Blog of Philip Bayliss at St Albans Osteopathy

Spinal stenosis

Spinal stenosis occurs when the space around the spinal cord narrows – most commonly in the lumbar spine and less so in the cervical spine. As the space narrows and pressure is put on to the cord, the blood and nerve supply are pinched and everything lower down in the body from the level where the stenosis is taking place can be affected.

The narrowing can be due to osteoarthritic changes where your body starts developing new bone, particularly around the facet joints at the back of the spine, to try and support the spine. This bony growth can cause encroachment within the central spinal canal or the foramina on either side of the spine where the nerves exit to supply the arms or the legs. The ligaments can also thicken which may increase the encroachment. A much less common cause is when there is vertebral collapse.

Patients with spinal stenosis usually present with back or leg pain (of one or both legs) which is often worsened when the patient walks beyond a certain distance and eased with rest. The patient may describe a feeling of tiredness, cramping or numbness in the legs which relieves when the patient rests and draws their legs up to their chest and takes the pressure off the spinal cord or nerve roots.

Spinal stenosis is most common in the those over 50 with spinal osteoarthritis and degenerative changes, however it can occur as a result of other conditions including:
• Paget’s disease
• Ankylosing spondylitis
• Hyperparathyroidism
• Congenital reasons

For those with spinal stenosis, it is most important to be aware that, in the worst case, the pressure on the spinal cord or nerve roots can be a medical surgical emergency. This is when the cauda equina (the amalgamation of nerves at the base of the spine) is compressed. If left untreated, the patient may experience loss of bowel or bladder control and weakness or paralysis of both legs. It is therefore vital to ensure that spinal stenosis is diagnosed and treated as early as possible.
Osteopathy, often in conjunction with acupuncture or dry needling as appropriate, can be a very effective treatment for this often painful condition although it has to be appreciated that the clock cannot be turned back. As spinal stenosis is usually a chronic condition which has taken years to develop, it can take quite a bit of time to really reduce the symptoms. That said, Osteopathy can often prevent a worsening of the spinal stenosis and vastly reduce the need for surgical intervention.

January 9th 2019

Stress management and Osteopathy

We all get stressed at some, or many, points in our lives. Have a look at these 20 tips for managing stress when it hits:

• Be active – gentle cycling, swimming, walking, gardening or any other exercise works wonders
• Breathe deeply - expanding your lower rather than upper rib cage when breathing in
• Get plenty of sleep. Be aware of when you are tired and take steps to refresh yourself
• Eat sensibly – fresh fruit and vegetables, wholemeal bread and pasta and cut down on fat and sugary foods
• Take time to relax daily
• Talk to someone you trust
• Remember to accept what you cannot change
• Avoid self-medication – cigarettes, alcohol and coffee
• Take time to play
• Do one job at a time
• Agree with someone for a change
• Look at how you manage your time and set a timetable – do not overload it
• Do something for others
• Accept when you are sick and do not pretend that you feel fine
• Remember that the answer lies with you
• Delegate to colleagues, family and friends rather than trying to do everything yourself
• Develop an absorbing hobby
• Don’t be afraid to say ‘NO’
• Be realistic about perfection and what you can achieve
• Recognise that you are a person with worth – just as you are

These 20 tips for stress management should be tempered with the fact that it is sometimes difficult or impossible to remove a stressor from your life. It is important to remember that one of the tenets of Osteopathy is that the mind and body are interdependent and that the stress ‘fight-or-flight’ response of the body often directly results in negative emotions and vice versa. Osteopathic treatment of the body to relax the muscles and ease breathing can encourage a return to optimism and health and ease the stressful symptoms and emotions. Specifically, gently stretching of the ribs and releasing restrictions in the thoracic spine with massage, articulation and thrusting (as appropriate) can alleviate the restrictions and tension you experience when you are stressed and improve your sense of well-being.

January 8th 2019

Referred pain

A hugely common question asked of Osteopaths is…”What is referred pain?”. Referred pain is a strange term which relates to pain felt in an area which is not the actual location producing the problem - the origin of the pain.

