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Pinner And Harrow Mobile Osteopaths
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Headaches

Tension Type Headache

Tension type headaches are the most common type of headache, being episodic, gripping/vice like, non pulsating, mild to moderate intensity pain, which are usually bilateral (both sides), and band like. They are initially experienced in the frontal (forehead) or occipital (lower back of skull) regions of the head. Tension Type Headaches are not aggravated by normal daily exercise, and often respond to over the counter analgesics (pain killers). On occasion, photophobia (severe sensitivity to light), or phonophobia (fear of loud sounds), may be present. In chronic cases headache will be more frequent, may be constant, and mild nausea (involuntary inclination to vomit) may be present.

The exact cause of tension type headaches is unknown, although there are known associations with tender contracted muscle, and emotional, or social, stressors. Manual therapy will address the musculoskeletal system of the head, neck, and back. There will also be an aim to identify any additional factors which may influence the symptoms present, e.g. posture. Identifying emotional stressors, e.g. work related or looking after children, may help someone suffering tension type headaches make changes aimed at reducing stress levels, therefore reducing the intensity/frequency of headaches suffered. Exercise, yoga, and relaxation techniques may also be beneficial, and advised.
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Workstation Ergonomics


Poor workstation ergonomics and laptop use can result in compromises to your posture, resulting in neck and back pain, as well as increased risk of suffering from Repetitive Strain Injury or similar.


General workstation advice-

sit back into your chair, making use of the lumbar support if you have one. Your elbows should be at a 90 degree angle, with your forearms horizontal to your desk. Avoid pressure on the back of your legs from your chair, allow enough space under your desk for your legs to move comfortably, and use a footrest if needed.

-if you are a touch typist, adjust your chair height so that your eyes are level with the top of your computer screen. Document holders should be next to the screen.

-typists who need to look at the keyboard may find it better to have the monitor slightly lower, so minimising the need for head movement between the two. Document holders should be between screen and keyboard.

-when using your mouse, do so with a straight wrist, and have it in a position where you do not have to stretch to use it.

-avoid glare on your computer screen.

-have frequent, regular breaks away from your workstation (5 minutes every hour), allowing you to move freely and take your eyes off your computer screen. 

If you suffer from RSI, including carpal tunnel syndrome and lateral epicondylitis (tennis elbow), you may consider that it is worthwhile using a vertical mouse, the aim of which is to hold the hand in a more anatomically neutral position. 


When using a laptop, or similar, for long periods of time, there are additional ergonomic considerations, especially if you do not have the ability to make a workstation around your laptop. This may be the case, for example, if you are working on a train, or you move your laptop between rooms of your house. Sustained laptop use can result in compromising your neck, shoulder girdle, and spine, with an increased possibility of suffering headaches.  Maintaining a head position in front of the bodies natural center of gravity, for example, increases the amount of work the muscles of the back of your neck and back need to perform, so compromising them. Due to the small nature of laptop keyboards there is an increased risk of RSI with using them. If possible, a separate (or ergonomic) keyboard, and mouse should be used, in combination with raising the laptop so that the screen is at an appropriate height. Alternatively, a separate screen which can be raised to an appropriate level, should be considered. This also being the case if the laptop has a small screen, so preventing eye strain, or any postural changes which may result from needing to see the screen effectively. 


Simple office and workstation based exercises

1-keeping your back upright, and your hands linked behind your head, gradually bend your head forward, so stretching the muscles at the back of your neck. Hold for 20 seconds

2-with your left forearm on the top of your head, place the palm of your left hand just above your right ear. Gently pull so that you bend your neck to the left, so stretching the right side of your neck. Hold for 20 seconds and repeat on the opposite side

3-stand side on to a wall with one straight arm placed palm onto the wall at shoulder height. Keeping your feet flat on the floor, stretch your opposite arm over your head towards the wall, so stretching the opposite side of your body. Hold for 20 seconds and repeat on the other side

4-with your hands clasped behind your back, push your shoulders back, so expanding and stretching your chest. Hold for 20 seconds

5-straighten one arm in front of you palm down. With your other arm flex your wrist, so stretching your forearm muscles. Hold for 20 seconds and repeat on the opposite side

6-with your palms together in front of you in the 'prayer' position, push your hands downwards so that you feel a stretch on the underside of your forearm. Hold for 20 seconds

7-fan your straightened fingers apart, so stretching the palms of your hands. Hold for 20 seconds

8-seated on a stable chair cross your right thigh over your left and rotate your body to the right, so stretching your lower back. Hold for 20 seconds and repeat on the opposite side
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Osteoporosis-reducing the risk

Living bone is continually, formed, remodeled, and reabsorbed during life, responding to the stresses and strains we put on it. Intake of various minerals and vitamins, primarily calcium and vitamin D, are vital for bone health.

