Musculoskeletal Consumer Review : Journal Vol 1

MCR

Musculoskeletal Consumer Review In Volume 2009:1 Neck-Related Headaches

1

The Buckling Knee

3

Posterior Pelvic Pain (Sacroiliac Joint Pain) in Pregnant Women 6 Iliotibial Band Friction Syndrome

9

Lumbar Spinal Stenosis

10

What is Sciatica?

12

Herniated Disc or ‘Slipped’ Disc

14

Repetitive Strain Injuries - Are you a victim of it? 16 Repetitive Strain Injuries - Prevention and Management 20 Shin Splints from the Periosteum

23

9 Things To Take Pressure Off Your Back 2 6 Manual Therapy - Spinal Vertebra Mobilisation 28

Enabling Better Health

Through Better Education

Neck-Related Headaches

From the Editor When we first started planning for what eventually became Musculoskeletal Consumer Review or MCR as we call it, we asked ourselves - “Does the world need another collection of articles on health conditions?”. So asked the people who knew best - our clients. Surprisingly, the answer was yes. But with a few caveats. First, write to them as intelligent people but who happen to have limited knowledge on matters of health. Second, don’t barrage them with jargon. Most did not appreciate being swamped with jargon. Last but not least, they wanted interesting and different topics. There are literally thousands of musculoskeletal conditions but only a few common conditions get written up on all the time. So with these few conditions in hand, we wrote clear ly and simply. We pitched the articles somewhere between a lay-person and a medical professional. And we looked at conditions less frequently covered by other sources of information. This journal collects a selection of articles from our main site. We hope that you find them useful if not interesting and that we kept faith the few caveats above.

MCR Published by Musculoskeletal Consumer Review A division of Core Concepts Pte Ltd

73 Tras Street, #02-01 Singapore 079012 Tel: 6226 3632 www.CoreConcepts.com.sg

Articles originally appeared in mcr.coreconcepts.com.sg

All rights reserved. No part of this book shall be reproduced, stored in a retrieval system, or transmitted by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. No patent liability is assumed with respect to the use of the information contained herein. Although every precaution has been taken in the preparation of this book, the publisher and author assume no responsibility for errors or omissions. Nor is any liability assumed for damages resulting from the use of the information contained herein.

MUSCULOSKELETAL HEALTH GROUP

Cindy Tan Editor, Musculoskeletal Review

Copyright 2009 Core Concepts Pte Ltd

H

ave you ever had the feeling that your headache is somehow related to the pain in your neck? How that it is such a coincidence that every time your headache is preceded by the stiff neck that you are experiencing? You are not imagining it! It is what the medical community calls cervicogenic headaches, which means headaches originating from the neck.

What are the usual complaints from people who suffer from cervicogenic headaches? Most sufferers complain of a deep dull ache starting from the base of the skull to the top of the head, usually over just one side of the head. It may be present on both sides if the neck pain and stiffness are on both sides of the neck. Other complaints include feeling pressure at the back of the eye and discomfort in the jaw.

What are some of the activities that aggravate this condition? Typically, activities that require the neck to be in a sustained strained position for a prolonged period of time will aggravate this problem. The neck posture is often faulty, the head is turned or tilted to one side or sufferer is adopting the “poke chin” position. Example of such activities include reading, using the computer especially the laptop, putting on make up, looking up for too long or watching

Nerves to the Head

Nerves

Another symptom that confirms the diagnosis is the presence of tenderness when pressure is applied over area of the cervical spine immediately under the skull. In some cases, when pressure is applied for long enough, sufferers feel some relief from the headache.

C1 vertebra C2 vertebra C3 vertebra Spinal cord source: visiblebody & core concepts

Artworks/Images: iStockPhoto

Musculoskeletal Consumer Review Volume 2009:1 

movies or theatre when seated on the side of the hall.

Why do these activities aggravate the headache?

C1-2 Nerve Compression

C1 vertebra

When we adopt the “poke chin” posture, we apply compressive Nerves exiting stress to the upper part of the between C1 and cervical spine, namely, C1 and C2 vertebrae get C2 levels (C1/C2 refers to the irritated when first two cervical vertebrae in compressed the spine). Similarly, when we turn our head to one side, we C2 vertebra compress the C1-2 level on the same side. This happens as most of the movement of the head occurs at these 2 spinal source: visiblebody & core concepts levels. So if we sustained these postures or repetitively perform them, these 2 levels will start What can we do? to degenerate and the cartilage wears out over time. This in turn results in stiffness of the upper We need to improve the cervical joint alignment cervical spine. and mobility at the C1-2 levels and to remove

What is relevance between the C12 levels and headaches?

the compressive forces, which is to adopt good posture. This will reduce the irritation to the nerves.

If the cervical facet joints are slightly rotated due The nerves that exit C1-2 and sometimes C3 to contractile forces of tight muscles surrounding supply sensation to the back of the skull to the the neck, the affected joints are already in top of the head and in some people to the jaw some amount of compression and may not area. The nerves that exit from the right side of allow full functional or physiological range. In the neck will supply only the right side of the this situation, physiotherapists can apply the “MUSCLE ENERGY TECHNIQUE” to realign the head, likewise for the left. joint position. This technique uses the muscles When these joints are stiff or mal-aligned, the to reposition the joint. nerves at the affected levels will be irritated causing pain. So when one has a right-sided Once the joint is in a neutral position, the actual upper neck pain or stiffness, the pain is always stiffness (hypomobility) can then be accurately assessed. Stiffness can be treated by various referred to the right side of the head. techniques, such as passive mobilization through . . . c o n t i n u e o n p a g e 18



Musculoskeletal Consumer Review Volume 2009:1

The Buckling Knee

H

aving a sense of the knee ‘giving way’ or ‘locking’ is a fairly common complaint by athletes who have twisted their knees in sports like basketball, netball, soccer or badminton. The sensation of ‘giving way’ is an indication that you might have torn your Anterior Cruciate Ligament (ACL) while the ‘locking’ sensation is an indication of a possible meniscus tear.

ACL Injury The ACL is a fairly strong ligament found between the knee-joint. Its main role is to limit the forward movement (anterior translation) of the leg bone (tibia) on the thigh bone (femur).

meniscus is better at the handling stress from an up and down motion. It doesn’t do as well under a twisting motion especially when compressed. This motion can cause a tear in the meniscus. The knee feels ‘locked’ when the torn part of the meniscus blocks the movement of the knee. Immediate swelling and severe pain in the knee are common signs of this Triad injury. However, there are occasions where there will be a delay in the onset of swelling or even no swelling at all. Remember how you injured the knee. It helps your Doctor or Physiotherapist in diagnosing this problem.

