Do you stand or walk like a limbo rocker? If yes, you may have sway back. Apart from slouching, sway back is another common bad posture that leads to back pain. Like most posture problems, it is easily correctable by treating and preventing its contributing factors.

What is SWAY BACK?

source: flickr kaliya

What contributes to SWAY BACK?

Typically, sway back posture arise from a combination of these four factors:

1. Weak abdominal muscles
2. Tight hamstrings and back muscles
3. Stiff spine and/or pelvis
4. Ligaments laxity or overstretching of your back and pelvis

One of the basic functions of abdominal muscles is to pull the upper part of the body forward, like when you do sit-ups. When they are weak, they are unable to pull the spine forward enough to a straight or neutral position. As with most bad postures, the back muscles tend to work harder than they should, causing them to tighten up. In this case, the back muscles and hamstrings tigthen up, pulling the back of the legs and upper back towards the buttocks. Overtime, causing the sway back posture to become more pronounced. Sway back is not an optimal posture; the weight borne by the spine is not evenly distributed. Instead, joints and ligaments are strained with additional weight. Strained joints stiffen up up over time. Making it difficult for them to return to their neutral, relaxed position even when no weight is bearing down on them. Ligaments, on the other hand, when strained over time become stretched. When the ligaments are loose, the spinal column becomes ‘loose’ and less stable. Perversely, it makes for sense for the body to return to the sway back position and rest on the joints as it is more stable, although bad in the long run. These four contributing factors that disturb the stability of the spine can cause the lower back to be more susceptible to injuries.

Treatments

Correcting back pains as a result of sway essentially requires us to treat and correct the four contributing factors.

1. Strengthening the abdominal muscles to better support the spine.
2. Release the the tight hamstrings and back muscles muscles either through deep tissue massage or myofascial release.
3. Increasing the flexiblity of the spinal joints with manual therapy techniques such as mobilisation or spinal manipulation to restore normal joint movements.
4. Unfortunately, nothing can be done to ‘un-stretch’ ligaments. Ligaments are very tough tissues that don’t stretch to hold bones together and don’t bounce back when stretched. To compensate for the instablity caused by the loose ligaments, specific spinal muscles have to be trained to better support the spine. These are your postural muscles found deep within the body.

Prevention

Like with most body pains, it would have been better if we never had to fix it in the first place. We can prevent sway back with the four simple tips below.

1. Good posture – Having a good posture by being conscious of your body. Tuck in your chin, stand up tall without slouching, your shoulder should be aligned with the hip to prevent excessive back arching. And lastly. stand evenly on both feet.
2. Abdominal muscles (Rectus Abdominis) strengthening – It is important to start training your Rectus Abdominis muscles to better support your spine, relieving strain off the spinal joints, ligaments and back muscles.It can be done with a simple exercise at home - Lie face up, bend both of your knees and hips on a firm surface. Rock your pelvis towards forward and upward and feel your lower back flattening on the firm surface. Hold in the position for 5 seconds then relax, then repeat this exercise for 3 sets of 10 repetitions.
3. Hamstring stretch – Lie face up. Straighten the knee. Hook a towel around the leg near the ankle and pull the leg gently towards the body. Feel the stretch at the back of the thigh and hold it for 20-30 seconds. Repeat it for 3 sets.
4. Back muscles stretch - Lie face up and with your knees bent. Twist your body to the side and feel the stretch on your back. If you cannot feel the stretch, turn the knees to the opposite side. Hold the stretch for 20-30 seconds. Repeat it on the other side and continue for another 3 sets.

One of the most popular questions we get is, “How do we treat back pain?” Understandably, if you are suffering any sort of pain, anyone would want to know how to get rid of it. But it is not the best first question. A better first question is, “How do we figure what’s causing the pain?

What is the difference?

Back pain like other sorts of pain is only a symptom. It is a sign that something is wrong. It is not a problem in itself. Unfortunately, it is one of a handful of symptoms that we have that is shared by thousands of conditions. We can trace from a specific condition to how it causes pain. But it is not as simple to trace back from pain to the specific condition. It is like watching someone climb up a mountain to the top. We know where they will end up. But just by observing someone standing at the top of the mountain, we cannot determine from which side of the mountain that person came up from. Take for example, some forms of internal organ problems (eg: kidney) cause back pain. If you were just treating the pain at the back without realizing that it is your kidney that’s the cause of it, you can imagine the result if the kidney was left untreated. While at the same time, there are some chest pains that are caused by issues with the muscles at the chest and not the heart.

