Christmas is over and the turkey wasn't the only thing that got stuffed. Many of us over-indulged in both food and alcohol and have come out the other side swearing to shape up...but we should be realistic about the shape we are currently in, and chose our exercise regimes accordingly! I am specifically thinking about the suitability of running as exercise for the unfit, overweight, or under-prepared.
Don't get me wrong, running is clearly fantastic exercise, it takes the weight off, gets the heart pumping, helps maintain bone density and improves general fitness but it is also high impact. That means it has the potential to impact heavily on a number of structures and do us more harm than good, so here are a few things to think about
So how does this depressing litany help us train smarter and more safely?
I'm going to get it out there. I can't help your slipped disc! A slipped, or herniated, disc is a protrusion of the soft inner matter of the intervertebral disc, through the outer fibrous layer and no amount of osteopathy (or anything else) is going to poke it back in. That doesn't mean I can't reduce your pain or increase your function as you deal with a slipped disc.
Slipped discs 101
As I mentioned above, the slipped disc occurs when the outer fibrous part of the intervertebral disc, the annulus fibrosis, breaks down and the fibres fray and part, allowing the inner liquid, nucleous pulposus, to create a bulge in the wall of the disc and sometimes to extrude. As the bulge occurs and some of the matter from the centre of the disc is displaced outwards the disc loses height and the ligaments muscles etc acting over the joint are all now too long to provide full stability, the body can respond to this perceived instability by tightening up all of the muscular tissue around the joint to protect it and make it immobile, this can be painful and can impair function. The loss of disc height and tightening of muscles can also bring into contact other structures which are meant to sit in close proximity but not touch, and they can become irritated and inflamed, as a result. The most common pain that suggests a possible slipped disc is pain down the leg...so called sciatica...I say, 'so called' because a true slipped disc will cause irritation to a nerve root instead of to the peripheral nerve (sciatic or otherwise) and the pattern will be slightly different but that's nerd stuff.
I have had patients tell me that their problem is due to a slipped disc...it must be...I had an MRI and the report says I have a slipped disc at L1-L2, the trouble is, their symptoms are consistent with S1 nerve root irritation...nerd stuff again...basically the slipped disc is far too high to give them the symptoms they are experiencing. 27% of over 40s without symptoms have herniated discs, maybe in multiple, so this tells us that many herniated discs don't cause pain.
Back pain, even back pain that mimics a 'slipped disc', can be caused by many different dysfunctions, either singly or in multiple.
What does this tell us? That there is a lot of uncertainty in diagnosis and even more in prognosis. So why bother to try and work out whether an injury is discal in origin?
The first is an issue of safety. Disc prolapses are usually painful rather than dangerous but sometimes they compress the nerves in the spinal canal (another nerdy fact, the spinal; cord ends before the low back and here the nerves in the spinal canal are called the cauda equina as they run separately like the hairs in a horses tail). If there is a likely disc prolapse it is useful to make the patient aware of the symptoms to look out for if rare but dangerous cauda equina syndrome is occurring. Secondly, I would modify my techniques where I suspected a disc prolapse. The chances of an osteopathic technique exacerbating a disc issue are slim but let's reduce that chance even further by selecting techniques that minimise the risk. Finally, the patient needs to know the possible prognoses (plural), a disc herniation can take a long while to heal and may not respond to osteopathic treatment, the chance of a complete cessation of symptoms in the short term is lower than for some other types of back ache, that doesn't mean it can't happen but it is important that the patient has realistic expectations of treatment.
Overall I have been pleasantly surprised how well many patients who have had classic slipped-disc symptoms and signs have responded to treatment despite the fact I can't 'pop the disc back in'
I thought you might like an example of the thought processes I go through to determine what needs treatment to resolve somebody's pain or dysfunction. This is the story of someone in their mid forties with no known underlying health issues who woke up one morning after a night in bed asleep and alone, with severe pain in their bottom region. The pain was and is enough to make them yelp during certain movements, it really hurts!..I know this because this patient is me and the morning was yesterday.