It is caused by the network of interconnecting sensory nerves which converge in the spinal cord effectively getting confused and linking areas which are supplied by the same nerves resulting in pain and other symptoms. A good example is headaches, in which pain caused by problems in the joints and muscles of the neck or jaw lead to referred pain in the base of the skull and in many areas over the head, forehead, around the eyes or into the temple areas.

Another perhaps stranger example is called viscero-somatic pain referral. The viscera are the internal organs of the body and the soma is, essentially, the musculo-skeletal part of the body. One of the most common pain referral patterns occur during a heart attack where nerves from the heart convey pain to the spinal cord of the upper back (T1 - 4 vertebral levels). As these levels also supply sensation to the left arm, left side of the chest and, less frequently, up towards the left shoulder and neck people can experience pain, tingling and numbness in these areas when having a heart attack. The brain is not used to receiving such strong signals from the heart and perceives them to be originating from the left arm and chest. (Please be assured that left arm and chest pain does not always mean you are having a heart attack - likelihood is that the pain will be of musculo-skeletal origin. Do seek medical attention if you are in doubt). A similar referral pattern can happen between the gall bladder and the right shoulder as an inflamed and irritated gall bladder can prompt a pain impulse in the diaphragm (the domed respiratory muscle under your ribs) which has a nerve supply from the same level as the right shoulder.

In all cases, referred pain is often felt as quite a diffuse, dull ache which is difficult to locate and may vary in severity. For example, clear sciatic nerve impingement (originating from the lower back or tension in certain muscles in the buttocks) often creates pain or sensory symptoms like tingling or numbness as a fairly clear line down the back of the leg possibly past the back of the knee towards the calf and ankle. Referred pain, say from the lumbo-sacral joint at the base of the spine, may cause only diffuse achy pain in random locations in the buttocks and into the back of the thigh and possibly calf. Local assessment of the thigh muscle may result in no abnormal findings however if the symptoms have been prolonged, the patient may experience tenderness, tightness or weakness in the back of the thigh.

A thorough examination by the Osteopath will establish whether the symptoms you are experiencing are referred or local to the site where the pain is being experienced. Further investigations may be required to achieve this diagnosis but often simply examining and assessing is sufficient and treatment results in a great improvement.

January 7th 2019

Fitness training - tips to avoid in injury

Many people start a fitness campaign with gusto at the start of the new year. This is great, however injuries often occur when there is a sudden rather than paced increase in duration, intensity or frequency of their activities. Many soft-tissue injuries can be avoided through proper conditioning, training and equipment. Other tips include:

·  Balanced fitness - develop a programme that includes cardiovascular exercise (at least 3 x 30 minutes of activity which increases your heart rate per week), strength training (particularly important as you get older) and flexibility (a yoga or Pilates class or session at least once a week).

·  Don’t do too much too fast - add new activities and exercises carefully whether you have been sedentary or very active and do not try to take on too many new exercises at any one time. Too much of an increase in weight or distance too quickly can set you back severely. Overtraining and not allowing the body adequate rest periods can exhaust the body and set you up for an injury.

·   Use proper equipment - change your trainers as often as every 6 months if you are very active or as they start to show signs of wear. Wear comfortable, loose-fitting clothes which let you move freely and release body heat.

·  Keep hydrated - have a drink at least every 15 minutes or so while you exercise and drink water regularly in your day-to-day life to rehydrate you.

·   Warm up - before your exercise routine, slowly increase from a walk to a jog, spin on a bike or gently mobilise your arms and legs jogging on the spot and revolving your arms. Warming up increases your heart rate and blood flow and loosens up your tendons, ligaments and joints.