Solution meets problem

It is only when we have a complete diagnosis, we can then treat. Otherwise, it is pretty much hit-and-miss. This is the reason why you often hear two persons having very different results with the same back pain treatment. That is because they actually have two different problems but share a common symptom – back pain.

Source: SkiNet

How does back pain get diagnosed?

In most cases, back (or neck) pain has its roots in the body’s musculoskeletal system. This system comprises of your bones, joints, ligaments, tendons, muscles, nerves and the nervous system. A competent medical professional will be able to rule out other causes quite quickly and refer to you to the appropriate specialists. If a musculoskeletal specialist determines that the pain might be a result of bone cancer instead of a problem with the musculoskeletal system, the patient will be referred to a cancer specialist. When diagnosing a patient, a musculoskeletal specialist will rely on 4 things:

1. The patient’s history of the pain.
2. A visual observation of the patient movements.
3. Feel of the affected and surrounding areas.
4. Specific movement diagnostic test to confirm or eliminate probable causes.

An example of a movement diagnostic test is the Thomas Test. In a simple example of Snapping Hip, a condition where a popping sound is heard and pain felt when the leg is moved forward or backward at the hip. To determine if it is an Internal Snapping Hip caused by tight iliopsoas, a muscle deep inside the thigh and pelvis or an External Snapping Hip caused by ITB tightness, a taut band running along the outer side of your thigh. The Thomas Test is a movement that helps us isolated a specific muscle; in this case, the iliopsoas to determine if the Snapping Hip condition is arising from the either two possible causes.

What about machine testing?

Diagnostic tests using machines of late have become controversial in some areas of medicine. In some areas like cancer treatments, detecting specific genetic markers have helped medical practitioners to quickly and accurately, pin-point the exact type of cancer; thereby enabling them to prescribe the most appropriate and effective drug. In the past, cancer treatment employed a cocktail of drugs with the hope that one of them works. Even when successful, the patient suffers a range of undesirable side-effects. Today, success rates are much higher with fewer side effects. Unfortunately in the area of musculoskeletal conditions today, the strength of machine testing is also its weakness. Machines such as Magnetic Resonance Imaging (MRIs) are capable to producing a significant amount of information with a great level of precision. If not properly directed, scanning the entire body will produce a tremendous amount of information. Even when scanning a specific part of the body, the direction and angle of the scan matters. That is only possible if we have some idea of what we are looking for; a probable diagnosis. Another thing that confounds the machine’s precision is our body’s amazing ability to adapt and compensate. There are certain types of conditions within our spine that we know cause pain such as bulging or herniated discs. But not all instances of bulging discs cause pain. It may eventually cause pain in the future but for the moment, something else is causing it.

This is a slight departure from our usual articles on musculoskeletal health. But the state of health of your joints, muscles and the ergonomic soundness of your surrounding workplace doesn’t add up to much without access to good fresh air. Watch and listen to Kamal Meattle at TED on 3 simple home & office plants common in Singapore to improve the quality of air in your home and office.

Who is Kamal Meattle?

Kamal Meattle has a vision to reshape commercial building in India using principles of green architecture and sustainable upkeep (including an air-cleaning system that involves massive banks of plants instead of massive banks of HVAC equipment). He started the Paharpur Business Centre and Software Technology Incubator Park (PBC-STIP), in New Delhi, in 1990 to provide "instant office" space to technology companies. PBC-STIP’s website publishes its air quality index every day, and tracks its compliance to the 10 principles of the UN Global Compact, a corporate-citizenship initiative.

Meattle has long been a environmental activist in India. In the 1980s he helped India’s apple industry develop less-wasteful packaging to help save acres of trees. He then began a campaign to help India’s millions of scooter drivers use less oil. His next plan is to develop a larger version of PBC-STIP, making a green office accessible to more businesses in New Delhi and serving as an example of low-cost, low-energy office life.

