"I am a recent mother. And I have been breastfeeding my 3-month old baby daughter. Since about 2 months ago, I have started have neck aches and around my upper back. I think this is related to my breastfeeding posture. Is there anything I can do about it? Thanks in advance! - Melinda Q."

Dear Melinda,

International Breastfeeding Symbol

Some things you can try out:

• Make sure you sit well supported, preferably with a high back chair or using pillows to support behind your back (place pillow vertically).
• A footstool to raise your lap, if your feet is not resting firmly on the floor and the baby is not high enough to feed. 
• Place a pillow or two on your lap to support your baby (so baby lay at chest level), draw your shoulder blades back and keep your chin in as you bring your baby towards you for nursing. Experiment with the placing of pillows to achieve the most comfort. Alternatively,there are several "nursing" pillows on the market that help raise baby to a comfortable height and position. Whatever position you choose to nurse in, make sure you have a good posture and feel comfortable.
• Have frequent short breaks (about 30s) while breastfeeding to stretch your neck.
• Place hot packs around neck and upper back for about 20 minutes each time.  Alternatively, try showering with warm water over the neck and upper back where it is sore. 

If your neck pain does not resolve within 3 months, it is best you seek a women’s health physiotherapist to help assess and manage your pains.

Low back pain is one of the most common reasons for consulting a physician. Despite little supporting scientific evidence, bed rest was considered the primary treatment for low back pain from the late 19th century. What has changed now is how back pain is understood and managed.

How Bed Rest Started as the Recommended Approach for Back Pain

Source: flickr amanky

Their theory of injury leading to an inflammatory response that requires rest to heal the body had a huge influence throughout the field of medicine even though their works revolves around only on inflammation and wounds. Physicians all over the world started to use rest as a treatment for a wide range of conditions, from myocardial infarction to normal childbirth.

TThroughout the 19th century, the orthopaedic principle of rest became dominant. The rationale of rest for back pain started from the idea that pain was due to injury. With injury, inflammation occurs and thus rest was essential for healing. If the primary injury was not properly treated with rest, chronic pain would develop. It was believed that movements, physical activities and repeated back injuries during the inflammatory phase may increase pain and so must be harmful, and thus should be avoided. This thinking was later applied in the treatment of a ruptured disc, where the disc "comes out". The idea was that with bed rest, i.e. lying down, disc pressure is the lowest and the disc will somehow "go back". Unfortunately, there was no scientific evidence back then to support bed rest as treatment. Orthopaedic doctors just followed with what was taught to them, i.e. bed rest. By 1900, a standard orthopaedic text was published and recommended two to six weeks of bed rest for acute back pain.

Doubts Began to Form in Approach to Back Pain

Although some doctors during the 19th century did question the use of bed rest, it was not until the 1980s that its efficacy as a treatment for back pain began to be seriously questioned. However, many then still felt that some rest was necessary, and initial studies only questioned the amount of rest that was needed rather than whether it was needed at all

In 1986, Deyo et al were the first few to investigate the use of bed rest in low back pain. The study compared the functional status and symptoms of a group that received 7 days of bed rest with a second group that received 2 days of bed rest. No difference was found between the two groups in terms of the functional status and symptoms. This later formed the basis for several guidelines that advise no more than 2 days of rest for patients with acute low back pain

Over the years, studies have emerged showing that bed rest of any duration is not effective for low back pain and that it often delays recovery. In fact, other than delayed recovery, prolonged bed rest can also have detrimental effects on the body. Patients with prolonged bed rest may end up with osteoporosis (bone calcium loss), muscle wasting due to muscle protein loss, deep vein thrombosis and undesirable psychological effects

Current Approach to Back Pain

So the question now is, if bed rest has been shown to be detrimental and ineffective in the treatment of low back pain, would early activity be better?

Several studies have looked at the effects of advice to stay active in the treatment of acute low back pain and found that advice to stay active was better or similar to advice to rest in bed. In an update of a 2004 Cochrane Review of trials on bed rest for acute low back pain and sciatica, it was found that for patients with acute pain, advice to rest in bed was less effective in reducing pain and improving an individual’s ability to perform every day activities than advice to stay active. For patients with sciatica, there was little or no difference between advice to rest in bed and advice to stay active.

For chronic back pain sufferers, exercise therapy has been supported by good evidence to reducing time taken to return to work and improving functional status. Patients prescribed with graded exercises have been shown to return to work sooner, have less disability, and have fewer pain complaints than patients treated with medications and bed rest.