Yesterday I woke and immediately felt it, lying in bed; a sharp pain in my...was it my coccyx? When I got out of bed I yelped because it hurt so much.
OK, so the coccyx doesn't usually become painful for no apparent reason. Had there been a fall, or other trauma to the area?
No trauma, in fact I'd had a lazy day the day before (Sunday) and spent most of it on the sofa. I had been decorating and been out dancing the day before but had no pain following that.
No trauma, doesn't sound like coccyx. Do you have a history of problems with the coccyx?
I hurt my left sacroiliac joint 9 months ago, actually it ached a bit in bed and I had a bit of sciatica a couple of nights last week.
Do you have any sciatica now?
No! It was just a couple of nights last week.
OK. So what movements and positions hurt now?
Lying in bed, sitting and walking hurt, but standing is OK. Actually sitting is OKish, it is standing from sitting that really hurts, that's when I yelp. Coughing sneezing and going to the toilet are pretty yelp inducing too.
But there are no issues with being able to go to the toilet?
Only braving the discomfort
Does anything make it better?
You said lying in bed was bad, can you get comfortable to sleep?
If I lie on my right side with my left leg forward I am comfortable but I tend to move in the night and then the pain wakes me. I had to get up at 4am for an ibuprofen last night
So the pain wakes you at night? You've not had any night-sweats, unexplained weight loss, nausea or change in appetite, constant fatigue, blood in urine or difficulty peeing, have you?
OK, lets have a look at you.
Now bear in mind I can't see myself from the back but I can't feel any puffiness and my low back doesn't feel affected so my suspicion is there is little visible asymmetry. None of the joints of the lumbar spine are tender to palpate and neither are either of the sacroiliac joints. The sacrococcygeal joint, however is very tender on both the left and right side. The coccyx itself isn't.
Lets try some movements
Well obviously rising from sitting hurts. Surprisingly though rotation right is the most painful spinal movement, actually bending forward and straightening from that doesn't hurt much. Right hip no pain on any movements but left hurts at full extension (moving leg back) and a bit on internal rotation of hip. I can only test these actively on my own, so using muscles, but on a patient I would then test the painful movements taking the joint through the range of motion with the body relaxed, so if it still hurt I would know it isn't muscles. In this case I know it isn't muscles because it hurts sitting and lying still.
For a little while I was a bit stumped as to how the sacrococcygeal joint became so painful during the night, without trauma but i think the evidence above is enough for a pretty good hypothesis.
We can be pretty sure it is the sacrococcygeal joint that is generating the pain. pressing on it hurts and releasing pressure on it, when standing from sitting, also really hurts (it isn't about the movement in this instance as standing from bending over is the same movement but doesn't hurt).
Pain that awakens someone in the night and comes on for no apparent reason are a couple of red flags and can, in the presence of other symptoms or signs suggest that further investigation is required to ensure that, for example, there isn't metastatic bone cancer. In this case there are no night sweats, weight loss, fatigue, nausea or appetite change, all possible indicators of cancer and no difficulty peeing or blood in urine, perhaps specifically indicative of prostate cancer, the most likely cancer in men to spread to the lower spine. The pain is also movement related and that is a very strong indicator that it is musculoskeletal and mechanical. It is also responsive to ibuprofen, suggesting the process is, at least in part inflammatory.
The saccrococcygeal joint is subject to anatomical variation. It can contain a disc, which can herniate, bulge or 'slip' but more likely may just be a simple synovial joint, or even may be ossified. Again red flags appear with difficulty going to the toilet, are nerves being compromised by a bulging disc?..Not in this case, it is just painful but there are no difficulties openoing or closing the valves, so to speak.
The most common cause of pain at this joint is irritation of the soft tissues around the joint, ligaments, capsule etc...and what irritates those? Being stretched. How does that happen? Either the coccyx is held uncomfortably, or the sacrum is. We know that there has been no trauma to the coccyx and that it usually takes one for it to move, so that leaves the sacrum.