"He has spent a great deal of time in India and abroad convincing corporate leaders, diplomats, energy ministers, and other government officials that his ideas about sustainability, individual responsibility, and respect for the environment can ensure a healthier future for everyone. ‘Either you are overwhelmed by the fact that there are so many problems and so many people,’ says Meattle, ‘or you find solutions to help in any way you can.’" Kamal Meattle in MIT’s Technology Review

A recent study found that the routine use of radiography (X-ray), MRI, or CT scans in patients with low-back pain but no indication of a serious underlying condition does not improve clinical outcomes. Meaning scans taken without first having an idea that it might be more than just a muscle strain. The study suggests that clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

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Sylvia Ho says, "Given that imaging such as MRI and CT scans are relatively costly and have no significant impact in such cases, it would be wise not take them unnecessarily. Even in cases of X-rays which are now relatively cheap, unnecessary exposure to the radiation should be considered." Sylvia Ho is a Principal Physiotherapist with Core Concepts, a musculoskeletal healthcare group.

Authors of the study added, "Rates of utilisation of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to adhere to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomised controlled trials. Patient expectations and preferences about imaging should also be addressed, because 80% of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging. Educational interventions could be effective for reducing the proportion of patients with low-back pain who believe that routine imaging should be done. We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging."

"You first need to know what you are looking for when ordering a scan. If the scan is not properly directed, it can sometimes miss crucial pieces of information.” says Sylvia Ho.

To further compound the issue on the utility of the use of routine imaging, detailed scans such as MRIs can reveal too much and mislead the clinician on the diagnosis. A report on the New York Times website (8 December 2008), The Pain May Be Real, but the Scan Is Deceiving, as part of their Evidence Gap series provides an excellent read on this issue.

Reference:

1. Imaging strategies for low-back pain: systematic review and meta-analysis, The Lancet, Volume 373, Issue 9662, Pages 463 - 472, 7 February 2009 doi:10.1016/S0140-6736(09)60172-0

2. The Pain May Be Real, but the Scan Is Deceiving (http://www.nytimes.com/2008/12/09/health/09scan.html)

Musculoskeletal Consumer Review caught up with Ms Cheryl Liew-Chng, CEO of LifeWorkz, a management consultancy specializing in Work-Life, Gender and Generations in the Workplace, to discuss about workplace health and the common – and often elusive - challenge of achieving work-life balance, from both the individual and organizational viewpoint.

MCR: What are some of the common challenges that you see with regards to work-life balance?

Ms Liew-Chng: The most common challenge we see is that of PMETs (professionals, managers, executives and technicians) finding themselves swamped and pressured at work, and the stress spilling over into their personal lives, causing relational strain, health issues and emotional issues such as guilt, anxiety and even depression.

MCR: What are some of the things that you can do to help someone with issues of work-life imbalance?

Ms Liew-Chng: The first step would be to understand the trigger that is causing the stress. Often it could be an overbearing boss, factors in the work environment, or worries about getting retrenched. Often it gives you a clue as to the origin of stress, which is not the trigger itself, but an internal conflict. For example, a person may have an unreasonable boss, but what may be really causing him stress is the fact that he does not say ‘no’ to any request the boss makes!

Through our workshops as well as individual coaching sessions, we help individuals to identify their core values, and see what mis-alignment is being caused by the choice they are making in response to the situation. Often, people perceive that they have ‘no choice’ and hence they feel powerless and depleted.

At LifeWorkz, we help individuals understand that they can create their own pathways to success and re-design their life and career to reflect their internal values. Then they are in the position to either negotiate or opt for something that reflects their internal values.

MCR: And how are the results of this process?

Ms Liew-Chng: We see individuals becoming happier and more effective in their multiple life roles – as a worker, a spouse, a parent – which really makes a difference to their loved ones. Often, there is a visible, tangible effect on their marriage and on the their children. They feel fulfilled and liberated, and no longer feel trapped by the inability to balance their lives. When this happens, it is a win-win situation; their employer wins too. When there is alignment between individuals and the organizations for which they work, the individual becomes a happier and more productive employee. That’s the belief that LifeWorkz is founded upon. Besides helping individuals, we see it as our mission to make organizations a better place to work in!

We have seen employers reap the benefits of such alignment – lower attrition rate, better staff engagement and commitment, and ultimately, it shows on the company’s balance sheet and bottomline. In one organization, we saw the attrition rate tumble drastically from 19% to 9%, and this was in the healthcare sector where 24/7 service is the norm and there is zero-tolerance for errors and any slip in standards. The organization won the Employer of the Year award, which was really, in the scheme of things, just the icing on the cake – and a fitting acknowledgement of the work we accomplished by helping them improve their workplace health and work-life balance.