No More than Two Days Bed Rest

Given the extensive research done in recent years on back pain and rest, there is rising evidence to point towards avoidance of bed rest for the management of back pain. Advice on early, progressive activity, with no more than 2 days of bed rest, will serve as the current approach to the management of back pain.

References

1. Allan, David B. and Waddell, Gordon(1989). A historical perspective on low back pain and disability, Acta Orthopaedica,60:3,1-23.

2. Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? The New England Journal of Medicine 1986; 315:1064-1070.

3. Gorden Waddell. The Back Pain Revolution, Churchill Livingstone, New York. 1999.

4. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001254.

5. Lindstrom I, Ohlund C, Eek C, et al.Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain: a randomized prospective clinical study with a behavioral therapy approach. Spine 1992; 17:641-652.

6. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavorial approach. Physical Therapy 1992; 72:279-293.

Hi, I am suffering from neck pain. My doctor ordered an x-ray for my neck. He said there are bone spurs but there was no need for surgery. Does that mean i have to live with my neck pain permanently? Will it get worse?" - Peter 

Hi Peter,

Source: Flickr

Many patients have gone for x-rays and been told that they have bone spurs (also known as osteophytes) in their neck or back with the implication that the spurs are the cause of their pain. However, bone spurs are simply just an indication that there is degeneration going on in the spine. They are not necessarily the actual cause of the patient’s pain. Bone spurs are by and large normal findings as one age and are quite common in people over the age of 60. It is important to know what is the actual cause to your neck pain because that will impact your treatment options.

However, if your doctor has determined that the actual cause of your neck pain is from the bone spurs, you can still manage your symptoms effectively and recover from your neck pain through conservative measures without the need for surgery; this is provided that you do not have severe nerve compression resulting in unremitting pain or weakness / motor loss.

Conservative or non-surgical treatment for patients with neck pain arising from bone spurs might include:

• Medication. Anti-inflammatory drugs, muscle relaxants or pain medication.

• Cortisone Injection. Cortisone shots help reduce joint swelling and pain. The effects of these are temporary and may need to be repeated.

• Physiotherapy. Physiotherapy, exercises and joint manipulation help restore flexibility and strength of the neck, improve posture and decrease the compression on the nerves.

In an earlier post, we discussed on what plantar fasciitis is about, including the causes, symptoms and treatment options available. If you think you might be sufferring from plantar fasciitis, read on and find out more about the exercises that you can do to help ease the pain in your foot!

Plantar Fascia Stretch

Pull your toes towards you with your foot pointed up till you feel a slight stretch on the sole of the foot. Do this daily for 3 sets of 10 repetitions holding each stretch for 15 seconds.

Upper Calf Stretch

To stretch the upper calf muscle (gastrocnemius)on the painful side, stand in a stance position with the painful leg behind keeping the knee straight and lunge forward till you feel a gentle stretch on your upper calf. Make sure that your shoulders, hips and knees are pointing front. Do this daily for 3 sets of 10 repetitions holding each stretch for 15 seconds.

Lower Calf Stretch

To stretch the lower calf muscle (soleus)on the painful side, stand in a stance position with the painful leg behind keeping the knee slightly bent and lunge forward till you feel a gentle stretch on your lower calf. Make sure that your shoulders, hips and knees are pointing front. Do this daily for 3 sets of 10 repetitions holding each stretch for 15 seconds.

Intrinsic Foot Muscles Strengthening

Grasp a piece of towel with your toes and slowly try to pick it up. Do this daily for 3 sets of 20 repetitions daily.

Plantar Fascia Stretch

Upper Calf Stretch

Lower Calf Stretch

Intrinsic Foot Muscles Strenthening

 This is a good video following up our earlier article on Arthroscopic Rotator Cuff Repair

Also here is another excellent video on Shoulder Impingment.

Hi,

If given a choice between taking calcium supplements and exercise for osteoporosis, which should I choose? And why? Thanks."  - Rosnah

Dear Rosnah.

click for larger view

Osteoporosis is a condition where the bone become fragile and have a high risk of fracture or being broken. By taking calcium supplements, we hope to optimise our bone density so as to make it stronger. However, it is noted that the effect of the supplements to to reduce the risk of a fracture is low approximately 1.13% to 2.05% depending on the site and the effect do not persist once supplementation stops.

Then, you have the option of exercise to manage osteoporosis. Exercise prevent osteoporosis due to the evidence that it can regulate bone maintenance and stimulate bone formation including the accumulation of mineral. Apart from that, exercise will also help you to strengthen your muscles, improve balance, and thus reducing the overall risk of falls and fractures.

