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Interesting research from the Cochrane institute (who systematically review and combine research to increase its power) suggests that topical (applied externally) NSAIDS (non-steroidal anti-inflammatories) are safe and effective in treating mild to moderate acute musculoskeletal pain in adults. Obviously I am not suggesting this as an alternative to visiting your osteopath but it is a great alternative to taking tablets orally, since the concentration required for those can cause unpleasant or even serious side-effects. The research doesn't test one brand against the other, although they were able to identify that gel formulations of diclofenac, ibuprofen and ketoprofen, and some diclofenac patches, were the most effective, other formulations were more effective than placebo but not by much. Measured side-effects were no worse than placebo. This research is not able to compare topical and oral preparations but other recent research has shown that topical diclofenac solution can provide as effective pain relief for people with knee or hand osteoarthritis as oral diclofenac, so the suspicion is that the results may well be similar across the board. All in all this is really good news for those who can't take NSAIDs due to, for example the effect on their stomach, more info at the Cochrane website here
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Managing problems caused by poor upper back and ribcage movement, when you aren’t having treatment5/7/2016 The upper back and ribcage (thorax) is, in my humble opinion, the most frequently implicated are of the body. It shouldn’t really be a surprise, after all it links the shoulders and through them the arms and the neck and the low back. Poor thoracic movement is so often a root cause of neck pain, shoulder and arm problems, even tennis elbow, mainly due to postural changes that cause stresses and strains further along the chain as the body tries to adapt and, of course, low back pain when it has to overwork to compensate for a rigid thorax. Much though I’d love you to come and get a preventative treatment on a regular, even weekly basis I recognise that for most people that is an expense and also a time commitment. For most people going to the osteopath is about getting pain free and removing an impediment to the activities they enjoy. This makes it unlikely that longstanding postural habits or neurological conditioning are going to be fully reversed and the problem may recur, or at least there may be twinges from time to time. I speak from experience. I remember having terrible problems with my neck and shoulder as a teenager, problems that recurred for years. The first time I went to an osteopath was to try and resolve this issue and he got me pain free for several years but it recurred, so I went back to the osteopath again…and again. I don’t have problems in that area now…now it is my mid-back…actually it probably always was…a slightly flexed and immobile area developed probably when I was a teenager and caused my slightly stooped posture that put more strain on the junction between neck and shoulder leading to the previous problems. I am working with my osteopath on it and feel that I have opened up my chest and am standing less hunched and lo I don’t get neck and shoulder problems, but I doubt I’ll ever fully resolve that flexed mid-back there is likely a skeletal change which will always be a mechanical point of strain…So I have to manage it. So what works to help increase mobility in the thorax. (if you are elderly, unwell or disabled check with an appropriate medical professional before trying any of these)
b.Strengthen your back muscles – Rhomboids in particular, exercises such as reverse flies, and rows can help pull rounded shoulders back into line. Lateral pull-downs or pull ups can help strengthen muscles that hold you straighter, or, with a light weight can be a really nice and effective stretch. When I work out nowadays I work on the principle that whatever I push I pull, so I would superset a chest press with a row, a shoulder press with a lateral pulldown etc and I have found that to really help
b.Yoga, pilates – these can be great ways of keeping that mobility c.Running – I find running really loosens my upper back. I don’t run far but I use my arms and find that often my mid back releases d.Abdominal excerises – I do declined sit-ups with a medicine ball rotating to alternate sides and again often cause my back to release. Russian twists and plain old crunches with the knees to one side or the other are also good e. Just hold your arms out and rotate, try it sitting with a cushion behind your low back to stop the movement coming from there I hope these help. If it hurts, stop, if you think you shouldn’t be doing it, or you feel like you are injuring yourself stop! What made me chose to borrow a lot of money and retrain to be an osteopath? I first heard of osteopathy when I was about 13 years old and the mother, Mrs X, of one of the boys my age who played in the street where I lived suddenly went from being bent over like a question mark to walking normally. I asked my Mum the source of this miracle...'she's been to an osteopath'. Fast forward (too) many years and somehow I've ended up being a sales-manager, I drive around a lot and I regularly get niggling neck and shoulder problems that make it difficult for me to turn my head properly. The GP sends me to a physiotherapist, it helps a bit, actually I think 'I quite fancy this for a career' and ask the physiotherapist about the training. It helps a bit but I'm still getting regular problems and when it returns I notice that my private medical insurance covers some limited osteopathic treatment, it triggers the memory of Mrs X. I find an osteopath and get some treatment. A few clicks and I'm well on the way to recovery, a few treatments and I'm fixed. The osteopath I saw treated