Calcium is needed for the rigidity of bone structure. Vitamin D is essential for absorption of calcium in the gut.

Osteoporosis is a progressive disorder, leading to weakening of bones due to a reduction in bone density (osteopenia is a reduction in bone density not severe enough to be classed as osteoporosis). This can lead to spontaneous bone fracture, or an increased risk of fracture due to, for example, falls. While many fractures, e.g. in the spine, are not painful, pain and dull aching may be associated with osteoporosis.

Risk factors for osteoporosis include age, low weight (BMI), early menopause (before age 45), being female, reduced calcium (and phosphorous and magnesium) intake, low vitamin D levels, being a smoker, lack of exercise for extended periods, and familial history of osteoporosis.

Certain medications can be a risk factor for osteoporosis, for example certain chemotherapy drugs for breast and prostate cancer, anti-convulsants, antacids, diuretics and corticosteroid use.

Chronic diseases, for example inflammatory bowel disease, may increase risk of osteoporosis, e.g. in the case of Crohn's disease, due to bowel resection reducing calcium and vitamin D uptake, or prolonged corticosteroid use increasing bone resorption/calcium excretion in urine and reducing the number of cells in the body which bone forms from, so inhibiting it's formation. Coeliac disease results in malabsorption of calcium in the intestines, likely resulting in increased secretion of a hormone (parathyroid hormone) which maintains blood calcium levels (helping maintain blood pH) by increasing bone resorption, so releasing calcium stored in the bone into the blood.  

Osteoporosis is also associated with, although the reasons are not certain, Type I diabetes and Chronic Obstructive Pulmonary Disease.

If osteoporosis is suspected a DEXA scan, which is a form of x-ray, is used to measure bone mineral density (BMD).

Reducing/minimising risk of fracture due to osteoporosis is mainly via diet and lifestyle changes.

Dietary sources of Calcium-
-dairy, e.g. milk and cheese
-leafy green vegetables, e.g. kale, parsley, cabbage, and broccoli
-sesame seeds
-sardines
-tofu 

Dietary sources of Vitamin D-
-fish, e.g. salmon and sardines
-milk (cow's) 
-eggs

In the presence of sunlight vitamin D is also produced in the skin, thus lack of exposure to sunlight may result in low levels of vitamin D.

For patients over the age of 65 where there is concern about risk factors and/or calcium and vitamin D intake, vitamin D, or combined vitamin D/calcium supplements may be prescribed. 

Lifestyle factors are also important with caffeine, alcohol, and smoking increasing the risk of osteoporosis. Therefore reducing intake of alcohol and caffeine, and stopping/reducing smoking can be important in reducing risk.

Weight bearing and resistance exercise will reduce osteoporosis risk, while other exercises concentrating, if need be, on balance and posture will reduce risk of falls with consequential fracture. Other risk factors for falls, e.g. issues with sight/eyes, may be identified and addressed.

Picture-food sources of calcium (source-Brookepinsent)
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Repetitive Strain Injury (RSI) and Lateral and Medial Epicondylitis (Tennis and Golfers Elbow)

There are various types of RSI. These are, as the name suggests, caused by cumulation of repetitive movements which may be large, such as those involved in sports, or small, such as typing, use of a computer mouse, or tool use.

Two of the most common forms of RSI are lateral and medial epicondylitis. Lateral epicondylitis or tennis elbow, does not commonly, despite it's name, result from playing tennis. The majority of cases are among office workers/computer users, or other people who make small repetitive movements, e.g. screwdriver, or other tool, use.

The lateral epicondyle is a bony prominence of the humerus (upper arm bone), and is located, if you stand with your arms at your side with the palms of your hands facing forward, on the outside of your elbow. The muscles which act to extend the wrist and fingers attach, via tendons, to the lateral epicondyle. Degeneration of these tendons can occur, particularly (due to poor blood supply) near the point which they attach to bone. This results in pain in the area of the lateral epicondyle, and, often, forearm, and possibly reduced grip strength. Often there is involvement of the shoulder region, particularly of one of the biceps tendons.

Medial epicondylitis is a similar condition, but with the pain affecting the medial epicondyle on the inside of the elbow, and affecting the muscles which flex the fingers and wrist.

Other forms of RSI include Thoracic Outlet Syndrome (TOS), Carpal Tunnel Syndrome (CTS), various forms of tendinosis (degeneration of a tendon without inflammation), and, less commonly, tendinitis (tendon injury with inflammation).