Solving the Problem

When athletes change direction quickly during their games, they twist their knee inwards. This increases the strain on the ACL and places the ligament at risk of tearing. The ACL tears when the knee is force downwards and inwards beyond the ligament’s ability to hold. Athletes who tear their ACL often report hearing a ‘pop’ on injury.

Sadly, the ACL doesn’t heal on its own due to the poor blood supply to the ligament. It would need to be reconstructed surgically by using either your hamstring tendon or patella tendon. Rehabilitation after surgery normally takes about 6-9 months before the athlete is able to go back to full training.

Unfortunately, the ACL is very rarely the only ligament involved in this kind of injury. It is normally accompanied with a slight tear in the Medial Collateral Ligament (MCL) and either a medial or lateral meniscus (cartilage) tear. These three tears are commonly known as the ‘Unhappy Triad’ or ‘Terrible Triad’.

Nevertheless, there are about 20% of people with ACL tears who are able to go about their day-to-day activities without having their ACL reconstructed. To cope without surgery, the following muscles need to have good strength and control: • Hamstrings

Meniscal Injury

• Quadriceps (thigh)

The meniscus, which is a crescent shaped cartilage between the knee, acts as a cushion to absorb the impact between the leg and thigh bone. The

• Gluteus Medius • Gastrocneumius (calf)

Musculoskeletal Consumer Review Volume 2009:1 

Besides doing strengthening exercises, slowly getting back into sports specific training is essential. This is so that your muscles can develop an anticipatory reaction (feed-forward mechanism) to prevent injury.

Choosing the R ig ht K nee Suppor t There are more than 10 different types of knee supports on the market at this current time. This gives us a headache deciding which one should you get. How one makes a choice for the appropriate knee support should depend on 2 major ‘type’ factors - type of injury and type of sport that knee support is required for A knee support SHOULD NOT be for long term daily wear as it will weaken the muscles of the knee, making one very dependent on the support. Knee support should be used as a TEMPORARY measure to manage your knee discomfort until professional advice is sought.

Lateral View of the Knee

Sports taping of the knee to support the ACL and MCL can also be done as a temporary measure for the athlete to cope with the injury until the end of the season.

BACK PAIN SPECIALISTS

The best way to manage your knee discomfort is to see your physiotherapist for prescribed exercises that would be beneficial for you and to strengthen your knee. Here is a simple guide to 5 of the more common types of knee supports.

Closed Patellar Knee Support This knee support is generally used to help control slight swelling of the knee and can also be used for jogging or brisk walking. Commonly used with knee pain that is difficult to isolate the area of pain. However, due to the “closed” nature of this knee support, it is not recommended for daily use if you’ve got to climb stairs or squatting. This is because it would compress your knee cap (Patellar bone) against your thigh bone when your knee is bent more than 45o thus increasing the risk of degeneration of the knee cap and increasing your pain.

Open Patellar Knee Support Similar indication to the closed patellar knee support but this can be used for daily use as it doesn’t compress your knee cap. Recommended for people who have pain behind their knee cap with difficulty climbing stairs or squatting.

Hinged Knee Support Generally prescribe by orthopedic surgeons or sports physicians for athletes with ligament

source: US GSA & core concepts



. . . c o n t i n u e o n p a g e 13

Musculoskeletal Consumer Review Volume 2009:1

P H Y S I O T H E R A P Y

C E N T R E

Appointment: 6353 5713 • 6226 3632 • 6887 4246 SHENTON WAY • PARKWAY PARADE • NOVENA S Q UA R E

Posterior Pelvic Pain (Sacroiliac Joint Pain) in Pregnant Women

P

osterior pelvic pain (PPP) is pain felt at or near the sacroiliac joints of your pelvis as a result of sacroiliac joint dysfunction.

These are joints located at the 2 dimples of the lower back. The pain often feels deep within your lower back and can occur on one or both sides of your back. In some cases, pain radiates down to the buttock and the back of the thigh. While pain may begin at any time during pregnancy, PPP on average begins in the 18th week of pregnancy and becomes more intense as the pregnancy progresses. The pain usually spontaneously resolves within 3 months post delivery. But in some cases it can become chronic and disabling.

2. Secondly, the SIJ is further strengthened by a complex mesh of ligaments and muscles such as the core stabilizers. These core muscles, such as the transversus abdominis and multifidus which surround the SIJ, act as active stabilizers by actively contracting to create a compressive force over the SIJ, gripping the joint firmly together. They act as a natural corset by providing that compression around the lower back and pelvic region -much like wrapping your fingers around the two Lego pieces, keeping them firm and tight. Posterior pelvic pain arises from sacroiliac joint dysfunction, in other words, when the stability of SIJ is compromised.

What are the Sacroiliac joints?

Why does it happen?

The sacroiliac joints (SIJ) are formed between the sacrum, a triangular-shaped bone in the lower portion of the spine, and the right and left ilium of the pelvis. The SIJ is a strong and stable weightbearing joint that permits very little movement due to its natural structure. The main role of the SIJ is to allow forces to be transmitted effectively through the body, absorbing impact from the legs to the spine during activities such as walking, running and jumping.

During pregnancy, mechanisms stabilising the SIJ is affected. This instability allows for increased motion, stressing the SIJ.

The SIJ is kept stable through two mechanisms: 1. Firstly, the rough, groove-like connecting surfaces of the sacrum and ilium interlock and help stabilise the joint, like two pieces of Lego together.



1. Hormones released during pregnancy relax the ligaments of the body to allow the pelvis to enlarge, in preparation for childbirth 2. Due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened. Moreover, the additional weight and altered walking pattern associated with pregnancy can cause significant mechanical strain on the sacroiliac joints, which may result in SIJ inflammation, giving a deep ache in the posterior pelvis.

Musculoskeletal Consumer Review Volume 2009:1

What are the symptoms?

SACROILLIAC JOINT (SIJ)

Of all the back pains experienced during pregnancy, posterior pelvic pain is the most common - you are four times more likely to experience PPP than lumbar pain.

Sacrum SIJ is the joint where the sacrum meets the illium

You may have posterior pelvic pain / sacroiliac joint dysfunction if you have: • Deep, boring pain in the back of the pelvis (around the sacroiliac joints) may • Pain occasionally radiate to the groin and thighs.

Left Illium

source: visiblebody & core concepts

• The pain is typically worse with standing, walking, climbing stairs, resting on one leg, getting in and out of a low chair, rolling over and twisting in bed, and lifting. The pain improved when lying down. • If there is inflammation and arthritis in the SI joint, you may experience stiffness and a burning sensation in the pelvis.