MCR: That’s great. But it seems many other organizations fail to see similar results from their workplace health and work-life efforts. In your opinion, what might be the reason for this?

Ms Liew-Chng: Very often, organizations adopt a programmatic approach to workplace health and work-life balance (‘let’s just implement this scheme’) without actually working within the fabric of the organization to change individuals’ mindsets and the corporate culture.

This can really short-circuit all the good intentions of the management, because without a culture change, people would be afraid to apply for any work-life scheme (thinking that it would back-fire on their career prospects and progression), and managers would very likely penalize these individuals because they are still operating on the old paradigm of ‘face-time’. They appraise workers based on the amount of time they clock in at the office, instead of the results they deliver. Such a culture would defeat any well-intentioned workplace health and wellness efforts, because the odds are stacked against the individual that wants to break free from the stress of work-life imbalance.

MCR: Can you describe what you do to help organisations’ workplace health and work-life efforts succeed?

Ms Liew-Chng: At LifeWorkz, we provide consultation, training as well as implementation expertise in helping organizations transit into a genuine ‘work-life balanced’ organization. The devil is really in the details, so clients tell us that our actual, hands-on implementation know-how is what they appreciate the most, along with our training that ensures a paradigm shift and culture change in their managers and all down the line.

Borrowing medical analogy, I would describe it as such: We do a holistic diagnosis of their corporate workplace health and work-life balance. Once the diagnosis is ascertained, we proceed to customize the prescription and treatment regime, based on the organization’s goal and comfort level – where they want to go, and the measures that they are prepared to take to get there. So there is no one-size-fits-all approach, but we work within the organization’s context – understanding the demands of the industry, and customizing workplace health and work-life approaches to their business model and operations.

Cheryl Liew-Chng

Qualifications   Bachelor of Arts, National University of Singapore Young Managers Programme, INSEAD Masters in Human Resource Development, George Washington University Professional Highlights CEO of LifeWorkz (www.LifeWorkz.org). Certified Work-Life Consultant by Ministry of Manpower, Singapore Speaker at prestigious international platforms such as the Alliance for Work-Life Progress and The Conference Board in USA Quick Facts Cheryl Liew-Chng is a recognized authority on work-life integration, women in the workplace, and the multi-generational organization. With two decades of experience across a wide range of industries, Cheryl is a lively and engaging speaker, and the author of Talents Onboard and co-author of Working Together - two landmark publications on work-life integration.

Musculoskeletal Consumer Review took an opportunity to sit with Dr. Leslie Tay, a Resident Family Doctor from Karri Family Clinic to discuss about the impact of medical information on the internet. Dr. Tay is also a famous Singapore food blogger providing insights into the local hawker’s lives, Singapore’s food culture and trends in the development of Singapore hawker food. His food blog has been featured in various newspapers, including The Straits Times and Lian He Zao Bao.

MCR: With the recent increase in health-related websites, what are your views about health information on the Internet?

Dr Tay: There are a wealth of very good information on the net as well as a lot of nonsense, so the real difficulty is in being able to separate the wheat from the chaff. A lot of my patients get mis-informed rather than informed by the stuff they read on the net.

MCR: What challenges do you see as a healthcare provider, given the large number of health-related websites and the ease with which sites can be updated?

Dr Tay: Well, it is a matter of building a strong doctor - patient relationship. Once there is a relationship of trust, it is usually easy to educate patients. However, there are always some patients who are rather skeptical and would prefer to believe what they read on the internet rather than what their doctor tells them. On the other hand, the internet can sometimes be used to support whatever we tell the patients. We can point patients to helpful websites which can help supplement the information that we give to our patients. So it is imperative for the healthcare provider to be familiar with some of the more reliable sources of medical information on the net and direct our patients to read them instead of other less reliable websites.

MCR: Are you seeing more patients bringing in information on the Internet during their consultation?

Dr Tay: Surprisingly, this doesn’t happen all that often. The most common thing that I usually hear of is that patients say that they read in the forum about certain issues.

MCR: Has there been any incidence of these patients requesting for clinically inappropriate interventions? If yes, what do you think would be an appropriate response to the patients?

Dr Tay: Yes of course. Usually, patients will read the internet and make a self diagnosis and thus request inappropriate investigations or therapy. Again it is a matter of educating and convincing the patient about the condition he is really suffering from.