·  Cool down - in my view this is more important than warming up and it should be the final part of your exercise routine. As your muscles cool immediately after cardiovascular exercise (even sports like swimming), stretching is vital to prevent them from shortening and tightening. Slow your movement or activity down in the last 5 minutes before you stop and then begin stretching slowly and carefully until you reach the point of muscle tension. Hold each stretch for 10 to 20 seconds and then slowly release ideally repeating 2 or 3 times for each muscle group. Don’t bounce the stretch. For example, if you have been running or cycling, make sure you stretch all the leg (calves, hamstrings, quads), buttock and low back muscles and include rotational stretches of the back. Stretching after all exercise will not only avoid short term injury but will also prevent injury in the future.

·   Rest - schedule regular days off from vigorous exercise and rest when tired.

·   Don’t just exercise at the weekend - try to get at least 30 minutes of moderate exercise every day, breaking it up into 10 minute chunks if you are pushed for time.

January 6th 2019

Osteopathic management of patients during pregnancy

I regularly treat pregnant women with a variety of symptoms ranging from low to mid back pain to pelvic girdle pain (including sacro-iliac and/or pubic symphysis dysfunction), rib pain, sciatica and general discomfort - particularly later in the pregnancy as the baby grows bigger. Having carefully established the diagnosis once I have taken the case history and examined, I use a number of different treatment techniques including soft-tissue massage, joint articulation, muscle energy techniques and manipulation as appropriate to ease the patients symptoms.

So it’s interesting to read The UK National Council for Osteopathic for Osteopathic Research (NCOR) report from 2012 which discussed the Osteopathic management of patients during pregnancy. The key findings were as follows:

Symptoms
• One of the most frequently cited symptoms of pregnancy seen by osteopaths is low back pain.
• Other symptoms include heartburn (for which there is acknowledgement of osteopathic treatment but currently little evidence), carpal tunnel syndrome, sacroiliac pain, mid thoracic pain and gastrointestinal symptoms.
• Differential diagnosis for carpal tunnel syndrome should include diabetes and thyroid disease.

Osteopathic Studies
• One study has found evidence that pregnant patients who received osteopathic care experienced improved outcomes in labour and delivery compared to those who didn’t.
• Another study has shown that osteopathic manipulative technique may help to improve or stop the deterioration of back-specific functioning in the third trimester of pregnancy.
• Non-supine positions during labour and delivery have been found to have clinical advantages including increased perineal integrity, reduced vulvar oedema and reduced blood loss.

Relaxin (the hormone which relaxes joints in the mother’s body ready for birth)
• It is still not established if higher levels of relaxin relate to a higher incidence of pelvic girdle pain in pregnancy; more studies have shown that there is no positive relationship.
• There is still a large gap of evidence in this subject area.

January 5th 2019

Knee pain

The knee is the largest and most complicated joint in the body which consists of many structures which, if damaged by anything from an acute traumatic event to general wear and tear over time, can require quite a bit of rehabilitation to correct.

Here are some of the more common knee problems:

• Osteoarthritis – essentially this is wear and tear of the knee which can be treated effectively, especially if the treatment is started early. You may find that your knee is aching or painful after certain activities such as climbing stairs with stiffness present particularly in the mornings or after rest. Pain may be experienced within the joint, all around it or in one place. There are many causes for osteoarthritis of the knee including pelvic torsion that results in more pressure being put onto one knee than the other or it may be due to secondary to osteoarthritis of the spine.
• Referred pain – knee pain may be referred from compression of the nerves supplying the knee at various levels down their course to the knee from the low back. It may also be referred from trigger points in muscles further up or down the leg.
• Biomechanical issues - such as kneecap lateral tracking (moving towards the outside) occur as a result of many issues including dropping of the foot arches, knock knees, lack of tone of the quad muscles nearer the inside of the leg(s), leg length differences or pelvic torsions.
• Chondromalacia patella - is related to the above issue where the underside of the knee cap becomes irritated as it passes along the groove at the base of the femur (thigh bone) often due to mal-tracking. Going up stairs or deep knees bends can be painful.
• Bursa inflammation – Bursa are like tyres filled with viscous fluid-like material which act as pads between muscles, tendons and bones around the knee. These can become irritated and inflamed, most commonly causing pain just above or below the kneecap.
• Children - Osgood Schlatter’s disease, where the quadriceps muscle at the front of the thigh pulls at the surface of the bone where its tendon attaches just below the knee. This often results in a painful, visible lump. Never ignore persistent knee pain in a child as there are serious diseases which need to be excluded.
• Sports injuries
Cruciate ligament tears/collateral ligament tears – the cruciate ligaments are found within the knee joint. Tears can occur when excessive force is applied to the knee joint with the anterior cruciate being affected the most often. Other structures such as the joint capsule and the collateral ligaments on the inside and outside of the knee are also commonly damaged. If there is a major tear there will be sudden and painful swelling in the knee at time of injury and the knee will feel unstable.
Meniscal/cartilage tears – the meniscus/cartilage is found lining the ends of the tibia and femur (shin and thigh bones that meet in the knee). Damage often occurs to these structures when the knee is over-rotated.