Diagnosing Sacroiliac Joint Dysfunction in pregnancy Your doctor and/or physiotherapist will conduct a thorough history and physical examination to determine the underlying disorders for your pain. That includes your description of symptoms, a series of tests designed to look at the stability, movement, and pain in the sacroiliac joints and surrounding structures. Imaging, such as computed tomography (CT) scan and

X-ray may also help in the diagnosis. Another reliable diagnostic method involves injecting an anesthetic agent into the SI joint, guided by an Xray machine, numbing the irritated area, thereby identifying the pain source. However, due to the concerns of fetal exposure to radiation, diagnostic procedures involving radiation is generally avoided.

Treatment and Management The first-line treatment of pregnancy-related sacroiliac joint dysfunction is physiotherapy and exercises that focuses on core stability of the trunk and pelvic girdle. Sometimes, a sacroiliac belt is prescribed to complement the core stability exercises and to give quick pain relief. Exercises will form a large part of the treatment and in some cases, mobilisation (a gentler form of manipulation) of your hip, back or pelvis may be used to correct any underlying movement

Musculoskeletal Consumer Review Volume 2009:1 

dysfunction. Other manual techniques include muscle energy technique (MET) and myofascial release. It is vital to engage a physiotherapist who is skilled in treating pregnancy-related pain as she is aware of the studies that support the use of specific stabilizing exercises and other treatment techniques, thereby preventing the dysfunction from escalating into a chronic condition. Other alternative treatments include anesthetic and steroidal injections into the SIJ that can help in pain relief, which lasts from one day or much more long-term. Oral anti-inflammatory medications are often effective in pain relief as well. However, these two treatments may be contra-indicated during pregnancy.

• To turn, pull with your left hand and take both knees over to the right so that you roll to the right. As soon as possible, bend your knees up as high as they will go - this helps to lock out your pelvis and lessen pain. • Reverse this to turn to the left. Getting out of bed • Roll onto your side with your knees bent up, move your feet over the edge of the bed and push yourself up sideways with your arms. • Reverse the process when you lie down. Standing from a sitting position.

Posterior Pelvic Pain Home Advice

• Sit on the edge of the chair.

Here are some tips for expectant women with posterior pelvic pain.. Lying down • Avoid lying on your back for long periods of time, particularly after the 19th week of your pregnancy. • Try lying on your side (preferably your left) with a pillow placed between your knees and another under your tummy. • If your waist sags down into the bed, try placing a small rolled up towel under your waist.

Turning over in bed • To turn to your right while lying on your back, arch your lower back, tighten your pelvic floor muscles and lower abdominal muscles and bend both knees one by one. • Turn your head to the right and take your left arm over to the right of your body. Hold onto the side of your bed if you can.



• Keeping your knees apart slightly and lean forwards till your head is directly over your knees, keeping your back straight. • Stand up by pushing up with your arms, with your back straight and tummy tucked in. This helps to hold your pelvic joints in their most stable position and may reduce your pain significantly. Reference: 1. Fitzgerald CM and Le J. Back pain in pregnancy requires practitioner creativity. Biomechanics. 2007 November 2. Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine. 1991; 16:549-552. 3. Ostgaard HC, Zetherstrom G, RoosHansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994; 19:894-900. . http://www.sidysfunction.com/articles/ lumbarbackandposteriorpelvicpain.html

Musculoskeletal Consumer Review Volume 2009:1

Iliotibial Band Friction Syndrome

T

ell any long-distance runner or cyclist about your stinging pain at the side of the knee or hip, and you will get a knowing sympathetic look. ITB (Iliotibial band) friction syndrome is one of the commonest complaints amongst runners, cyclists and intense court sports. ITB friction syndrome gets its name from the Iliotibial Band rubbing against a bony protrusion just at the side your knee. The ITB is a continuation of one the largest hip muscles and spans as a thick band of tissue on the outside of the thigh. Starting from the pelvis, it runs over side of the hip and ending just below the knee. Just before it crosses the knee, it runs over a protrusion in the thigh bone (lateral femoral epicondyle). The frequent rubbing of the band over this bony protrusion from bending and straightening of the knee irritates the band, causing an inflammation. The tighter the ITB, the harder it rubs over the protrusion.

What tightens the ITB?

Bio-mechanical Gait Problems with foot structures such as high or low arches and uneven leg length typically tighten the ITB on one side. A complete biomechanical assessment helps determine the faults. Where appropriate, foot orthotics can correct these problems.

Weak outer hip muscles Weak outer hip muscles forces the ITB to work harder to compensate and becomes tight as a result. Exercise to strengthen the outer hip muscles helps to lighten the load on the ITB. Despite avoiding all the three issues mentioned, athletes with a high training volume often still experience painful ITBs. In such cases, deep tissue massage will help release the tight band. Don’t forget to stretch the ITB. Ignoring ITB tightness can lead to groin pain and low back pains.

Three basic things tighten the ITB. 1. Training methods 2. Bio-mechanical gait issues 3. Weak outer thigh muscles

Training Methods Running on banked surfaces, inadequate warm up or cool down, increases in distance too fast or excessive downhill running are faults associated with running which strains the ITB. In cycling having the feet toed inwards commonly causes the band to get tight.

ITB: Bony Protrusion ITB snaps over protrustion lateral femoral epicondyle (protrusion)

Irritated ITB

Knee-cap

source: visiblebody & core concepts

Musculoskeletal Consumer Review Volume 2009:1 

THERAPY AT HOME FOR STROKE AND NEUROLOGICAL CONDITIONS

Lumbar Spinal Stenosis

L

umbar spine stenosis is a condition where the space in the lower spinal canal narrows. The spinal canal houses the spinal cord along the back. Narrowing of this space causes pain, numbness to weakness in the legs in more serious cases. In extreme cases, loss of bladder and bowel control. This condition typically affects adults over the age of 50.

Compression of the spinal cord The pain symptoms result from the spinal cord being compressed by the narrowing spinal canal. Depending on the amount of pressure on the spinal cord, the symptoms varies. Beginning from mild pain when there is some compression to weakness in the leg when there is so much pressure that signals sent to the leg muscles are cut off. In some cases, compression of the nerves of the lumbar spinal cord can cause loss of bladder, bowel and sexual functions. People with lumbar stenosis find a bent forward position while walking, sitting down or squatting helps relieve the pain. This position relieves some of the pressure by decompressing the compressed area. Bending backwards on the other hand increases the pain.

Why does the spinal canal narrows? In most case, the spinal canal narrows as a result of degenerative changes in the lower back vertebrae as we age. The degenerative process causes excessive bone growth (osteophytes), ligament enlargement (ligamenteous hypertrophy), or loss of spinal disc height. This is the main reason why lumbar stenosis

most commonly seen in adults over the age of 50.