The sacrum is a vaguely triangular bone which has joints with the coccyx at the bottom, L5 (the bottom lumbar vertebra) at the top and the ilium part of the innominate bones (main pelvic bones) at the sides. None of the other joints are painful but the history tells us that there has been a problem in the past with the left sacroiliac joint and that there may have been some recent disorder there, so it would make sense to think about whether that was likely implicated. Pain is worst (apart from when pressure is released) when the left leg is back (hip extended) and relieved when lying in bed with the left leg forward, it also hurts when lying on my back, where the weight of my leg is forcing the leg straight.
If you've read the sacroiliac joint series in this blog you'll know that the evidence suggests the joint doesn't move much unless certain conditions are met, however my mechanism of injury 9 months ago opened the joint and rotated the left innominate posteriorly relative to the sacrum, which would have the potential to be in the category of those rare occassions when the joint actually does move out of alignment. It doesn't have to have moved much, but either not having fully resolved it at the time, or (perhaps having weakened ligaments when I hurt it last time) repeating the injury enough to move it a little but not to cause pain in the joint itself could lead to my sacrum being twisted between the innominates...and most importantly relative to the coccyx. bringing my leg back and even lying all night with it flat against the bed would increase that twist.
So this is my best guess but all diagnosis is exactly that...a best guess. Phrases such as, 'we'll do a scan to make sure' give a false sense of certainty. A person may have a disc bulge at the right level but it may be asymptomatic and the pain may be driven by another structure. Certainly the orthopaedic tests we do have limited specificity and sensitivity and on their own can only form a small part of the picture, but when combined with the palpatory findings, anatomical knowledge and experience informing our perception of the likelihood of each scenario and most importantly the patient's history of this and previous ailments we can build a good picture and a reasonable diagnosis.
The traditional method of evaluating whether a treatment is beneficial in reducing pain is to measure it against placebo (a sham treatment that has no anticipated external beneficial effect) in a blinded trial (single, in this case, as it is a bit difficult to blind the practitioner as to whether they are giving real or sham treatment) and to use scales and questionnaires for patients to record their pain levels before and after treatment. Although the pain levels will be subjective the scales and questionnaires used are consistent and as such the results from a large population can be considered robust.
In this meta-analysis editorial complementary medicine sceptics Colquhoun (pharmacologist) and Novella talk about the lack of evidence of any consistent placebo exceeding effects in over 3,000 papers regarding acupuncture.
Recent research by Richard Harris (co-president of the society for acupuncture research) shows that there is an effect on the neurotransmitters in the brain which is very different for real as opposed to sham acupuncture. With traditional placebo effects such as sham acupuncture additional endorphines are released which reduces pain, with real acupuncture the effect seems to be that more receptors are created instead and in disorders like fibromyaglia where there appear to be an insufficiency of receptors this suggests the acupuncture is not just providing relief but is actively curing the condition.
Perhaps the problem here is that we think of placebo as non-intervention, when in fact it can be a very powerful intervention. This research suggests that the placebo effect does necessarily not operate in addition to other pain relief effects for all interventions and so other effects with different long term consequences to the placebo effect may be being masked by this comparison to the placebo.
Also notice the highlighted fields of expertise. I am not implying improper conflicts of interest , lack of fairness or intellectual rigour, just a mind-set. If you are a pharmacologist comparing two pills, which look smell taste and feel the same but have different active chemical ingredients then 'placebo' is just background noise and the difference must be entirely due to the ingredients...one assumes! Likewise if your field of expertise is under attack as being nothing more than placebo then maybe you have a vested interest in understanding more about what placebo is.