MCR: In your opinion, for patients who brought in information on the Internet, do you think that it made any difference to the quality of care the patients received?

Dr Tay: I think every patient is different and we need to cater the consultation to the patients’ needs. Patients who bring in information from the internet have a certain mindset and expectations. So they need to have those needs met in order to have a successful consultation. So the onus is really on the practitioner to cater to the needs of his patient.

MCR: What advice would you give to your patients when they come across any health-related websites?

Dr Tay: Well, whatever sounds too good to be true is usually not true. Always treat with suspicion any website that is trying to sell a certain product. Not everyone who places a "DR" in front of his name is a real medical practitioner, so you should always do a quick search on the internet to see his real credentials. And when in doubt, always check with your family doctor.

Dr. Leslie Tay

Qualifications M.B.B.S (Sydney) Graduate Diploma in Family Medicine MBA Professional Highlights Dr Leslie Tay is a practising Resident Family Doctor with Karri Family Clinic. Past work experiences include Raffles Medical Group and the Children’s Emergency Department at KK Women’s and Children’s Hospital. Spent two years in Bangkok and was involved in mission work as a Doctor in the border regions of Thailand. Quick Facts Dr Tay loves food and photography. He combined these two interests and started an online food blog, ieatishootipost.sg, with its own forum with over 800 registered members. Besides food reviews, Dr Tay also provides insights into the hawker’s lives, Singapore’s food culture as well as trends in the development of Singapore Hawker food. His food blog now averages a hit rate of 8000 a day.

What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome refers to a condition whereby blood vessels and/or nerves that pass into the arms from the neck are compressed, due to narrowing of the thoracic outlet which is the space between the collarbone (clavicle) and the first rib. This can lead to pain, tingling or numbness along your neck, shoulder, arm and hand.

What are the causes?

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• Trauma. Traumatic events e.g. car accident causing injury, bony or soft tissue changes to the thoracic area.
• Repetitive activities e.g. those involving repetitive overhead movements, prolonged typing on a computer, and poor lifting techniques can increase strain on tissues in the neck and shoulder to cause compression of the vascular and neural structures in the thoracic outlet.
• Anatomical defects e.g. extra rib from the neck at brith (cervical rib) narrowing the thoracic outlet and increasing the susceptibility of compression.
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  Poor posture. Slouching and drooping shoulders or forward head position can cause increased tension in the side neck muscles and stretching of the nerves, leading to compression in the thoracic outlet.
• Muscle enlargement e.g. increased muscle bulk at the neck and shoulders from weight lifting can increase susceptibility to compression of the thoracic outlet.
• Weight gain. Increased amounts of fat and connective tissue in the neck can increase susceptibility of compression as well.
• Tumors at the top of the lung can impinge and compress on the blood vessels and nerves nearby.

What are the signs and symptoms?

Thoracic outlet syndrome has varying extent of signs and symptoms and can generally be classified into 2 main types based on the strutures involved.

What are the treatment options?

Conservative management may be effective especially when the condition is diagnosed early. It includes the following:

• Physiotherapy where a variety of exercises are given to improve the strength and range of movement of the neck and shoulder muscles and joints. These help to open the thoracic outlet and relieve pressure off the compressed blood vessels and/ or nerves. Posture correction and education on self-management are important as well to promote restoration of function.
• Pain medications, muscle relaxants and anti-inflammatory drugs may be given to help reduce inflammation and encourage muscle relaxation.
• Relaxation techniques e.g. breathing exercises may help to reduce tenison in the neck and shoulder muscles and facilitate good posture.

If symptoms are severe, persistent or worsening or conservative management has failed, surgical intervention involving removal of the first rib may ne required to open the thoracic outlet. Following that, rehabilitation is needed to strengthen the muscles and restore function.

Are there any preventive measures?

Thoracic outlet syndrome may not be preventable in some cases due to inherited anatomical defects and other conditions. However, risks for the development and deterioration of the syndrome can be reduced by:

• Avoiding repetitive or prolonged activities with arms held out or overhead, e.g. overhead stocking of shelves, sleeping with arm above the head.
• Avoiding prolonged typing at the computer; have frequent rest periods.
• Avoiding repetitive carrying of heavy objects; adopt good lifting techniques.
• Improving posture; ensure good ergonomics and correct posture at the neck and shoulders.
• Reducing weight if obese.