My job as an Osteopath is to assess the joints and muscles of the knee, hips, back and feet holistically focusing on everything so that the cause of your knee pain can be determined. The problem will then be treated with soft tissue massage, articulation, stretching and manipulation as appropriate. Advice may also be given on effective exercises and hydrotherapy (hot and cold packs) and medication. If need be, you will be referred for further medical assessment.

January 4th 2019

Workstation set-up

Quite a number of my desk-working patients are presenting to me with back, neck and other problems such as tennis elbow because they are spending hours at a workstation which is not properly set up for them.   Here are some key factors to consider to ensure that your workstation is helping and not hindering your mental and physical well-being:

Chair

    • Ensure that your hips are higher than your knees your feet are flat on the floor or foot rest.  Adjust your desk height if possible rather than adjusting your chair height to suit a lower desk height.   Use a foot rest if your feet are not able to touch the ground.
    •  Seat depth - you need to be able to sit back in the chair to get enough support from the back rest but there should be about a fist’s width between the back of your knee and front of the seat. Consider using a pillow, cushion or lumbar support behind your lower back if your thigh length is not long enough.
    •  Seat tilt -  can be used to ensure that your hips are slightly higher or level with your knees (you are aiming for a 90 to 120 degree angle at the hip).
    •  Arm rest - ideally you have adjustable arm rests which do not stop you from drawing your chair close to your desk (you are better removing them if they get in the way).  They should be supporting the elbows while the shoulders are relaxed.

Desk height

    • Ideally you can use an electronically (or peg or screw system) adjustable desk to prevent it being too high or too low for you.  Desk raisers can be obtained to increase your desk height.
    •  Your elbows should be level with or very slightly higher with the desk top when they are at a right angle and your shoulders are relaxed.  

Monitor

    • The monitor should directly in front of you at arm’s length and at a height where the top is at eyebrow level. Avoid twisting to see your monitor.  Position it at 90 degrees to any light source to avoid glare.
    •  If you are using a laptop, consider piling the laptop on to a pile of books (or use a laptop raiser) so that the screen top is at eyebrow level and buy a separate bluetooth or attachable keyboard and mouse.  These changes should prevent neck, back and arm or hand problems.
    • Copyholder - if you are referring to paperwork a lot while using a computer, consider using a copyholder attached to the side of your monitor to avoid long periods of neck flexion.

Keyboard and mouse

    • Ensure that your upper arm and elbow are close to your body, your arm is bent at approximately a 90 degree angle at the elbow, the forearm parallel to the desk and you are as relaxed as possible.  
    • Avoid over-reaching for the mouse and keep the wrist as straight as possible when using it or the keyboard.  You could consider buying a gel wrist rest to help achieve this position.

Telephone

    • Consider buying a headset if you use the phone a lot and avoid cradling the phone between your head and shoulder.  

Also…

    • Remember to sit tall and try not to slouch
    • Take regular breaks from your desk every 35 to 40 minutes to avoid postural fatigue (where the muscles become tired and sore from lack of movement)

January 3rd 2019

Sports injuries of the shoulder

Patients often present with problems in the shoulder area that start with microscopic muscle tears and strains as a response to heavy exercise and, as the person continues to exercise without leaving enough time for the body to deal with these strains, the passing aches a few days after a workout worsen to become regularly painful. They haven’t left enough time for recovery.