What are the treatment options? In severe cases where there is weakness in the lower limbs or loss of bladder and bowel functions, surgery is an option to immediately relieve the pressure off the nerves. In milder cases or immediately post-surgery, rehabilitative treatment is recommended to improve posture and strength of the muscles around the lower back and abdominal region. This helps reduce the amount of compression on the spinal cord in the lower back area.

N

ote that even after surgery, treatment and continued self-management through exercises is important as degeneration, the primary cause, continues. As we continue to age, we continue to get more excessive bone growth, our ligaments enlarge and our spinal disc continues to lose their height.

Spinal Stenosis Spinal Stenosis occurs when the spinal canal spaces narrows, and the spinal cord gets compressed. Spinal cord (blue areas)

Spinal canal space (dark brown region)

Narrowed space pressing on the spinal cord

Cerebral Care

(an associate company of Core Concepts)

Tel: 6226 3632 Fax: 6226 3571 source: debivort and core concepts

www.CerebralCare.com.sg [email protected]

10

Musculoskeletal Consumer Review Volume 2009:1

5. A shooting pain that makes it difficult to stand up

What is Sciatica?

T

he sciatic nerve is the largest and longest nerve in the body with a diameter of almost 2cm. It starts from the sacral plexus, a network of nerves in the pelvis region, branching out down into each of the legs. The sciatic nerve carries out two basic functions, namely motor (movement) functions and sensory (feeling) functions. When the nerve is compressed, the symptoms are called sciatica. Aside from sharp shooting pain, symptoms such as loss of reflexes, weakness and numbness are often present when both its motor and sensory functions are imparied.

Sciatica-like symptoms may also be caused by other than compression on the sciatic nerve such as. 1. Sacroiliitis is an inflammation of your sacroiliac joint, where your hip meets the spine. Inflammation caused by trauma or arthritis can give you sciatica-like symptoms.

What Causes Sciatica?

2. Lumbar Facet Joint Syndrome is pain that comes from the joints of your back causing not only back discomfort, but also it can give you sciatica-like symptoms. The facet joint, like any other joint of your body, such as the knee or elbow, can get inflamed and cause pain.

One common cause of sciatica is a herniated disc or “slipped disc”. The herniated disc protrudes and places pressure on the nerve root which connects to the sciatic nerve.

3. Iliolumbar Syndrome is simply inflammation or a tear of the Iliolumbar ligament. This ligament extends from the spine to the iliac crest, which is the back of your pelvis.

As the longest nerve in the body, there are ample opportunities for the nerve to be compressed. They include:

Your doctor or physiotherapists can perform one or more movement tests to determine the exact cause of your symptoms.

1. Piriformis Syndrome is pain caused by the piriformis muscle that may be in inflamed, or irritated. This muscle is in your buttock and lies right on top of the sciatic nerve as it exits the spine and goes down your leg. When inflamed or irritated, this muscle swells and applies pressure on the nerve giving you the sciatica like symptoms. 2. Spinal Stenosis, which is the narrowing of the spinal canal can cause sciatica-like symptoms. The narrowing can be caused by disc problems as well as arthritis of the spine.

12

If severe pain symptoms occur along with bowel or bladder control problems, consider this as an emergency and is to be evaluated as soon as possible by a neurologist or orthopaedic specialist.

Treatment As nerve pain is caused by a combination of pressure and inflammation on the nerve root, and treatment is centered on relieving both of these factors: 1. Manual treatments for sciatica including physiotherapy treatments such as mobilisation and manipulation to help relieve the pressure and inflammation with electrophysical agents. 2. Medical treatments for sciatica (such as NSAID’s, oral steroids, or epidural steroid injections) to help relieve the inflammation.

One or more of the following sensations may occur as a result of sciatica:

2. Burning or tingling down the leg

damage that has been repaired to increase stability and to protect the ligament. This is the ONLY type of support that should be worn every waking hour until advised to remove either by your surgeon or physiotherapist. This support however is not allowed for most sports due to the metal parts of the support.

3. Weakness, numbness or difficulty moving the leg or foot

Adjustable Stabilizing Knee Support

Musculoskeletal Consumer Review Volume 2009:1

When sciatica has resolved, the patient should maintain optimum conditions for their spine. The fact that the spine has had a prolapse, and is not normal, does not preclude a relatively normal lifestyle. Specific exercises such as core stability exercises to maintain flexibility and strengthen the abdominal and spinal muscles are important.

Choosing the Right Knee Support . . . continued from page 4

. A constant pain on one side of the rear

Sciatic Nerve

3. Surgery for sciatica (such as microdiscectomy or lumbar laminectomy) to help relieve

What Are The Symptoms?

1. Pain in the rear or leg that is worse when sitting.

both the pressure and inflammation may be warranted if the sciatic nerve pain is severe and has not been relieved with appropr iate manual or m e d i c a l treatments.

This type of knee support would be suitable for sports if there is no metal support. Normally

recommended for athletes who have recovered from ligament injuries and are just starting to go back to sports but still have a slight fear. Gives athletes a fair amount of support.

Patellar tendon support Commonly for people who complain of pain over the patellar tendon on running or jumping. Purpose of this support is to compress the patellar tendon to dissipate the strain to across the whole tendon and thus decreases pain.

Musculoskeletal Consumer Review Volume 2009:1

13

Prolapsed Disc

Herniated Disc or ‘Slipped’ Disc

A

herniated disc is known by many names, bulging disc, compressed disc, herniated intervertebral disc, herniated nucleus pulposus, prolapsed disc, ruptured disc and, perhaps the most inaccurate of all, slipped disc. It is one of the better known spinal conditions and yet few know what it truly means. Let us that a look at the structure of the disc and understand what happens when a disc is said to herniate.

Structure of a disc A spinal or inter-vertabral disc sits between two spinal vertebrae. It acts mainly as a cushion to take up the pressure off the spine. Most people imagine the disc as a rubber disc with a softjelly centre, much like a jelly donut. It is perhaps more accurate to imagine a ball of jelly wrapped around with a string over and over again until the jelly ball is completely covered. So instead of a solid rubber material, the soft center is actually covered by a ring of tough string or fibres. This ring of fibre is known as the outer annulus fibrosus, which surrounds the inner ball of jelly, nucleus pulposus.