me in his front room, I liked the idea of that lifestyle, perhaps do a bit of gardening or cooking between patients, even better than being a physiotherapist. Years go by and my sales manager job no longer exists, I take the opportunity to go travelling and when I return, so does my neck problem. I head to an osteopath, which reminds me that it was always something I wanted to do,, just at the time when I am trying to work out what to do and luckily for me, the week before applications to the British School of Osteopathy close for that academic year. Sadly, with about 70 steps to my small top floor flat, the idea of practicing from the front room is history, but if there is a big enough gap between patients I may pop home to do some cooking. So you have your chair and your desk well set-up. How can you make your workplace even more conducive to working without causing or contributing to any musculoskeletal problems? Mice/Mouses People use mouses (My preferred version, OED suggests both are common usage and mice is actually commoner) widely throughout their working day. Mouse use can be a significant factor in repetitive strain injuries such as tennis-elbow. So here is my advice. There is no anatomically comfortable way to use the tracker pad or wiggly nub thing on your laptop whilst leaving the keyboard in the right place for both hands to use it, so try to use a separate peripheral as much as possible. You want the area around your mouse, clear and unencumbered. I you find that you have to extend your wrist to use your mouse then you need one of those mousemats with a built in wrist support (it is going to depend on the size of your hand relative to the size of the mouse). If you are still getting repetitive strain injury, it may be because there is a low grade problem with your wrist, elbow or shoulder, so come and see an osteopath and get checked, or it may be that you need a different type of mouse. Some people get on better with a mouse where the hand is held with the palm facing inwards not downwards, others with tracker pads; there are lots of options, so don’t suffer unnecessarily. Keyboards Just like mouses there are different options; ergonomic, split and even perpendicular keyboards. Every type is a compromise, your hand may be in a better position to type but may require a larger or more awkward movement to reach the mouse…A perpendicular keyboard would be pretty awkward for a non-touch-typist! So you are going to have to try and see what works best for you. Choice of keyboard is nowhere near as important as setting up your chair desk and keyboard position properly, it really is the cherry on the icing on the cake. However, don’t miss this cheap and easy fix, if you are using a (non-perpendicular) keyboard and want to guard against repetitive strain and/or carpal tunnel syndrome ideally you want your wrist in a straight position. If your wrist is extended when you type then you need a wrist support, which is a sort of squishy sausage of cushion that sits in front of your keyboard. Phones Do you use your phone a lot at work? Do you write or type notes whilst on the phone? Holding your phone to your ear with your shoulder is a really good way to mess with your neck. Get a headset. Some people have their phones at the back of their desks so they have to stretch awkwardly, or on the wrong side, or with too short a cord on the handset. If your phone is awkward to reach, move it! Everything else It is simple, If you use it often, make sure it is easy to reach and comfortable to use. If you can’t do that from one position, then move position for different tasks and/or declutter to make it possible. It’s obvious stuff but it may just save you a lot of discomfort. How to set up your workstation - Part 2 About the chair OK, so today, the slightly delayed, second part of how to set up your work-station, this time concerned with your chair. We all occasionally work in silly places; at the breakfast bar perched on a bar stool, with a laptop on the sofa etc but if you are going to be spending many hours a day working, sat in a chair, it is important to get it right, or at least as right as you can. The type of chair you need will be determined by the work you do and also by your desk. What kind of chair do you need If you often turn, perhaps to switch between documents and computer screen, you need a swivel chair. No ifs, no buts, holding yourself in a twisted position for any period of time is a disaster waiting to happen. If you regularly have to get up and down, you probably need a chair on casters, why? Think about the position you put yourself into trying to tuck your chair in, perhaps you do those little bunny-hops? My back muscles are going into spasm just thinking about it. If you’re going to have casters then make sure the floor around your desk is flat and unimpeded, ideally without a thick pile to the carpet. You want to be able to wheel the chair easily. Trying to drag a chair on wheels over an uneven surface can be as hard as doing those bunnyhops! You also want a chair that adjust for height, more about that in a minute. How should you position your chair So you’ve got the right chair, or at least the best you can find in the office, and now you need to know how to position it. There are two major considerations, height and distance (well, and being face on but we covered that earlier). Height is easy, you want your shoulders relaxed and your elbows at 90’ when you’re working. Ideally you want your knees at 90’ also, so if you’re not very tall you may need a footrest to achieve this. Now to one of my pet hates…You have set the chair at the correct height, but you still can’t work with your arms relaxed…Why? Because you can’t get close enough to your keyboard or document…The arms on the chair won’t fit under the desk! I used to work in an office which was very hierarchical. Team leaders’ chairs could be identified because they had