This cumulative injury commonly occurs in the shoulder as, unlike the hip joint for example which is very congruent with the ball and socket fitting tightly together, it is all about the muscular balance. Often the rotator cuff and other muscles connecting the arm to the main part of the body via the shoulder become unbalanced and muscles like the biceps overwork to try and compensate for weakness and instability. The tendon of one of the heads of the biceps passes through a narrow groove at the top of the shoulder (the bicipital groove). This tendon becomes inflamed and sore as the person trains more and fails to rest sufficiently. If any area continues to be inflamed, tissue repair is inhibited and damage may occur.

In the case of bodybuilders, what starts at a little niggle in the upper arm indicating that the biceps tendon might be being compromised, progresses steadily to be a debilitating injury which requires rest. For any serious bodybuilder or athlete, these enforced rests can be a major handicap to progress however if the person continues stressing the shoulder, they may be forced to stop training completely. It’s therefore better to seek treatment at the niggle stage rather than wait until the shoulder is regularly painful. If their shoulder does become persistently painful and sore, they should also avoid the exercises below - especially if they involve using the body as resistance. They should go for increased repetitions with lighter weights. The lighter style of training will flush blood through the area promoting recovery and, at the same time, enable the trainer to hold on to the hard-gained muscle. In addition, they should apply ice to the top of the arm / front of the shoulder area to reduce the swelling and inflammation in the area - particularly after training.

The specific exercises in bodybuilding that make people more prone to these kinds of injuries are: parallel bar dips, close grip bench press, shoulder press to the front, incline dumbbell curls, chest pullover across bench and chin and flat bench flying (particularly when going to low).

January 2nd 2019

Cranial Osteopathy - treating babies

There are a number of reasons why parents bring their babies to a Cranial Osteopath like :
• Delivery types - babies delivered using forceps or ventouse can cause tension in a baby’s head which can result in a cone head or even bruising from the forceps. Babies can show their discomfort by crying particularly when their head is being touched or when they are laid down on their backs or have clothes or hats put on them. Cranial Osteopaths can identify and release these tension patterns.
• Breast feeding issues - if there is tension in the jaw joints or other bones of the baby’s head, neck or whole body which are involved in their latch and suckling then their feeding can be difficult and they can take in air and be have colicky symptoms. Also, quite often an intense or difficult birth can lead to the baby finding it difficult to find a comfortable position to feed. Often babies prefer to turn their heads to the right rather than the left to feed. In all these cases, Cranial Osteopathy can help release these tensions and help with breastfeeding - enabling you to feed the baby longer if you wish to do so.
• They won’t stop sucking - babies who constantly suck, cluster feed or snack can result in mothers giving up breastfeeding as they are exhausted and in pain. They are often not doing so because they are hungry but because, firstly, the sucking motion is calming to them and releases pain relieving chemicals and, secondly, sucking actually relieves the tension in their head (possibly caused by a traumatic or forceps or ventouse delivery). Treatment can help ease these tensions, calm the baby and the sucking reduces so that they only eat when they are hungry.
• Babies needing to be held continually or swaddled - often these babies have had a shocking or surprise delivery. Babies who have experienced a C-section, a fast delivery or some sort of stress around or just before delivery can be in a state of stress or anxiety which manifests in wanting to be constantly held, being very light sleepers or being jumpy or needing swaddling. The gentle nature of Cranial Osteopathy can ease this anxiety and lower the tone of the nervous system.
• The stiff arching back baby - also noted for their ‘strong’ neck although their necks are not strong they’re stiff. These babies arch a lot and throw themselves backwards. In this case, the delivery has usually been quite long and they may have got stuck low down or engaged for a long time prior to delivery. This long duration of compression leaves them upset and cranky and they struggle to sleep or don’t like lying on their backs. Again, Cranial Osteopathy can help relax and calm them by releasing the compressive tension and relaxing the ‘wired’ nervous system.
• Curled up ‘little frog’ baby - these babies usually have their knees curled up so they are like a little ball. Often these babies have had a surprise like a C-section or a fast birth and therefore haven’t had their bodies stretched out properly as they travelled through the birth canal. This curled knees up position can result in windy, colicky and reflux problems all of which can be relieved with treatment.
A check-up anytime from about 4 weeks after delivery really helps to minimise these problems and ensures that the baby’s alignment is correct and their nervous systems are calmed and unwound.