These measures help to prevent increased strain and tension on the muscles and connective tissues in the neck and shoulders, hence reducing the susceptibility and degree of compression of blood vessels and nerves in the thoracic outlet. -TSH

References

1. Mayo Clinic. (2008, Nov 8). Diseases and conditions: thoracic outlet syndrome. Retrieved Nov 24, 2008, from www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800
2. MedicineNet. (2008, Feb 20). Thoracic outlet syndrome (TOS). Retrieved Nov 24, 2008, from www.medicinenet.com/thoracic_outlet_syndrome/article.htm
3. Novak C.B. (2003). Thoracic outlet syndrome. Clinics in Plastic Surgery. 30: 175– 188.
4. The National Pain Foundation. (2008, Mar 27). My Treatment: thoracic outlet syndrome. Retrieved Nov 23, 2008, from http://www.nationalpainfoundation.org/MyTreatment/articles/ThoracicOutletSyndrome_Overview.asp

For centuries it has been afflicting man. It is intangible, mysterious and yet ubiquitous. Myofascial Trigger Points are the commonest cause of undiagnosed or misdiagnosed aches, pains and other puzzling symptoms. The daily clinical experience of thousands of physiotherapists, massage therapists and physicians verifies that most back and neck pain and headaches which are recurrent and stubborn are caused by trigger points or muscles knots.

Jane, in her 40s, suffered from recurrent one sided headaches over the eye, behind the ear and on top of the head. On days when she was gripped with a bad attack of pain she felt a spill of pain on her cheek, back molar teeth and the ear. It didn’t help to have occasional ringing in her ears and dizziness which she related to a chronic sinusitis. Given her symptom complex over 2 years she had seen several doctors, had scans, trigeminal nerve tests and medications. She happened to talk to a friend who was getting treated for a neck pain with us and mentioned that she should give physiotherapy a shot for her headaches. On her first visit trigger points in her Sternocleidomastoid muscle were found. She is surprised how although the front of her neck never hurt, when I applied pressure on the trigger points in her neck it spread her pain in the exact location of her headache. Over the next few sessions she excitedly reports that her cheek, teeth and ear pain had disappeared. What is perplexing to her that her sinus symptoms have cleared too!

What makes trigger points fascinating is how they often cause pain far away from the actual site where they exist, i.e. referred pain.

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An example of this far away pain referral is in a patient who presented with carpal tunnel syndrome. However, when examined, the median nerve was not involved. Interestingly the muscle (subscapularis) in the arm pit had a trigger point which was the culprit! Back pain almost always has a myofascial component. Besides the back muscles which can harbor trigger points, surprisingly pain in the low back can be due to trigger points in the stomach, buttock or calf muscles.

Besides musculoskeletal pain, myofascial trigger points can cause toothaches or earaches, e.g.: from muscles in the jaw area.

Some of the other intriguing symptoms caused by trigger points are numbness or hypersensitivity. Autonomic symptoms such as increased perspiration or nasal secretions, hyperemia, nausea and dizziness are also associated with trigger points.

Some of the other intriguing symptoms caused by trigger points are numbness or hypersensitivity. Autonomic symptoms such as increased perspiration or nasal secretions, hyperemia, nausea and dizziness are also associated with trigger points.

So what are trigger points?

A trigger point or a muscle knot as it is often termed is an area of contraction within a muscle. This can be likened to a small patch of spasm in a muscle and is different from the entire muscle being tight. Because of the local contraction the blood flow to the immediate area stops resulting in a restriction of the blood supply (ischemia). This leads to accumulation of metabolic waste products and toxins which sensitize the trigger point causing it to send out pain signals and further increase contraction. Thus the local physiology of a trigger point involves a vicious cycle of a metabolic crisis.

Clinically trigger points can be identified by examining signs, symptoms and by manual palpation. Usually there is a taut band in the affected muscle, and along this band a hard nodule which is the trigger point can be felt. A twitch response is often elicited when pressure is applied followed by a spread of the referred pain. For objective validity of trigger points research has used various tools – EMG, HiRes imaging ultrasound, algometry and tissue biopsy. The recent use of Magnetic resonance elastography (MRE) imaging (which is a modification of MRI) and recovering small molecules in vivo from tissues has provided groundbreaking evidence in the existence, detection and the chemical nature of myofascial trigger points.