arms. ‘Aren’t these slightly too high hard plastic arms comfortable to rest my own forearms on’, said no one ever. Get them removed, if you can, they usually unscrew, even if it looks like a demotion. Kneeler chairs and stability balls Patients often ask me what I think of kneeler chairs and stability balls. There is some evidence that kneeler chairs, set to 20’ allow the lumbar spine to more closely mimic standing posture (Bettany-Saltikov J, 2008). As to whether that is a good thing? Actually there doesn’t appear to be a correlation between lumbar lordosis and back pain (Ashraf A, 2014) (Murrie VL, 2003) and more directly there doesn’t seem to be evidence of a measurable causative effect between low back pain and long periods sitting (Darren M. Roffey, Eugene K. Wai MD, Paul Bishop DC, Brian K. Kwon MD, & Simon Dagenais DC, 2010), which was a surprise to me. That doesn’t mean that for some individuals a standard chair won’t cause back pain and the kneeling hair isn’t going to be more comfortable or irritate pre-existing conditions less. The same goes for balance balls, there is evidence that people with low back pain have deep abdominal muscles that fire less strongly when sitting and that balance balls cause deep abdominal muscles to fire (Rasouli, Arab, Amiri, & Jaberzadeh, 2011), these muscles were thought to be essential for ‘core stability’ and that their poor firing left the back unprotected and unstable; however there is also evidence that those patients who have these muscles damaged or missing for one reason or another, often manage desk jobs without developing low back ache (Lederman, 2008) My advice is to go with what is comfortable, if you can swap throughout the day then maybe that is a good solution, but don’t forget to adjust heights etc to make sure each sitting position is optimal and don’t forget that kneeling chairs don’t swivel, so aren’t great if you are swapping between documents and screen work. Next time, the other bits and bobs at your workstation References Ashraf A, F. S. (2014). Correlation between Radiologic Sign of Lumbar Lordosis and Functional Status in Patients with Chronic Mechanical Low Back Pain. Asian Spine Journal, 565-570. Bettany-Saltikov J, W. J. (2008). Ergonomically designed kneeling chairs are they worth it? : Comparison of sagittal lumbar curvature in two different seating postures. Studies in Health Technology and Informatics, 103-106. Darren M. Roffey, P., Eugene K. Wai MD, M. C., Paul Bishop DC, M. P., Brian K. Kwon MD, P. F., & Simon Dagenais DC, P. (2010). Causal assessment of occupational sitting and low back pain: results of a systematic review. Spine, 252-261. Lederman, E. (2008). The myth of core stability. Journal of bodywork and movement therapies, 84-98. Murrie VL, D. A. (2003). Lumbar lordosis: study of patients with and without low back pain. Clinicical Anatomy, 144-147. Rasouli, O., Arab, A. M., Amiri, M., & Jaberzadeh, S. (2011). Ultrasound measurement of deep abdominal muscle activity in sitting positions with different stability levels in subjects with and without chronic low back pain. Manual Therapy, 388-393. I’m often asked for advice on work stations so I thought it would be useful to share that advice with you. I’ll tell you what I know in bite sized chunks over the next 3 weeks. The first thing to say is that in most cases you are going to have to work with what you are given, rather than being given carte-blanche to design your own workstation, money no object, so I’ll try and give you any workarounds I can think of. The basic principle of comfortable working is that you want to be as relaxed as possible whilst doing your work, so you want to avoid holding your body in a twisted position, you want your shoulders and wrists relaxed and anything you need to read should be easily read without straining your eyes. What kind of desk and how to set it up? In order to avoid twisting whilst working you want your work to be straight ahead of you. The beauty of a curved desk is that , if you use it with a swivel chair, you can turn from your computer to a paper document on which you might be working, keeping it straight ahead and still maintaining the same distance from your work. If you only ever work at a computer then a straight desk is unlikely to be an issue. What to do if you can’t change your desk If you have paper documents to read and for only the occasional mark-up you may find it useful to have a document holder attached to your screen so that it is in roughly the same position as the screen and a small movement of the neck or just the eyes will allow you to change from one to the other. If you do need to work regularly on both computer and paper, but not at the same time, you could consider a screen on an arm that can be moved away and leaves the area below free for paperwork or you could set up parallel workstations side by side and make sure you roll the chair between positions rather than twisting your body. How high should the desk be? In order that your wrists and shoulders are relaxed, your elbows should be at about 90’. Most people won’t have a height adjustable desk, so you’ll need to adjust the height of the chair to achieve this (more about that in part 2). For some very tall or very short people standard desks are the wrong height. You can buy height adjustable desks, or, very cheaply, raisers which sit under the feet. What about standing desks? Standing desks are an attractive idea but we were barely more designed to stand still than sit still for hours on end. People who spend all day standing on their feet, particularly if standing still develop their own problems. I know people with the luxury of space, who have both a sitting and a standing desk and they swap between the two, I can see a clear benefit in that. For us mere mortals who only have room for one desk I think it depends. If you use a seated desk with no problems I don’t see a need to swap, you may be jumping