acute stage of management, a sports physiotherapist would assess the site of strain and deep tissue mobilization might be required to break down the excessive scar tissues that have been laid down over the site of strain. A therapeutic ultrasound would also be used to speed up the rate of healing and manage the any swelling, if present. Gentle stretches, closely monitored by the sports physiotherapist, would be taught to help align the scar tissues. Kinesiotaping may also be done to aid the healing process.

Following the acute stage (about 1 week), your sports physiotherapist will start to progress your hamstring stretches to dynamic stretches and also to start you on resisted hamstring strengthening exercises. Before you’re able to return to sports, your sports physiotherapists will have put you through some form of agility drills to prepare your muscles for the gruelling demands of the game. This process may take about 2 – 4 weeks, depending on the extent of your injury.

Stretch to prevent a recurrence

The key to prevent a recurrence of this injury is to ensure that you adequately warm up your muscles with static and dynamic stretches before the start of your game and during the half-time break. You should ideally hold each stretch for 15-20 seconds for 3-6 repetitions for the static stretches, and at least 15-20 reps for the dynamic stretches. Read on here for static hamstring stretches.

Enjoy your game.

What can i do for a hamstring “pull” is a post from: Musculoskeletal Consumer Review

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