How we treat trigger points?

While several methods are available in the treatment of trigger points, e.g.: dry needling, spray and stretch, manual compression is one of the most effective ways to treat trigger points. The therapist palpates the muscle and locates the TrP along the taut band and applies pressure to deactivate the TrP. This is followed by stretching the muscles using various techniques. Current research states that deactivating a TrP can normalize or reset processes in a muscle through gamma motor control; this will stretch an overactive muscle or improve functioning in a poorly functioning muscle.

The crux of treatment is identifying the causes which lead to development of trigger points and correcting them. Faulty postures, bad ergonomics, a structural variation e.g. scoliosis or short leg, overuse and injury are a few. Parallel to releasing the trigger points we change muscle imbalances which stress muscles and create overuse in some. The fascial covering of a muscle is also treated using myofascial release to resolve strain patterns. Unless the treatment is broadened to consider all these factors muscles will simply be returned to positions where trigger points will re-develop.

References:

1. The Trigger Point Therapy Workbook, by Clair Davies and Amber Davies
2. Myofascial Pain and Dysfunction: The Trigger Point Manual by David Simons, Janet Travell, Lois Simons
3. Archives of Physical Medicine and Rehabilitation, 2008
4. New Views of Myofascial Trigger Points: Etiology and Diagnosis, Archives of Physical Medicine and Rehabilitation 2008

Do you have pain on the outer side of your wrist during several activities such as cooking, lifting a bag, and playing music? You might have DeQuervain’s syndrome. Also known as DeQuervain’s tenosynovitis or washerwoman’s hand or mother’s wrist, it is a condition which affects women more commonly.

Pathology

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Symptoms

The primary symptom of DeQuervain’s syndrome is pain at the base of the thumb. The pain may be sudden or gradual. If untreated for a prolonged period it may spread further into the thumb or the forearm. Commonly associated with the pain is a swelling localized to the base of the thumb. There is difficulty in moving the thumb and wrist in movements such as gripping, pinching and lifting. Often, a stiff or a stop-and-go sensation can be felt at the thumb with a squeaking sound as the tendons try to move within the sheath.

Causes

DeQuervain’s syndrome is an idiopathic condition, which means no particular known cause is known. It is supposed that the commonest cause of DeQuervain’s syndrome is an overuse of the wrist, e.g. activities that involve frequent lifting, wringing or peeling. Activities that eccentrically load the wrist, i.e. stretch the wrist with load, stresses the wrist a lot more. Examples of eccentric activities that load the wrist include lowering a child or putting a heavy stack of plates down.

DeQuervain’s syndrome is often considered under the spectrum of repetitive stress injury. Occupations that are at a risk are office workers, musicians, carpenters. New mothers are at a particular risk of developing this syndrome because of the movement of frequent lifting of the baby. Other causes can be a direct injury to the wrist or rheumatoid arthritis.

Test and Diagnosis

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Treatment

Treatment of DeQuervain’s is more successful if started early. Initial treatment for a very acute or inflamed tendon might involve immobilization of the thumb and the wrist in a splint or brace. This allows for early healing and prevents aggravating the inflammation. In addition, the use of painkillers might be useful. However not everyone might need immobilization. Often physiotherapy treatment will settle the condition adequately. Physiotherapy treatment includes the use of Ultrasound in the initial phase to help settle the inflammation. This is progressed to graded stretching and strengthening to prevent irritation of the tendons. Patients’ habits and work styles are often observed by the therapist to suitably advice activity modification. Patients should avoid repetitive thumb and wrist movements that flares up the pain. Occasionally when the pain does not settle, a corticosteroid injection might be useful. For a few cases that are resistant to conservative management surgery might be an option.

Musculoskeletal Consumer Review took an opportunity to sit with Dr. Razmi Rahmat, a Consultant Spine and Orthopaedic Surgeon from Centre For Spine and Orthopaedic Surgery to discuss about the common neck problems seen in his clinic and the management for those problems.

MCR: What are some of the common neck problems seen in your clinic?

Dr. Razmi: The most common cause of neck pain is actually simply overuse! Most young, economically viable and techno savvy people, spend too much time in front of the computers. The muscles and ligaments that hold the cervical spine become fatigued and strained and these cause pain. The next cause is degenerative, due to wear and tear from over use or from injury. It can also be part of ageing process. Traumas like whiplash injury from car accidents make up the rest.