January 1st 2019

Exercise therapy in the management of hip and knee Osteoarthritis

The National Council for Osteopathic Research have provided a snapshot summary (2017) of key Osteopathic and Osteopathically relevant literature on the subject of Exercise therapy in the management of hip and knee Osteoarthritis (OA). OA is a very common condition affecting over 8.5 million people over the age of 45 in the UK. It is effectively ‘wear and tear’ where the cartilage within the joints of the body starts to wear away and various other changes take place within the joint. The muscles around the joint start to tighten and stiffen resulting in symptoms including gradually developing pain aggravated or triggered by activity, stiffness lasting under 30 min on awakening and after inactivity and occasional joint swelling. Management of OA is divided into three areas: pharmacological; non-pharmacological; and surgical. Appropriate exercise or physical activity is recommended in all patient groups, irrespective of demographics, severity of the condition, and pain levels experienced.

Although it may seem sometimes counter-intuitive, there is strong evidence that exercise reduces OA pain and improves physical function. The 2014 NICE guidelines for the care and management of osteoarthritis in adults suggest that exercise is appropriate for all sufferers of osteoarthritis, irrespective of age, comorbidity, and pain levels. They also recommend a mix of aerobic and strength exercises, and that the patient be encouraged to carry out the exercise themselves.

The main findings of the report were as follows:

• There is strong evidence suggesting that exercise in general can help patients manage the pain of hip and knee osteoarthritis (OA).
• The benefits of exercise on pain levels continue after the intervention period, with some patients reporting a reduction in pain for between 3 - 18 months after cessation.
• Appropriate exercise can be prescribed irrespective of age, pain level, comorbidity and disability. Catering to the patient’s specific needs and circumstances may improve adherence, which is important for improvements in outcomes.
• Exercises in group or individual settings are equally effective, so patient preference should drive this decision.
• There is no evidence to suggest that one type of exercise (aerobic, strength, or range of motion) is superior to another. Management plans often combine these approaches in an attempt to improve effectiveness.
• There is some evidence that specifically strengthening the muscles of the leg through resistance exercises will reduce pain in sufferers of knee OA.
• Effectiveness of specific exercises, dosage, frequencies and intensities are unclear due to a lack of both quality and quantity of data.

January 1st 2019

Holiday Dates

Monday 24th December: open

Tuesday 25th December (public holiday): closed

Wednesday 26th December (public holiday): emergency appointments may be available. These can only be booked by phone (03 356 1353) after 8.00am, on the same day.

Thursday 27th December: open

Friday 28th December: open

Saturday 29th December: closed

Sunday 30th December: closed

Monday 31st December: closed

Tuesday 1st January (public holiday): closed

Wednesday 2nd January (public holiday): emergency appointments may be available. These can only be booked by phone (03 356 1353) after 8.00am, on the same day.

Thursday 3rd January: open

Friday 4th January: open

Saturday 5th January: emergency appointments may be available. These can only be booked by phone (03 356 1353) after 8.00am, on the same day.

Sunday 6th  January: closed

Monday 7th January: open

Tuesday 8th January: open

Wednesday 9th January: open

Thursday 10th January to Sunday 20th January: closed

Week beginning Monday 21st January: normal hours

December 24th 2018

 

Philip Bayliss, Registered Osteopath, 43 Thames Street, St Albans, Christchurch, NZ. ☎️03 356 1353