However, effectiveness of exercise to increase bone mineral depends heavily on adequate availability of dietary calcium.This is most notable in ladies who have menopause. Therefore, in my opinion, it would be better if you decide on managing osteoporosis on both front rather than choosing just one form of treatment. This will allow you to ensure that you body have enough amount of calcium for the effect of exercise to utilise them to improve your bone density to its full potential.

Ever wondered how a belly-dancer is able to move and control her hips effortlessly to the rhythm? She will need to have good control of her lower spine, pelvis and its supporting muscles systems, in particular the “myofascial slings".

Stability of Pelvic Girdle / Sacroiliac Joints

The pelvis consist of the sacrum (triangular base of the spine) and 2 iliums and they are connected to one another via the sacroiliac (SI) joints. The SI joints need to be stable for the pelvis to function normally, so that they can act as shock absorbers between the lower limbs and spine, and to act as a proprioceptive feedback mechanism for coordinated movement and control between trunk and lower limbs. The SI joints (pelvic girdle) achieve stability via:

Form Closure: The shape, structure and congruency of the sacroiliac bones and associated sacral ligaments provide the passive stability (i.e. 2 lego pieces fitted together).

Force Closure: External forces exerted by muscle systems, through their attachment into connective tissue (ligaments and fascia), to compress and stabilize the sacroiliac joints and hence the pelvic girdle. Adequate force closure is vital to allow for movement of the sacrum during activities such as, walking, transferring, stair use, and bending.

The combination of form and force closure is known as the “self-bracing” or “self-locking mechanism” of the SI joint. Form and force closure should be balanced. If a person lacks form closure, perhaps because genetics or anatomy, they will require more stability from muscles that assist in force closure. This is where myofascial slings come into play.

Myofascial Slings

The ‘slings’ that provide force closure and stability in the pelvic girdle include the anterior oblique, posterior oblique and the posterior longitudinal slings.

Anterior Oblique Sling

Anterior Oblique Sling includes the pectorals, external and internal obliques and transverse abdominis. When this group of muscles contract, it provides stability by acting like an abdominal binder, compressing the entire pelvic girdle, especially the front, securing the symphysis pubis.

Posterior Oblique Sling

Posterior Oblique Sling includes the latissimus dorsi,the contralateral/ opposite gluteus maximus and biceps femoris. This sling provides stability by simultaneous contraction of the latissimus dorsi and contralateral gluteus maximus. They also act on the sacrotuberous ligaments thereby compressing the SI joint.

Longitudinal Sling includes the deep multifidus muscles (attached to the sacrum), the deep layer of the thoracolumbar fascia and the sacrotuberous ligament via the long head of the biceps femoris muscle. Contraction of the deep multifidus muscle will rotate the sacrum forward thereby increasing the tension of the ligaments surrounding the sacroiliac joints, and ‘lock the joints in”, thus increasing its stability. Also, as with the contraction of the deep multifidus muscles, the tension of the thoracolumbar fascia increases, giving rise to a “pumping up” phenomenon which in turn increases the compression of SI joints.

Failure of any of the myofascial slings to secure pelvic stability can lead to lumbo-pelvic pains and dysfunctions. This is especially apparent in expectant women and women following childbirth in whom posterior pelvic pain (PPP) and symphysis pubis dysfunction (SPD) are common. Athletes involved in high-impact activities who have lumbo-pelvic pains from walking, lunging and landing from jumps, often suffer from dysfunction of these myofascial slings. This is due to overloading of the ligaments of the pelvis and/or lumbo-pelvic junction (including the sacroliliac joints) during activities in which loads have to be transferred between legs and trunk, thereby injuring the lower back and pelvis.

References

1. Liebenson, C.The relationship of the sacroiliac joint, stabilization musculature, and lumbo-pelvic instability Journal of Bodywork and Movement Therapies (2004) 8, 43–45.
2. O’Sullivan, P.B., Beales, D.J., Beetham, J.A., Cripps, J., Graf, F., Lin, I.B., Tucker, B., Avery, A., 2002. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine 27, E1–E8.
3. Pool-Goudzwaard, A., Vleeming, A., Stoeckart, C., Snijders, C.J., Mens, M.A., 1998. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to ‘‘a-specific’’ low back pain. Manual Therapy 3, 12–20.
4. Snijders, C.J., Vleeming, A., Stoeckart, R., 1993. Transfer of lumbosacral load to iliac bones and legs. Part I: biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise. Clinical Biomechanics 8, 285–294.

What is plantar fasciitis?