MCR: What can a patient expect when he/she goes to you with complaints of neck pain? (i.e. Procedures you do as an Orthopaedic Doctor to find out the cause?)

Dr. Razmi: The first step would be a good history taking to find out more about the pattern of pain or disability. Often it gives you a clue as to the origin of pain. Next would be a thorough clinical examination, to find the location of pain, assessment of range of motion and most importantly if there is any nerve involvement. Then comes the radiological investigation, which would be in the form of plain x-rays and MRI. Both are important and must be done, as different modality will allow the doctor to assess different tissues. In some cases, nerve conduction studies and electromyographic tests are necessary in some more complex cases.

MCR: What are some of the symptoms of herniated cervical disc protrusions?

Dr. Razmi: The most common symptom would be neck ache. This can be severe and of acute onset or it can be chronic. Some herniated discs are one sided and these give rise to pain going down either the left or right arm. There can be tingling or sensation of numbness. In more serious cases, the herniated disc can press on the spinal cord. This has more serious consequence as it can cause a person to lose fine motor skills in the upper limbs in the early stages and paralysis of all 4 limbs in the late stage.

Dr. Razmi Rahmat

Qualifications M.B.B.S, Masters of Medicine Fellow of the Academy of Medicine, Singapore Fellow of the Royal College of Surgeons Professional Highlights Dr. Razmi is a practicing orthopaedic consultant at Gleneagles Hospital, Mount Elizabeth Hospital and East Shore Hospital. His current research interests are in repair and regeneration of diseased spinal discs using autologous chondrocytes transplantation. First surgeon in Singapore to perform stand alone anterior approached spine fusion using the Synfix implant. In 2003, he was selected to represent Singapore in the Junior ASEAN Orthopaedic Travelling Fellowship. He spent a month travelling around the ASEAN region to share as well as learn with the leading surgeons in the region. Awarded a clinical fellowship at the Spinal Unit, Department of Orthopaedic and Trauma, Royal Adelaide Hospital in Adelaide.

MCR: If a patient has pain radiating from the neck to the hands, what can be done to determine nerve-related problems?

Dr. Razmi: The most useful investigation would be an MRI scan. MRI scan is 100% safe as it uses magnetic field rather than radiation. It is very accurate and can give excellent details on soft tissue problems, like ligament, muscles and more importantly the nerves. In some complex case where by we may need to differentiate whether the numbness is caused by compression of nerve in the neck or carpal tunnel syndrome where the compression occurs in the wrist, then a nerve conduction and EMG is useful.

MCR: What is the course of treatment for radiculopathy problems?

Dr. Razmi: Most spinal problems are approached conservatively first. These would include, a period of rest and modification of lifestyle and activities. All activities that aggravate the symptoms should be avoided or lessened. Medications like anti-inflammatory painkillers will help during the acute period. However it is not advisable to take it long term. New neuropathic pain medications that alter the sensitivity of the affected nerve like Gabapentin and Pregabalin can also be used. Nerve supplements in the form of Vitamin B complex are good to “strengthen” nerve function.

One of the most useful modes of treatment is physiotherapy. In the early phase, heat therapy, gentle stretching and gentle spinal mobilisation will help greatly in overcoming muscle spasm. Later, gentle intermittent cervical traction can be applied. Next come exercises to stretch and also to strengthen muscles around the neck.

Acupuncture can also be tried. However, harsh or rough manipulation by sinseh can be harmful rather than beneficial. Targeted epidural steroid injection around the affected nerve can also be done but it has to be guided by CT scan and must be done by a highly trained spine or radiology specialist. Finally, if all these measures fail, then surgery needs to be considered to decompress the affected nerve.

MCR: If a specific nerve is found to be inflamed, what treatment can be given to reduce the inflammation?

Dr. Razmi: The most effective way to reduce inflammation of nerve or neuritis is rest and the use of anti-inflammatory medications. Rest comes in the form of avoidance or reduction of activities causing the inflammation. A cervical collar is useful to immobilise the neck so that it reduces movement of the neck and helps settle the inflamed nerve. Anti inflammatory medications will help reduce the inflammation fast and at the same time acts as a painkiller. Only in very severe cases are strong opiates like Morphine is needed to control the pain. This will require admission for monitoring. -CG