Picture-Lateral Epicondylitis/Tennis Elbow (source-BruceBlaus)
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Sources of back and neck pain-the Intervertebral disc (IVD)

Anatomy

The bodies of adjacent spinal vertebrae are separated from each other by an intervertebral disc. The disc functions to absorb compression forces (acts as a shock absorber), and allow movement of adjacent vertebrae. 

Each disc comprises a central, gel like, nucleus pulposus, comprising primarily of water, with collagen (structural protein) fibres, as well as hydrophilic (water attracting) proteoglycans. The proteoglycans, acting to draw water into the disc via osmosis, internally pressurise the disc. The nucleus pulposus is surrounded by the annulus fibrosus, consisting of layers of fibres arranged in alternating directions. 

To put it simply, each intervertebral disc consists of a softer gel like region, surrounded by a tough, but flexible, fibrous region. 

The outer fibres of the annulus fibrosus are the only part of the disc to have a nerve supply.

The disc is avascular (does not contain blood vessels), this contributing to the disc’s poor healing properties. Blood vessels which supply the disc terminate in the cartilaginous vertebral end plate located between the disc and vertebral body.

Daily change in disc height occurs, with reduction in height due to sustained compressive loading (greater in heavy, compared to light, manual work), and increase in height following sleep/sustained recumbence. Reduction in disc height results in extra pressure on structures such as facet joints, and reduction in size of the intervertebral foramina (spaces through which nerve roots exit the spine).

The amount of proteoglycans in the nucleus pulposus tend to reduce with age, thus reducing water content of the nucleus, and reducing disc height. This causing similar effects to daily changes, as well as more permanent osteoarthritic changes, for example, to facet joints.

While intervertebral disc injuries can occur anywhere they are present, the most common area is that of the lower lumbar spine, therefore being a common cause of low back pain, and, if a nerve root is affected, giving symptoms in the leg, i.e. sciatica. 
 
Many herniated discs are asymptomatic (without symptoms), this being evidenced by MRI scans showing herniated discs in pain free patients. Just because an MRI scan shows a herniated disc does not mean that it is the cause/source of pain felt.
The four stages of disc degeneration-

-degeneration-age related degenerative changes weaken the outer annulus fibrosus of the disc

-prolapse-deformation of the disc occurs, there may be some impingement on surrounding structures

-extrusion-part of the nucleus pulposus breaks through a tear in the annulus fibrosus

-sequestration-some of the nucleus pulposus which has passed through the tear in the annulus fibrosus separates from the disc and lies in the spinal canal

Picture-vertebrae and herniated disc impinging on nerve root as it exits spine (source-Blausen.com)
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Sources of back and neck pain-facet (apophyseal) joints

While there are major differences in size and shape, the majority of vertebrae in the cervical (neck), thoracic (where the ribs attach), and lumbar (small of back) regions of the spine exhibit broadly the same structure, including facet joints.

While the intervertebral disc functions as part of the weight bearing joints of the spine, facet joints, which are found at the back of each vertebra, articulate directly with the adjacent vertebrae, and act to guide, and limit, range of movement at the various levels of the spine. 

While facet joint injury can occur anywhere the joints are present, the most common area is that of the cervical spine. There may also be reduced range of movement at the injured joint level. The causes of injury are varied, and may be influenced by postural/biomechanical adaptations of the body, e.g. increased lordosis (concavity) in the lumbar, or cervical spine, and/or changes in the spine due to age, e.g. due to reduction in intervertebral disc height, or osteoarthritic changes. Classic injury presentation may, for example, follow sustained looking up while painting a ceiling, or, more often, this is the neck pain patients wake up with following going to sleep without pain.

Picture-vertebrae showing facet joints (source-Blausen.com)
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Sources of low back pain-the Sacroiliac Joint 

The sacroiliac (SI) joints are located below the lumbar (small of back) region of the spine, between the sacrum of the spine, and the ilium of the pelvis. These are large joints, strongly reinforced by various ligaments, which allow a small amount (a few millimeters) of movement. The functions of the SI joint include shock absorption/force transference from the lower limbs (legs) to the body, and vice versa, stability during the push off stage of the gait cycle (walking), as well as allowing widening of the pelvic girdle while giving birth. 

Dysfunction of the SI joints results in their irritation, and may occur from too little, or too much, joint movement. This may be due to repetitive small movements, or a larger traumatic force, such as stepping off a high pavement/step unexpectedly. SI joint dysfunction is common during pregnancy due to the action of hormones on the ligaments which surround the joint, combined with the increased weight of pregnancy. While, generally, patients do not suffer repeated sacroiliac joint dysfunction, there are, for example, biomechanical reasons which may cause this.

Picture-Sacroiliac joint from the back (Source-Blausen.com)
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