How the disc works Imagine that you have blown up a small red balloon and ’sandwiched’ it between two slices of bread. When you squeeze the slices of bread together, the balloon resists the squeeze and expands out of the side of the sandwich. Your disc works in exactly the same way, only that the disc’s wall is much thicker and has a jelly center

14

instead of air. Now, instead of squeezing the balloon down evenly on both side, squeeze down the sandwich at just one end. The balloon should expand out at the other end of the sandwich. If this position is held for long time, the balloon will becoming permanently stretched at one end. When you let go of the sandwich, the balloon end will not shrink back fully but will remainly slightly loose. The more often you stretch it and the longer you hold the stretch, the looser is gets over time. The jelly center bounces back but the tougher surrouding fibres won’t. If they are over-stretched, they either break or remaining stretched.

Stages of disc herniation Like the balloon sandwich, the disc doesn’t burst immediately unless squeezed extremely hard. Instead it will get stretched gradually over time. More accurately, each disc fibre gets stretched over time. So it is a gradual process happening over each fibre at a time. It is rarely a sudden process. You don’t wake up one morning to find a bulging disc when the disc was perfectly fine the day before.

Bulging Disc At this early stage, the disc is stretched and doesn’t completely return to its normal shape when pressure is relieved. It retains a slight bulge at one side of the disc. Some of the inner disc fibres could be torn and the soft jelly (nucleus pulposus) is spiling outwards into the disc fibres but not out of the disc.

Musculoskeletal Consumer Review Volume 2009:1

At this stage, the bulge is very prominent and the soft jelly centre has spilled out to the inner edge of the outer fibres, barely held in by the remaining disc fibres.

Stretched Spinal Disc When a disc is stretched in one direction for a prolonged period, the tough fibres of the disc become overstretched and the disc does not return fully to its previous shape. Imagine the disc between two vertebras is like a balloon sandwich. Even Pressure Balloon No Pressure

Herniated Disc or Extrusion Herniation is a term to mean protrusion. In the case of a herniated spinal disc, the soft jelly has completely spilled out of the disc and now protruding out of the disc fibres.

Balloon bulges at one side

Prolonged Uneven Pressure After pressure is removed, the balloon shrinks back to its smaller shape. But the earlier overstretched bulging side is a little wrinkled

Sequestered Disc Here some of the jelly material is breaking off away from the disc into the surrounding area.

Can discs heal? Unfortunately, a damaged disc cannot heal itself. It has little blood supply (only at the flat top and bottom of the disc) and the disc tissues cannot regenerate themselves. Once the disc fibres are stretched, it is currently not possible to un-stretch back to their original state.

Is there pain?

bulges evenly all round

Pain felt from a herniated disc is more often caused by the disc or its soft jelly core pressing on its surrouding tissues which have more nerve endings. So it is possible to have a herniated disc and yet experience no pain if the herniated disc does not pressed against any nerves Another source of pain is when the disc first herniates, the nucleous pulposus reacts with the blood supply surrounding the disc to produce chemicals that can also irritate to the surrouding tissue causing inflammation. Reference:

There are few nerve endings in the spinal discs, mainly in the edge of the disc facing out from your back. So there is often little or no direct pain felt from a degenerating, bulging or herniated disc.

Musculoskeletal Consumer Review Volume 2009:1

1. P. Prithvi Raj MD, FIPP, ABIPP (2008) Intervertebral Disc: Anatomy-PhysiologyPathophysiology-Treatment , Pain Practice 8 (1) , 18–44 doi:10.1111/j.1533-2500.2007.00171. x 2. Medline Plus, http://www.nlm.nih.gov/

15

Repetitive Strain Injuries - Are you a victim of it?

R

epetitive Strain Injuries is really a blanket name for health problems that result from over-use or misuse of muscles, tendons, and nerves. Unlike strains and sprains, which occurs from a single incident, RSIs develop over time. Therefore, repetitive strain injuries are also called Cumulative Trauma Disorders (CTD). Other names include repetitive stress syndrome, occupational overuse syndrome and repetitive motion disorders. RSIs are the most common form of occupational (workplace) illness; some so crippling that sufferers may require surgery or face permanent disability. Though RSI is not localized to any one type of job, the odds are higher for occupations that involve repetitive work, such as, working at the assembly line, food processing jobs, or at visual display terminals. It can take years to develop and therefore tend to strike when the worker is in his prime of career usually around the age of 40. Occupation-related RSIs are caused by any combination of the following factors (see “Occupation-related RSIs Risk Factors”).

• Tenderness • Swelling • Aching • Electricity-like tingling and/or numbness Loss of joint movement • Weakness and decreased coordination of the injured body part • Crackling • Muscle spasms Symptoms may occur at any time i.e. during work, immediately after work, or even many hours (or days) after work. Typically, one first experience symptoms when he is not working. For example, an injured worker may have no pain at work and wake up in the night with a painful neck or arm. Jobs that pose a particularly high risk of RSI are: • Assembly line worker • Checkout scanner

What are the signs & symptoms of RSI?

• Computer keyboard operator

RSIs can affect almost any part of the body, but they often occur in upper body. The most commonly affected body parts are the fingers, hands, wrists, elbows, arms, shoulders, back, and neck. One or more of the symptoms below may be present in the injured area:

• Garment worker

16

• Food handler

• Hand tool operator • Machine operator

• Meat packer

• Hand-arm vibration syndrome, also known as Raynaud’s Phenomenon

RSI symptoms can be mild, but they can also become so severe till activities of daily living become difficult to perform, including turning taps, opening a jar or getting dressed.

Disorder of blood vessels, usually in fingers or hands, which causes the affected area to lose color and feel cold or painful. • Thoracic outlet syndrome, a neurovascular disorder

What are the most common RSIs?

Compression of the nerves and blood vessels in the shoulder, causing numbness in the fingers and weakening of the pulse. It can cause pain anywhere between the shoulder and the tips of the fingers. It results from the compression of blood vessels from activities that pull the shoulder back and down, such as carrying heavy bag packs and constant overhead motions such as stacking dishes or supplies.

There are many repetitive strain injuries, because many different parts of the body can be affected. However, most job-related repetitive strain injuries affect the upper part of the bodythe spinal column, neck, shoulders, arms and hands. • De Quervain’s syndrome also known as washerwoman’s sprain, radial styloid tenosynovitis Inflammation of the tendons in the wrist that control the thumb. • Subacromial bursitis, also known shoulder impingement syndrome

as

Resources

Occurs as a result of the subacromial bursa ( a fluid-filled sac) being squashed or ‘impinged’ between the rotator cuff muscles (Supraspinatus, Subscapularis, Infraspinatus and Teres Minor) and the collarbone, during repeated overhead shoulder movements. • Carpal tunnel syndrome (CTS) Results when the median nerve in the wrist is compressed between tendon and the bone, leading to inflammation. Sufferers usually experience numbness, tingling and pain in the thumb, index finger, middle finger and inner side of ring finger. CTS typically affects people who overuse their hands on piano or computer keyboards, giving rise to injuries to hand and wrist.