I've always been interested in the idea of degrees of placebo and in the different capacity to to initiate placebo in different people at different times using different means. If osteopathy were placebo, would it matter if it were better placebo (for some people) than ibuprofen and if the pain relief generated allowed normal behaviours which in turn allowed the body to better heal itself? Hang on! Isn't that the meaning of one of the central tenets of osteopathy 'the body contains its own medicine chest'. I'm not suggesting that osteopathy is 'just' placebo but now that we know the placebo effect is real and isn't always present in the same way and at the same magnitude (therefore can be reduced, turned off or increased), isn't it something we should be trying to understand better and shouldn't we be a little more critical in appraisal of effect versus placebo in future?
this blog entry was inspired by an article in the Guardian here
A recent study by Public Health England suggested that 41% of Britons aged 40-60 fail to exercise so much as 10 consecutive minutes brisk walk each month. This is shocking, so much so that I have difficulty believing it, but even assuming it is an exaggeration it does highlight an underlying truth that a significant proportion of middle-aged Britons fail to do any significant exercise.
The focus in the media is on the benefits to your heart. By walking just 10 continuous minutes at a brisk pace every day, an individual can reduce their risk of early death by 15%. They can also prevent or delay the onset of disability and further reduce their risk of serious health conditions, such as type 2 diabetes, heart disease, dementia and some cancers.
The human body is not designed to be sedentary, it relies on movement for far too much. Obviously it survive without movement, people do, but it can't function properly.
There are so many systems which rely on movement some more obvious than others, here's a few, by no means the full list
Joint health - The joints are lubricated by synovial fluid, this nourishes the cartilage which lines the joints, the synovial fluid is spread across the joint surface by a combination of one surface of the joint wiping the fluid across another and by the loading and unloading of joint surfaces causing alternate high and low pressure and pumping the fluid around the joint, both of these processes need movement (weight bearing for the latter).
Bone health - Bone density responds to loading both direct loading from weight-bearing and from the pull exerted by muscles. Activity, preferably weight-bearing, is therefore important to maintain bone-density,
Circulatory health - The heart is not the only circulatory pump in the body, in fact it is not really up to the job on it's own, it relies on other smaller pumps most of which are muscular and rely on activation of muscles through movement to aid venous return. If circulatory pumping is inadequate then there is the potential for stasis, this is how sitting still on a long flight can contribute to the development of a deep vein thrombosis as blood can start to clot when it isn't flowing. Stasis can also contribute to ulcer formation and even in extreme cases the thickening and weakening of the heart's muscular walls.
Antibody response - Studies have demonstrated that the immune system also uses muscular pumping systems to speed up your antibody response to infection. Infective particles are presented and recognised quicker and antibodies are created and distributed more rapidly decreasing the time it takes to counter threats and giving them less time to multiply and increase their potential to threaten you.
Enough time sat here writing this...I'm off for a swim, maybe you should do the same!
I plan to add some recommended exercises to this site in the near future but until I do here is a really good and and well explained exercise to do before you train, or just during the day. The point is that it improves balance and proprioception in three dimensions. Three dimensional proprioception is critical since although our knees and ankles move most significantly in the anterior posterior plane we need strength, and more importantly quick automatic pretensioning reactions, in other planes in order to prevent knee and ankle sprains and strains. For those whose knees tend to drop inward when running, cycling or working out, this is also great since this will help you body build up appropriate strength, get used to firing the right muscles at the right time and understand where your limbs are in space in order to start to correct or limit that issue. This exercise will work a surprising range of muscles quite hard. We've talked about muscles around the knees and ankles but think about what is going on at the pelvis also.
No more spoilers, read Steve's blog and watch the video. It's not as easy as it looks, so take Steve's advice and perhaps try it holding onto a chair first.
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints. It is the most common autoimmune disease of the joints and left untreated the uncontrolled inflammation not only causes pain but also bony remodelling of the joints, which can lead to deformation and disability. The condition often requires lifelong treatment with medications that are not without side-effects.