Plantar fasciitis is a term given for the painful and inflamed flat, fibrous band of tissue (also known as the plantar fascia or plantar aponeurosis) that connects your heel bone to your toes. The fascia acts as a shock absorber and supports the arch of the foot. With plantar fasciitis, there is an excessive strain placed on the fascia. This excessive strain causes tiny tears in the plantar fascia exceeding the body’s capacity to recover, resulting in inflammation. In turn, this causes weakness, irritation, swelling and pain along the plantar fascia, especially in weight-bearing activities.

What causes plantar fasciitis?

Plantar fasciitis is likely to happen with the following:

• 
  Source: http://en.wikipedia.org/wiki/File:PF-PlantarMove.jpg
  Faulty Windlass Mechanism: The windlass mechanism describes how the plantar fascia supports the foot during weight bearing activities. A ‘windlass’ is the tightening of a rope or cable. The plantar fascia simulates a cable attached to the calcaneus (heel bone) and the metatarsophalangeal (toe) joints. Dorsiflexion (foot up towards the shin) during the push-off phase of gait causes the plantar fascia to shorten as the winding of the plantar fascia shortens the distance between the calcaneus (heel bone) and metatarsals helping to elevate the arch. When there are faulty biomechanics in the foot, the effective use of the windlass mechanism is inhibited and this increases the strain on the plantar fascia.
• Excessive foot pronation: Excessive pronation or inward rolling of the foot also inhibits efficient use of the windlass mechanism. This decreases shock absorption through the plantar fascia which in turn increases the tension on the plantar fascia.
• Tight calf muscles: Having tight calf muscles can cause excessive foot pronation contributing to excessive foot mobility which increases the level of stresses on the plantar fascia.
• High arched foot: A high arched foot lacks the normal joint mobility which reduces the foot’s ability to absorb shock from the ground, thereby increasing the stresses on the plantar fascia.
• Ill-fitting or worn out shoes: Wearing ill-fitting or worn out shoes may change the foot biomechanics, causing undue strain on the plantar fascia.
• Excessive walking and running on hard surfaces: This increases the shock transmitted to the plantar fascia, increasing the strain on the plantar fascia.
• Overweight: Being overweight increases the level of stresses applied to the fascia due to the added body weight on the foot, increasing the strain on the plantar fascia.

What are the symptoms?

Source: Flickr

How is plantar fasciitis diagnosed?

Diagnosis of plantar fasciitis can be done by examination of the feet. During examination of the feet, your physician or physiotherapist will observe how your feet are aligned and how they work (i.e. biomechanics of the feet) in standing and in walking. Your physician or physiotherapist will also look out for any high or low arches, and tight calf muscles that may potentially cause plantar fasciitis. The ankle and foot joints will also be examined to identify if there is a lack of or excessive mobility. X-rays of the heel can be also be done to rule out heel spurs (bony growth). Your physician may send you for an ultrasound scan of the fascia to see if there is any thickening and/ or swelling of the fascia in plantar fasciitis.

What are some of the treatment options?

Several conservative treatment options are available for patients with plantar fasciitis and includes the following:

• Rest: Reduce the activities that cause you pain. Minimise walking or running on hard surfaces.
• Ice: Apply ice on the affected region that is swollen, painful for about 15 minutes, 2-3 times daily.
• Anti-inflammatory drugs: Taking anti-inflammatories may help to settle the inflammation and curb the pain. However, you may want to check with your doctor on the kinds to take if you have stomach or respiratory problems.
• Injections: Steroid (cortisone) injections can be given to help reduce inflammation if the pain remains bad despite other measures. It may help to relieve the pain in some people but does not always cure the problem.
• Exercises: Stretch your calves or your plantar fascia and do strengthening exercises for the intrinsic muscles of the foot. It is important to strengthen the intrinsic muscles of the foot so that the longitudinal arches of the foot will be stiffened during gait reducing excessive stresses on the plantar fascia.
• Proper footwear: Wear shoes with thicker, well-cushioned midsoles and heels and those with good arch supports. Avoid old or worn out shoes that may not give a good cushion to the heel.
• Orthotics: Use orthotics to correct biomechanical faults in the foot during weight bearing activities.
• Night splints: A special splint may be worn overnight to keep the calves and plantar fascia slightly stretched preventing tightening up of the plantar fascia overnight.

In cases that do not respond to conservative management, surgical release of the plantar fascia called plantar fasciotomy may be considered. Although the success rate of the procedure is about 70 to 90 percent in patients with plantar fasciitis, there are potential risk factors involved. The risks include nerve injury, infection, rupture of the plantar fascia and failure of any improvement of the condition.