Labour Organization. 1. International Listening to our pain. Preventing workplace injuries and illnesses through ergonomics. World of Work. No. 21, September/October 1997 2. National Education Association. Repetitive Stress Injuries Handbook –Education Support Professionals. Website: http://www. nea.org/esphome/nearesources/repstresspart3.html 3. New York Committee for Occupational Safety and Health. Repetitive Stress Injuries Website: . ht t p:// w w w. nyc o s h .or g / work pl ac e _ hazards/ PhysicalHazards/rsi.html

• Materials handler

Musculoskeletal Consumer Review Volume 2009:1

Musculoskeletal Consumer Review Volume 2009:1

17

Occupation-related RSIs Risk Factors Risk Factor

Explanation

1. Repetition

Doing the same motion over & over without allowing your body to rest & recover from the stress and strain.

2. Awkward or fixed posture

Working in awkward positions i.e. repeated overhead motions; reaching down and behind your body; lifting & twisting; or stay in a fixed/ sustained position for a long time.

3. Fast pace

Having to work quickly.

. Forceful movements

Using a lot of effort & strength to do the job i.e. lifting, pulling, pushing and even small movements like pounding fingers on keyboard.

5. Frequent & difficult lifting

In a badly designed job, lifting even 10kg can cause injuries. Loads over 30kg are always dangerous for one person to lift.

6. Excessive Vibration

Usually caused by power tools i.e. drills.

7. Insufficient recovery time

Inadequate rest breaks.

EToNI

For Pregnant Women with Musculoskeletal Pains www.Etonia.com.sg

Neck-Related Headaches . . . continued from page 2 the MAITLAND technique or with the clients’ active movement with the MULLIGAN SNAG technique. If the joints remain stiff even after a few sessions of mobilization, MANIPULATION can be applied. Once the ideal mobility has been achieved, the client will be expected to maintain it by self mobilization with a strap.

18

Once the mobility is improved, the headache will be resolved. The client can remain pain free for a long time provided the original cause of poor posture is solved. Good ergonomics here is paramount..

Musculoskeletal Consumer Review Volume 2009:1

Musculoskeletal Consumer Review Volume 2009:1

19

Repetitive Strain Injuries Prevention and Management

I

n the previous article, Repetitive Strain Injuries - Are you a victim of it?, we highlighted that repetitive strain injuries (RSIs) are mostly occupation related, but such oversue injuries can be caused by activities outside of work, such as sports and hobbies, including badminton, tennis, golf or playing a musical instrument. Furthermore, older workers are more prone to RSIs because the body’s ability to repair the effects of wear and tear decreases with age. RSIs are mostly caused by job demands and workplace conditions. If the conditions and demands of a job causes RSIs, they can be corrected by using ‘Ergonomics’, the science of matching jobs, systems, product and environments to the physical and mental abilities and the limitations of workers, instead of making the worker fit the job. Prevention of RSIs is possible if either ergonomical changes can be made to accomodate the worker, by changing the physical set-up of the workstation or he position or way one does his tasks, or both. The following are ergonomically suggestions to avoid RSIs.

friendly

1. Avoid Repetitive Work Muscles work by contracting and relaxing, stretching your tendons in the process. Repeated stretching and pulling can cause the tendon to swell and get sore. If the muscles and tendons do not get enough time for rest and recovery, the risk of injury is increased. This is because as muscles get tired from doing the same motion

20

repeatedly, more effort is exerted to do the job. Remedy Rest the muscles doing most of the work to prevent tiredness. Take frequent “micro” breaks, in which you use different muscles to do the task or pause for a few seconds. This relieves your muscles more effectively than uninterrupted periods of work with only one or two long rest breaks.

awkward postures. For example, using an Allen key instead of a screwdriver can reduce twisting and bending of your wrist at awkward angles. In addition, minimize static postures that are “out of neutral” as these put further stresses on your body. For example: » Work tables, chairs and countertops should be designed to eliminate frequent bending and extended bending and leaning » Organize work tables so that materials are within easy reach » Keep arms and elbows low and close to your body while working and reach without stretching and straining » Keep reaches below shoulder level » Avoid stacking materials above shoulder height

2. Avoid Awkward and Static Postures A “neutral” body position is the most comfortable working posture, in which the shoulders are downswards and relaxed, with the arms close by your sides, elbows bent with your wrists and hands straight. Deviating from the neutral posture will increase the stress on joints, muscles, tendons, nerves, and blood vessels. For instance, if you work bent over and leaning forward, with your arms above shoulder level in a “fixed” or “static” posture, you are likely to stress the lower back and shoulders. Such static activities are very tiring and stressful, and can potenially speed up the wear and tear of your back and shoulders.

» Keep your elbows at the height of the work counter » Support your forearms with armrests or other padded surfaces » Have enough room in work area to use your arms while keeping your wrists straight

3. Avoid Prolonged Standing Standing in one position for a long period of time can put stress on your spine, back muscles and legs.

Remedy

Remedy

Move around and change your posture often. Take “micro” breaks. If you have been bending or kneeling, switch to other tasks to rest your back and knees. Also, using the right tool for your tasks can reduce

The stress caused by prolonged standing can be reduced by:

Musculoskeletal Consumer Review Volume 2009:1

Musculoskeletal Consumer Review Volume 2009:1

» Using foot rests, to alternate the weight bearing foot by shifting your weight often » Stand with knees slightly bent to prevent locking, and thus relieving stress in the knees » Take “micro” breaks; general rule is a 5-minute break for every 45-60 minutes of standing. Take this opportunity to change positions or move around

4. Reduce the Amount of Force You Use Using a lot of effort & strength to do the job, even small movements like pounding fingers on keyboard will increase the stress your body takes. Forceful movements such as pushing, pulling, tugging, and sliding objects put strain on your lower back. They also stress the muscles, tendons, and joints of your shoulders, arms, upper back, and legs. The more force you use, the more you risk fatigue and injury. Remedy » When moving a heavy object, use trolley, carts or equipment designed for pushing instead of pulling. Pulling stresses your shoulders and arms compared to pushing. This is because when you push, your body weight is being used to an advantage. » Avoid pushing or pulling in an awkward posture as more force is required to move the object. Similarly, avoid pushing or pulling an object above shoulder height or below waist height. Modify your position to optimize your working position and strength. » Look out for large amounts of friction between the surface and the object as this increases the force used. Put a medium

21

between the two to reduce the friction i.e. wheels or sliding board.