out of the frying pan into the fire but if you do suffer with problems from working at a traditional desk then it may be part of the solution but remember, whichever you chose you need to get your elbows at 90’, face your work head-on and anything you need to read needs to be at a comfortable distance for your eyes. Next week I’ll continue with your chair and the following week I’ll talk about the items on and around your workstation Rheumatoid Arthritis (RA) is a condition I always look out for. Symptoms can be exactly the sort of thing a patient may come to an osteopath to treat, so I do see these patients from time to time. Apart from the fact that medications, for all their faults, can prevent joint destruction and disability, and I want my patients to be able to make an informed choice as soon as possible about their treatment pathways, there are some osteopathic techniques which would have an increased risk for a patient with this condition, so I would avoid them and work differently. We know what RA is, that it is an autoimmune inflammatory condition that affects the synovium (the material lining synovial joint capsules) but we don't fully understand why some people are susceptible and what triggers it on those people. Some interesting research involving a very large group of people studied over many years has come to the conclusion that high overall cholesterol levels are linked with later development of Rheumatoid Arthritis - in women only, in men there is no relationship. How does this information help us? Well! The link is not so clear as to suggest that the high cholesterol is responsible for the RA and high cholesterol is not suggested as a reliable indicator for future RA, but the findings suggest that the early development of RA may use hormone-related metabolic pathways and the findings may have implications for future disease prevention and management of patients at risk of RA associated cardiovascular disease. I love the NHS! I know I don't work within it but if I have an emergency or need medication or surgical intervention, I love the fact I can go and get help free at the point of need. Did you know that the government wants your views on the future of the NHS? Me neither. Apparently they do, just not enough to tell us about it. The proposal is a bit impenetrable but here are some of the items that I fed back as, of concern, to me: Unless I am mistaken it doesn't include 'healthcare free at the point of use' as an aim, surely that is one of the cornerstones of the NHS. The planning is built on the basis that there are £22bn of efficiency savings available over 5 years when most pundits say £15bn maximum http://www.theguardian.com/society/2015/nov/18/nhs-cannot-make-22bn-cut-sought-by-government-finance-chiefs-warn The plan relies on our already broken GP system to keep people out of hospital and wants them to offer more out of hours services but fails to acknowledge how overstretched GPs are now (try booking an appointment for a specific day). Given the number of GP trainees has fallen, how will they staff this increase in service, even if they manage to fund it? Very close to home for me at the moment the plan looks to provide care in the home yet doesn't mention carers at all. I know from firsthand experience how much support carers need both to provide the care and to ensure they in turn are looked after and don't fall ill. Anyway, those are my main concerns, yours may be different. Have your say by clicking the link below I was in the gym today...No, really I do go. Once again I saw the foot end of the decline sit-up bench was propped on a Reebok Step. This seems to have the norm for young men (it is almost always men). I think the thought process is 'it gets harder the more declined it is, I must be working my abs more' WRONG. Your abs only work over a very small range, once you go beyond that you are flexing your hips, not your back. Your upper body is exerting maximum effect as a lever being pulled by gravity on the muscles trying to move or hold it when it is horizontal, so to be effective the muscle you want to be firing when you are horizontal should be your abs. If you're starting at 60' , you'll be past the abs by about 45' and predominantly strengthening your Psoas muscle, which is great but an overlarge Psoas can trap the nerves going into yous legs and particularly the outer thigh causing numbness or discomfort, it can irritate the bowel causing diarrhoea and worst of all...No one can see your Psoas anyway! There's a reason these benches are made so they only decline about 30' So here's a thought. In my last post I talked about the new research which had proven once and for all that the pop (cavitation) you sometimes hear when a joint is manipulated is carbon dioxide suspended in the synovial fluid (the joint lubricating fluid) forming a bubble which explodes under the negative pressure caused by pulling the joint surfaces apart quickly. They also noticed what they thought may be water rushing into the joint after the event. So lets assume that the cavitation has enough force to drive the carbon dioxide through the capsule round the joint, which creates a pressure gradient whereby water is attracted in to equalise the pressure, so effectively carbon dioxide has been replaced with water. One of the effects will be on the compressability of the the synovial fluid, gases are compressible and liquids aren't. That is why a car with old brake fluid will have a spongy feel to the brake pedal, as much of the force applied is absorbed by the gas compressing. Maybe, just maybe, this is one of the ways that manipulations help joints to function better, by effectively changing the brake fluid, so that joints are less compressed. |
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February 2024
AuthorDamian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy Categories
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