An ankle replacement surgery is where the joints of the ankle are fitted with a prosthesis or an implant to replace the existing worn out joints. It is usually recommended for the elderly and relatively inactive person as one of the major complication from such a surgery is loosening of the ankle joint due to overuse. After the surgery, you will be placed on a cast to protect the joint for a period of 6-12 weeks before you can gradually put weight on it. An ankle replacement can generally last 5 – 10 years depending on the activity level of the patient.

Who will need such a surgery?

An ankle replacement surgery is usually recommended for people with a degenerated or arthritic ankle joint that causes them pain and difficulty in moving the ankle or walking. In a degenerated or arthritic joint, the articulating surfaces are not smooth as compared to a normal joint with cartilages that allow for smooth gliding of joint surfaces over each other. The lack of smooth articulating surfaces in a degenerated or arthritic ankle can be due to either wearing away of cartilages or due to osteophytes (also known as bone spurs). This can cause pain in the ankle especially during movements of the ankle joint and on weight bearing activities like walking. With an ankle replacement surgery, an implant can be fitted into the degenerated or arthritic ankle to allow for smooth gliding of the joint surfaces, permitting pain-free movements to take place.

What happens during the surgery?

Ankle Replacement

What happens after the operation?

After the surgery, you will wake up with your leg in a cast or a splint. A tube may be attached to the ankle to drain off excessive bleeding. You will be taught to walk using crutches without putting weight on the operated foot. Your ankle will also be immobilized in a cast or ankle splint to protect the artificial joint for a period of 6 -12 weeks depending on your surgeon. One of the major complications that may arise from the operation is the loosening of the prosthesis. A typical ankle replacement may last for 5 -10 years depending on the activity level of the patient. In fact, research has shown that the artificial ankle joint has a better lifespan in an older patient than in young active patients. One of the reason is that younger patients tend to be more active than sedentary older patients and hence a higher risk of loosening the joint. In such cases, an ankle fusion may be a better alternative for this group of young patients with heavy and prolong activity requirements. Regular X-rays will be taken after the ankle replacement surgery to ensure that the implant has not moved out of place. Gradually your physiotherapist will improve on your rehabilitation exercises and introduce weight bearing activities on your ankle again.

Reference

• http://www.aetna.com/cpb/medical/data/600_699/0645.html
• Wood and Deakin (2003), Total ankle replacement – The results in 200 ankles. J Bone Joint Surg 2003;85-B: 334-41.

Spasmodic torticollis (ST) is also called cervical dystonia. Dystonia is a neurological movement disorder characterised by involuntary muscle spasms and sustained muscle contractions. Dystonia can affect just one muscle or a group of muscles or all of your muscles. In the case of ST, the muscles in the neck go into involuntary contractions. These sustained muscle contractions result in twisting, turning or tilting of the head and neck, and sometimes jerky head movements. Pain can also accompany the involuntary muscle contractions in the neck.

Although it is said that ST occurs as a result of a dysfunction of the brain, the exact cause to how the nervous system of the brain goes awry remains unknown. ST can resemble other disorders such as Parkinson’s disease, epilepsy, muscular dystrophy and wry neck. In order to exclude these conditions, various diagnostic tools are utilised by the physician. The electromyography (EMG) is used to help assess and diagnose muscle and nerve disorders. It can help to confirm whether the patient is having ST or another condition. A Magnetic resonance imaging (MRI) may be used to rule out ST and identify the presence of tumour or stroke whereas a blood test will reveal the presence of toxins.

ST usually occurs between the ages of 25 to 55 years old, with a higher incidence in women than in men. There also seems to be a genetic link, with 3 percent of patients reporting at least one relative with ST, and 50 percent of patients with a family history of tremors in the hand or head.

The symptoms associated with ST always occur slowly or intermittently, reaching a plateau in 2 to 5 years. The pain that is normally associated with ST is always focused on one place. Frequently, the pain is noted at the side of the neck or at the back of the shoulders.

To date, there is no cure for ST. However, there are a number of treatments that have been shown to provide some relieve. These include botulinum toxin injection, stress reduction techniques and physiotherapy. If all these intervention fail, patients will have two choices of surgical procedures, either deep brain stimulation or denervation surgery. A deep brain surgery is where a thin insulated wire is inserted into the brain via a small hole cut into the skull. This wire will then send electrical pulses to the brain to block the nerve signals that caused your head to twist. On the other hand, a denervation surgery involves cutting the nerves or the muscles that are responsible for the contorted posture associated with ST.