5. Be Careful How you Lift

Shin Splints from the Periosteum

6. Design Computer Workstations to Fit You

Faulty lifting techniques stress the back muscles, tendons, ligaments and spine. Even if the load is mildly heavy (less than 10kg), improper lifting can cause serious back injuries. Remedy The key to proper lifting is to keep the back in its natural position. Squat lifts put less stress on your back, but only if you can fit the object between your knees. Otherwise, attempt to fit the object as close to your body as you can. The best solution is to reduce the size and weight of the load and make repeated trips. Here are some tips for a safer lifting procedure: » Stand close to load with feet apart » Tighten stomach muscles and tuck in bottom

Workstations must consider a worker’s ability to comfortably see and handle the work. Chairs with adjustable features and proper back support are essential to prevent injury and improve overall comfort and work performance. For example, the differences in chair height can affect the whole body. If the chair is too high, it can: » Press thighs against the table

Occupation-related RSIs Risk Factors Because

» Reduce blood flow to the feet

1. Pronation of your foot arch

When the foot over-pronates (over rotate), the foot pushes almost entirely off the big toe, straining the big toe and the outside of the shin. When under-pronating, too much weight is borne by the outside edge of the foot, again straining the shin

2. Tightness of your calf muscles

A tight muscle cannot help absorb shock well. When taut, it transmits forces directly through to the connecting bone.

3. Running with shoes with a lack of support or cushioning

The leg has to absorb whatever leftover forces the shoe fails absorb from each footfall. These leftover forces strain the muscles and connective tissues such as the periosteum.

. Running on hard surfaces

When the running surface does not give, more shock is ‘reflected’ back to the runner.

5. Poor running biomechanics

The human body absorbs and dissipates forces through its skeletal and muscular systems. When this system does not function well through irregular running gait or a mal- functioning component such as a tight calf muscle, other parts of the system has to compensate and becomes over loaded over time.

» Make wrists bend up » Force the head to lean forward and look down » If the chair is too low, it can:

» Keeping spine upright, bend knees or squat down

» Raise shoulders and arms causing stress and fatigue especially if the table is at chest level.

» Never pick up a load unless both feet are firmly on the ground, and the load is no higher than your shoulders. Minimize

splints actually come from the bone in most cases; or more accurately, from the periosteum, a thin sheath that covers all bones whose function is to be provide nourishment to the bones. This sheath is rich in nerve endings, so it feels pain. When the periosteum is over-strained and irritated, it gets

Causes Of Shin Splints

» Raise knees higher than hips and encourage slouching

» Use stronger thigh muscles rather than smaller muscles of the back for the lift

H

ave you had pain in your shin that does not go away with rest? Runners most often complain of shin splints especially those that run often on hard surfaces, a common enough situation here in Singapore. Unlike other injuries where you feel pain at the muscle, ligaments or joints, the pain from shin

» Press seat against back of thigh

» Arch your lower back inward by pulling shoulders back and sticking out your chest, keeping spine in neutral position

» Face load directly. Do not twist your shoulders to reach the load. Bring object close to the body. The closer the load to the body, the less pressure it puts on your back

22

long reaches and avoid fast, jerky movements

Remedy A good chair should have: » Adjustable seat heights and depth » Backrest that is adjustable for the height (up/down) and angle (forward/backward) to help support the lower back

Musculoskeletal Consumer Review Volume 2009:1

Table 1: Common Causes of Shins Splints

Musculoskeletal Consumer Review Volume 2009:1

23

inflamed causing pain. In the case of shin splints, it is the sheath covering the tibia.

muscles do not work well or work too forcefully, it strains the periosteum covering the shinbone. See table 1 for causes of shin splints.

What pulls at the periosteum?

Repeated strain onto the periosteum will lead to the inflammation, causing the pain.

Most of the muscles in thecalf, ankle and foot attach directly to the shinbone. When these

Bone Cross-Section Dense Bone Matter

Bone Marrow

Periosteum, a thin sheath of dense fibrous connective tissue. It contains osteoprogenitor cells that grows and heals bone.

Occupation-related RSIs Risk Factors Cause

Treatment Solution

1. Pronation of your foot arch

An arch support or shock-absorbing insole is highly recommended.

2. Tightness of your calf muscles

Sports massage to release the tight muscle.

3. Running with shoes with a lack of support or cushioning

Get properly fitted with the right shoes. If unsure, a podiatrist, kinesiologist or sports physiotherapist can help you choose.

. Running on hard surfaces

Run on softer surface

5. Poor running biomechanics

A rehabilitation program which includes stretching your tight muscles, strengthening of muscles to correct muscle imbalance and correction of biomechanical abnormality in your running gait Table 2: Shin Splint Treatment Options

Treating Shin Splints The best way to treat shin splint is to remember RICER (Rest, Ice, Compression, Elevation, and Referral). Completely rest and ice the painful region immediately when pain is first felt. Compress and elevate your leg above your heart if there is swelling and get a medical professional to review your condition. See Table 2 for treatment options.

your ankle or shin to reduce the pulling force off the periosteum. A final word of warning, chronic compartment syndrome can also cause shin splints, where pressure builds up within the muscle and restricts blood flow. This requires immediate medical attention as restricted blood flow can lead to nerve and muscle death. Whenever any type of pain persist, it is always prudent to seek proper medical advice

A course of anti-inflammatory can help decrease your pain. A sports physiotherapist may also tape

source: stained image: flickr/akay & core concepts

24

Musculoskeletal Consumer Review Volume 2009:1

Musculoskeletal Consumer Review Volume 2009:1

25

9 Things To Take Pressure Off Your Back

O

ur spine bear a tremendous amount of load day-in, day-out. Here are 9 simply quick things that you can do to lighten the load and why they work.

Pressure Relievers 5. Choose an office chair that offers good back support (preferably with an adjustable backrest, lumbar support, armrests, and wheels) and set up your workspace so you don’t have to do a lot of twisting.

Allows the spine to stay in an optimal position as you work, without having the back muscles constantly supporting you.

6. Try not to overload briefcases or backpacks (see “Lighten your load”).

Reduces loading of the back muscles and disc pressure. As the muscles fatigue, our bodies will adopt a rounded upper back posture to compensate, resulting in poor posture and associated injuries

7. Make frequent stops when driving long distances.

Prevents fatigue mentally and physically to allow some mobility in the spine and stretch out muscles that are placed in the shortened position as we drive

8. While driving, sit back in your seat, and if your seat does not provide sufficient support, place a rolled blanket or some towels behind your lower back. Try to shift your weight occasionally. If you have cruise control, use it when you can. Also consider using a foam seat cushion to absorb some of the vibration.

Allows the back to be in a proper posture.