A team of boffins (they look about 12 years old to me, I must be getting old) at Friedrich-Alexander Universitat in Erlangen, with the help of research from an international project, has discovered that a type of cell called innate lymphoid cells are instrumental in the resolution of inflammation. Furthermore, in patients with Rheumatoid Arthritis it appears that these cells become dormant, they, in effect, go into a state of hibernation. When they are awoken they put an end to the inflammatory process and the pain and destruction associated with it.
The possibility of treatments which increase the numbers of innate lymphoid cells in future may lead to much better outcomes for patients with, not just rheumatoid arthritis but also potentially any condition based on chronic inflammation, these might include conditions as varied as Crohns disease and ulcerative colitis, psoriasis and even cirrhosis of the liver.
Read the press release here
The body needs to find time to repair itself and schedules downtime so that structures can be restored to better function.
Did you know that nostrils are periodically switched throughout the day and night, with one fully open and the other partially blocked in order that it can rest and repair from the fast moving particles you inhale?
The intervertebral discs also have a repair cycle. When we lie down and take the weight off them, they decompress and fluid and nutrients are sucked in so that they are plumper by about 10% and we are actually measurably taller at the beginning as opposed to the end of the day by about 1.5-2cm.
However, the rhythm is not just a response to our activity, scientists at the University of Manchester have discovered, there is an intrinsic diurnal rhythm in the DNA of the substance of the discs. Genes concerned with homeostasis (repair through the restoration of the balanced state) are switched on when we rest at night. It was found that chronic inflammation and ageing both reduced the ability of the disc tissue to respond to the circadian rhythms. Furthermore the loss of circadian rhythms led to accelerated deterioration of intervertebral disc tissue. Read more here
Another team at University of Manchester, looking at the mechanisms behind the inflammation causing Rheumatoid Arthritis have found that the body also secretes natural anti-inflammatories (notably cryptochrome) to reduce inflammation during the night and again this is disrupted if we don't have a period of rest and darkness, read more here.
So, what are the implications? The suggestion is that a regular sleep pattern, in darkness, is perhaps important to both mediate inflammation and to maintain disc health. The understanding that long term inflammation reduces the effectiveness of the circadian disc repair system means that a poorly regulated body clock could lead to a double whammy of decreased inflammatory suppression and of that inflammation then leading to a degraded intervertebral disc repair mechanism. There are some positives though; understanding how the body suppresses inflammation during the 'night' phase means we could potentially develop methods to artificially trigger that state, which could be especially useful for those with autoimmune conditions where inflammation is chronic and damaging, and understanding how ageing interferes with triggering nocturnal intervertebral disc repair may mean that we could find a way to reverse that also.
In the meantime though, all in all, perhaps your grandparents were right when they exhorted you that 'early to bed, early to rise makes a man healthy, wealthy and wise'...well the first part, at least!
No apologies. This week’s blog contains an abundance of anatomical terms. The good news is that there is a summary at the end, so you can skip straight to that if you just want the gyst.
Mark Laslett – Identified that the SIJ can be implicated in dysfunction in two different ways:
1. pain derived from the joint, this has been proven to exist by injecting anaesthetic into the joint space which causes the pain to abate, showing it derives from there. Bussey and Milosavljevic found that there are nociceptors throughout the joint capsule, ligaments and potentially throughout the subchondral bone suggesting that trauma or tension to any of these structures could lead to pain and Vleeming et al propose that this pain could be driven by assymetric tension across the joint. Furthermore sacroiliac joints are prone to degenerative changes. A report delivered at the National Association of Spinal Surgeons suggested that in the studied cohort, with a mean age of 53, 35% of joints had serious degeneration and a further 30% minor and that it tended to occur more in men.
2. contribution, as a load bearing mechanical junction between the pelvis and spine, to dysfunction, leading to pain elsewhere. Mark Laslett was sceptical about how much a joint with little rotational or translational movement could influence other structures but let us see the avenues that other researchers are pursuing
A pelvic torsion will cause a functional leg length discrepancy, conversely a leg length discrepancy of 1 cm can cause increase a fivefold increase in pelvic forces.