9. Sleep on your side if you can, and curl your body up a bit, and if possible, with one knee bent and the other straightened. Also, choose a pillow that keeps your head level with your spine; your pillow shouldn’t prop your head up too high or let it droop. Choose a mattress that’s firm enough to support your spine (so that it doesn’t sag into the bed) and that follows your body’s contours.

The spine will be well supported when it is in the neutral position

Occupation-related RSIs Risk Factors Pressure Relievers

Why They Work

1. While standing to perform ordinary tasks like ironing or folding laundry, keep one foot on a small stepstool, shifting between feet occasionally

To reduce the excessive lordorsis (inward curvature of a portion of the spine) that some people may have especially in standing. Particularly those with weak abdominals. The foot on stool will take the pelvis into posterior pelvic tilt, hence reducing the lordosis

2. Don’t sit or stand in the same position for too long. Stretch, move about or take a short walk when you can.

26

Allows the different postural muscles to have a little rest. The spine is made of many vertebrae stacked on top of each other, allowing each segment to move. Therefore, our spine is built for movement and not to be in one position for a prolonged period of time

3. When bending from the waist, always use your hands to support yourself.

Reduces torque on the lower back.

. Because vacuuming can take a toll on your back, tackle rooms in chunks, spending no more than 5 to 10 minutes at a time doing this task.

Offers the back a chance to rest after a period of sustained bending. Muscles can get strained and fatigue, thus compromising the support to the lumbar spine

Musculoskeletal Consumer Review Volume 2009:1

Why They Work

Musculoskeletal Consumer Review Volume 2009:1

It also facilitates the neck to be aligned properly

Weight shifting offers pressure reliefand cruise control allows the foot to rest and not sustained effort on the accelerator Vibrations can cause injury to the back

27

Manual Therapy - Spinal Vertebra Mobilisation

O

ne physiotherapy modality is fast becoming de rigeur in the treatment of referred pain cause by stiff joints is manual therapy. Today, manual therapy is the main stay of modern physiotherapy moving away from the dependency on Electro Therapy Agents such as Ultrasound, Short Wave and TENS as the primary treatment modalities. Referred pain is a very unpleasant sensation localised to an area separate from the site of the causative injury or other painful stimulation. Often, referred pain arises when a nerve is compressed or damaged at or near its origin. In this circumstance, the sensation of pain will generally be felt in the territory that the nerve serves, even though the damage originates elsewhere.

Manual therapy consists of a range of interventions, including hands-on techniques such joint mobilisation. Joint mobilisation is thought to help maintain or improve extensibility and tensile strength of the articular tissues, reduce the effects of mechanical limitations, elongate hypomobile capsular, ligamentous and connective tissue. It also stimulates mechanoreceptors and therefore may be responsible for inhibiting the transmission of nociceptive stimuli and in doing so, reduce pain perception. (Kisner and Colby 2002). In Singapore, there are two common concepts of manual techniques used for spinal mobilisation– the Maitland Concept and the Mulligan Concept.

Maitland Concepts Maitland’s Concepts (often also referred to as the Maitland Technique) involve the application of passive and accessory oscillatory movements to spinal and vertebral joints to treat pain and stiffness of a mechanical nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude. • Grade I is a small amplitude movement performed below the range of resistance and is suitable for treating highly irritable conditions. Use of Grade I enables the slack in collagen to be taken up when connective tissue is not under load and can relieve pain by working on neural structures (Threlkeld). • A Grade II mobilisation is wider in amplitude but still below resistance. Use of Grade I and II are appropriate when palpation elicits pain before restriction of movement.

28

Musculoskeletal Consumer Review Volume 2009:1

• Grade III and IV are used when resistance to movement is encountered before pain. A Grade III is a large amplitude movement performed within resistance and generally used to improve range of motion. • Grade IV is a small amplitude movement performed within resistance used for chronic aches of low irritability. • Grade V is a high velocity thrust used in manipulation. Application of Maitland techniques to the vertebrae is along an anterior-posterior axis or transverse irrespective of the angle of the joint. Peripheral joints are similarly treated with Maitland techniques on planes appropriate to the condition, usually on the plane where there is pain or restriction. These may be anteriorposterior, transverse or longitudinal.

Mulligan’s Concept Maitland argues that the comparable pain response “is nearly always found with the unphysiological movement rather than the physiological movement”. Conversely, Brian Mulligan applies movement in sympathy with physiological movement. Mulligan is guided towards restoration of correct physiological tracking by the absence of pain. His techniques are designed to deal with problems of restricted or painful movement but are not highly irritable. These techniques are therefore used for conditions that are not acute when the biomechanics of the joint may be altered without inducing pain. The appropriateness of the technique is judged against Maitland’s criteria of severity, irritation and nature of the condition. Mulligan does not prescribe grades of movement or oscillatory movements. He prescribes taking the joint through its full range of movement and this entails taking it into resistance. The physiotherapist superimposes an accessory movement onto the patient’s active physiological

movement with the aim of over-riding the obstruction and re-establishing correct alignment. The accessory movement takes the joint through what would be the normal physiological movement of the joint. The preinjury joint tracking is re-established reasserting the ‘joint memory’ or prior conditioning of the healthy joint. Mulligan’s principle techniques are NAGS, SNAGS and MWMs. NAGS are Natural Apophyseal accessory Glides applied to the cervical spine with the patient passive. SNAGS are Sustained Natural Apophyseal accessory Glides whereby the patient attempts to actively move a painful or stiff joint through its range of motion whilst the therapist overlays an accessory glide parallel with the treatment plane. MWMs are Mobilisations With Movement and are applied to the peripheral joints. The underlying principle to MWMs is derived from Kaltenborn (1989 in Exelby 1995) who argued that joint surfaces are not fully congruent, physiological movements are a combination of rotation and glide, and glide is essential to pain free movement. Glide occurs in the direction of bone lever movement where its articulating surface is concave and in the opposite direction when convex. The treatment plane lies at a ninety-degree angle to the concave articulating surface of the bone and treatment is applied parallel to the treatment plane. The anterior-posterior and posterior-anterior movements used in Maitland’s techniques follow the same planes in peripheral joints. However, in treating the spine Maitland will follow the planes of the intervertebral body joints whilst Mulligan techniques follow the plane of the zygapophyseal joints. Exelby argues that the zygapopheseal joints guide the spine and so improving their glide by applying NAGs and SNAGs will improve the range of spinal movement. Applying treatment on the plane of the intervertebral body joints results in compression on the zygapopheseal joints and will not promote glide.

Musculoskeletal Consumer Review Volume 2009:1

29

Shoulder and Knee Rehabilitation Specialists www.Back2Sportsr.com.sg