Vleeming et al suggested that the sacroiliac joint can adopt a constantly braced force closure when there is load unpredictability or constant high loading and this can become a dysfunctional norm with muscular bracing and indeed muscular hypertonia and fatigue, furthermore, Iliacus can pull the ilium forward causing a relative counternutation of the sacrum in such positions as lying supine and straight leg raise, if the patient hasn’t braced and force closed adequately.
In pregnancy, pelvic girdle pain can be caused by insufficient bracing. People tend to brace the contralateral (good) SIJ using Biceps femoris and External Oblique when flexing bad sij, Sjödahl et al found evidence that, when performing an assymetric straight leg raise, women with pelvic girdle pain fail to tense their pelvic floor…is it also part of that force closure process? One muscle that doesn’t appear to be directly part of the process despite a longstanding belief it was involved is transversus abdominus, according to studies in vitro by Gnat et al.
McGrath et al have found another source of sacroiliac region pain. The posterior rami of the sacral nerves form a plexus (network) in the gluteal region close to the sacroiliac joints. They identified two potential places areas where it is proposed that entrapment may occur:
1. under Long Posterior Sacroiliac Ligament
2. where the medial branches of the posterior rami penetrate the deep fascial layer to innervate sacral multifidus and become cutaneous
You can think of this nerve entrapment as very similar to sciatica but much more localised.
So to sum up. The sacroiliac joints themselves have pain responsive nerves and may be responding to trauma or degeneration. The long-standing assumption that sacroiliac movement could lead to a pelvic torsion and contribute to dysfunction and pain elsewhere is now being questioned but new models involving uneven soft tissue tensions and bony plasticity may provide an alternative mechanism but a similar outcome and finally the area around the sacroiliac joints may be prone to sciatica type neuropathic pain, this may also be influenced by uneven forces and soft-tissue tensions.
So how much and how does the sacroiliac joint move? Well, we can’t look at the joint in isolation we need to look at the whole pelvis and that means also looking at the pubic symphysis which is the joint at the front. After all it is a closed ring so if one joint moves then it must be compensated for elsewhere.
A study looking at people in the flamingo stance showed that one side of the pubic symphysis moved 1.4 mm relative to the other in men, 1.6mm in nulliparous women and 3.1mm in multiparous women.
One of the newer developments in research has been the use of Roentgen stereogrammetry. This uses tiny metal balls embedded in the bone either side of the joint and 2 x-ray devices to create a stereo image that can be used to calculate movement of the markers relative to each other in all planes. This is a more accurate method than others which have been prone to error. The sacroiliac joints do move…but not very much at all. The main movement is the nutation (nodding forward) of the sacrum between the ilia and that is typically of the order of a couple of degrees (although it does vary according to position) and is in fact 40% less in men than in women.
Kibsgård et al looked at women with confirmed SIJ mediated pelvic girdle pain and used tiny metal balls inserted into the bones either side of the joints to accurately measure movement of one side relative to the other. They found very little sacroiliac joint movement despite significant movement of one side of the pubic symphysis compared to the other.
So, what is happening? How can the pubic symphysis move significantly without the sacroiliac joint following suit? Kibsgård et al suggested that this unexpected finding was likely to be either down to setup error or plasticity of the bones of the innominate bones, the latter of which would concur with a study by Paul Goudzwaard et al who showed that the innominate bones could deform up to 3.5mm whilst the pubic symphysis moves mainly in the transverse plane (rather than rotating).
One final piece of the puzzle, Adhia et al discovered that although there wasn’t significant difference in the degree of SIJ movement there was increased asymmetry of iliac rotational motion in patients with SIJ pain. So they didn’t rotate more, or less but they moved differently.
To sum up, the studies using the most accurate techniques currently available indicate that the sacroiliac joints don’t usually move very much and that sacroiliac pain and reduced movement don’t appear to be linked but there is a difference in how the ilia move in affected patients and it seems that the innominates are deformable to account for pubic symphysis movement
Damian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy