Standing Firm - Why it sometimes hurts to stand from sitting?
The sit-to-stand (STS) is a test used to measure lower-limb strength in older people or those with significant weakness (1).
It is considered an easy, quick and fairly valid measure, which involves measuring the time taken to stand from a seated position a certain number of times, or recording the number of repetitions you can do in a given period (2).
The findings of recent studies suggest performance in this test is influenced not just by factors associated with strength, but also balance and mobility, and a vast array of psychological factors (1).
But what about when sit-to-stand hurts?
Low back pain can reduce spine, hip and pelvic floor motion due to conscious or unconscious guarding associated with pain (3).
Multiple studies have shown there are changes in how energy is transferred between bone and soft tissue in the spine, pelvis, and legs associated with pain (4). And that inefficient energy flow or transfer then places more demand from everything. A cycle of back pain-altered biomechanics can start, creating more back pain. With all the changes in energy transfer and muscle power, everyday activities such as standing up from a sitting position can become difficult.
Muscle coordination, balance and mobility are affected, and psychological factors start to play in and effect our beliefs and so the cycle continues (1).
Stopping the cycle can be easy.
You just bypass your traditional route to standing and try something different altogether.
Try these simple tips. You may not need all of them:
RELAX before you start
WIDER STANCE - think SUMO wrestler
SLOW DOWN (TIMING) - move more slowly
HANDS ON KNEES
BREATHE OUT - this is a big one. The less compression in the container of the torso the better.
Many people are surprised they can suddenly sit-to-stand with no pain after weeks or months experiencing twinges and outright muscle spasms when trying to stand after sitting.
After a few days of pain free sit-to-stand, you can try heading back to your old ways as there is rarely a “right” way to do something. You can get up and down any way you choose, each one of them equally valid.
As a lot of research shows, the way you do something does start to matter. If you always get up and down via your arm on the desk, leaning forward to create momentum, it means the strengths necessary to do it another way are waning.
Can this help if I have pain elsewhere?
This can also break the cycle if you experience pain in hips, knees and feet.
references
1. J Gerontol A Biol Sci Med Sci. 2002 Aug;57(8):M539-43. Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people. Lord SR1, Murray SM, Chapman K, Munro B, Tiedemann A.
2. Exp Gerontol. 2018 Oct 2;112:38-43. doi: 10.1016/j.exger.2018.08.006. Epub 2018 Sep 1. The sit-to-stand muscle power test: An easy, inexpensive and portable procedure to assess muscle power in older people. Alcazar J1, Losa-Reyna J2, Rodriguez-Lopez C1, Alfaro-Acha A3, Rodriguez-Mañas L4, Ara I1, García-García FJ5, Alegre LM6.
3. Explain Pain Supercharged G. Lorimer Moseley and David S.
Butler. Adelaide City West: NOI Group Publishers, 2017. ISBN: 978-0-6480227-0-1
4. Gary L. Shum, PhD, et al. Energy Transfer Across the Lumbosacral and Lower-Extremity Joints in Patients with Low Back Pain During Sit-to-Stand. In Archives of Physical Medicine and Rehabilitation. January 2009. Vol. 90. No. 1. Pp. 127-135.
Nourish the physical
It's time to make sure the body doesn't stop moving over the southern hemisphere cold spell. We've pulled out some new moves. We've trialed them with living, breathing patients at the clinic and refined them with colleagues and been inspired by some unlikely sources.
All the movements are hopefully simple enough, novel enough and inventive enough to inspire you to move your body just a little bit more in the environment you move through every day. Keep your nerves flossed, your muscles pumped, your tendons lubricated, and every part of you sliding and gliding without mishap. Peel yourself out of that chair and wiggle and jiggle with us.
Look out for Catherine squashing ants. Vicki exuding calm and peace. Mark displaying movements for the less mobile gentleman. Angie embarrassing her children (and potentially herself) with her speedy flossing maneuvre.
REMEMBER THE RULES PEOPLE:
- easy and painless
- lots of repetitions (I can do it I can do it I can do a little bit more) 25-75 repetitions (1-3) sets/day
- joyful, fun, no protocol, no commitment beyond maybe a few days
- if you’ve tried to make it easier and it still feels bad (or pointless) then STOP
You might notice that many of us are wearing the same clothes as this time last year. Rest assured we are a year older, we just haven't been shopping. Mark might have got some new fancy socks. No fast fashion here!
INSTA VIDEO SERIES
We will try and post a video a day over the month of June. Fingers crossed!
Mobilisation Series 2018
No. 1. Prancing - variation on legs up the wall. Great for hips, knees and ankles. Also an excellent neural mobilisation for the legs as well as improving drainage from the lower limbs. If your legs start to get a bit tingly then have a break. Try again another time. That tingling feeling should improve over time.
No. 2. Seated rib twist - Great mobilisations for your upper back, ribs and posterior shoulders. While seated, keep a straight back with arms fully extended in front of you. Then twist left to right as far as you feel comfortable. See if you can increase your range as you go.
No.3 Catching Butterflies - Just imagine catching (and releasing) butterflies fluttering by. Excellent mobilisations for shoulders, upper back and lower back.
No.4. Prayer Pull - in all the good vibes around you into the prayer position. Great for shoulders and wrists. Get all your co workers around to do it too. That would be a sight!
No.5. Foot and ankle mobilisation - This one is better performed on soft floors. Just like Mark in this video you will probably feel pretty tense through the top of your foot and ankle. Take it slowly!
No.6. Seated Cat Camel mobilisation - Nice one for the desk worker to get the upper back and lower back moving. Probably more appropriate when at work than getting on the floor and doing it on all fours!
No.7. Semi squat - So this one is equal part strengthening and equal part mobilisation. Good for hips, knees and the low back. Start with a chair that is pretty tall or the edge of your bed. Imagine you are going to squash some ants with your bum. That’s about how much sitting pressure you will need. Repeat as many times as you feel comfortable. Catherine is quite good at squashing ants with her bum. That’s how she did it when she was a kid.
No. 8. Prancing feet - Nice little mobilisation for the feet and ankles. This has the added advantage of being great for mobilising nerves and pumping fluid from the lower legs. Mark’s hamstring flexibility needs a little work. You might be able to get your bottom closer to the wall. Mark likes looking at his socks. They have bananas on them.
No. 9. Picking Apples - No body really likes fruit picking for hours on end. It’s hard work! But imagining doing it for a few minutes is great for your shoulders, upper ribs and upper back. Petra likes picking apples in particular. She really likes Modi apples. She is smiling imagining herself picking Modi apples.
No. 10. Flossing - A playground and Youtube favourite. Little do people know this started as a hip, pelvis and low back mobilisation. Floss those hips! Angie can Floss. Mark cannot Floss. That is why Angie is demonstrating Flossing and not Mark. We can all thank Angie that she didn’t let Mark do the Flossing video.
No.11. Touching the back of the chair - Sitting at the desk all day does no one’s upper back, neck and shoulders any favours. This one is pretty easy and may even be incorporated into your office chair dance routine to show your work colleagues. You know you want to! Catherine can do the twist. Well, Shake it up Catty now Twist and Shout Cmon cmon cmon Catty now Cmon and work it all out
No.12. Seated hip twist - Keeping with our twist theme. This little mobilisation can help with your hips and low back. Probably go easy if you have some very stiff and sore hips. Start with a higher seat and do less of a pivot in the seat. Ease into it! Petra used to dance. Dancing is good for the soul as well as the hips. Petra does not dance on request. So don’t ask!
No. 13. Drive the bus - Pretty self explanatory this one. Just make out the bus doesn’t have very good power steering and you really have to put your back into it. Good for the upper back and lower back. If you steer a bit bigger you’ll get a bit more movement into the back of the shoulders. Angie drives the bus. You can tell by the grin she is in charge. Get on board the Mobi Bus!
No.14. Bow and Arrow - One of our personal favourites. Terrific for mobilising the upper back and shoulder blade area. Do it nice and slow with some deep breathing. Angie doesn’t own a bow and arrow. She does have nice red boots though.
No.15. Thread the needle (standing) - Excellent for the upper back and the back of the shoulders. Try to thread one arm under the other until you touch the tip of shoulder on the wall. Mark’s needle work is terrible. It is gender stereotypical to say it is a man thing. Try harder Mark!
No. 16. Walk the line - Walking the imaginary line makes you swing your hips (butt) from side to side. Really good mobilisation for the low back and hips. Catwalk Cat demonstrates walking the line. She exhibits a suitable amount of sass. Be sassy. Be like Cat.
No.17. Downhill Skiing - It’s winter and the slopes are calling. Practice some downhill technique which will help get your shoulders, hips, knees moving. Petra and Angie are having a downhill race. Neither of them have been skiing before. This should be fun!
No.18. Tip the waiter - Nice mobilisation to relieve tension from the forearms and elbows. Clearly Mark wasn’t impressed with his waiter service. His tip seems to come with some regret. Smile Mark! It can’t have been that bad?
No. 19. Ballerina - Pretending you are a ballet dancer comes with some cool benefits. This mobilisation helps your low back, side of your hip/thigh, upper back, arm and shoulder. That’s lots of birds with one stone! Angie doesn’t know her Arabesque from her Grand Jété. This does not stop Angie pretending she is a graceful Swan. She is a Southern Hemisphere Swan though - dressed in black.
No.20. Half-pike - Excellent mobilisation for the posterior chain of large muscles through the back, bum and legs. Mark’s half-pike does not resemble anything like you would see in gymnastics. He seems more like the Tin Man from Wizard of Oz. He is all heart though....no problems there!
No.21. Jack Rabbit Slims Twist Competition Inspired by the classic dance scene in Pulp Fiction with Uma Thurman and John Travolta. This little move is great for hips, knees, ankles and low back. Petra has da moves. She is winning that trophy if it’s the last thing she does! Ummmm....don’t’ tell her there isn’t a trophy.
Ain't that swell(ing)?
A relaxing exercise to relieve tired legs and promote fluid return
There will never be enough research to provide answers to every possible clinical question but in regard to uncomplicated swelling, there are some well researched options including: compression, elevation and specialised physical activity.
Swelling can occur in a single joint, or in a limb due to trauma, congestion due to inactivity or heat, or post-surgery. Complicated swelling in a limb or more widespread swelling can be caused by issues with the heart and vascular system or the kidneys.
When you see both ankles swollen after a long, hot, day at the races, this is most likely simple, uncomplicated swelling, with some pooling of lymph fluid. Lymph is mostly contained within a series of vessels called lymphangions but it continuously circulates in and out of the tubes, into the tissues, to provide nourishment and collect leftover metabolic products. The tubes are muscular and capable of contracting and propelling the lymph forward in a series of movements but they also rely on the compression of the skeletal muscle contractions that happen during normal everyday activities, like walking (1).
So if you’re standing around in high heels at a party or standing in the sun watching your son’s soccer match for long periods, then the lymph fluid can pool at the end of the limbs - fat toes, swollen ankles and tight rings on your fingers. You may also experience a sensation of heavy legs.
My take home advice for this uncomplicated swelling is a mobilisation at home. I might also suggest it for people who might be struggling to move some fluid in their ankle after a sprain, or they are experiencing slightly swollen legs in the afternoon (lymphoedema tardis) on hot days. It can also be helpful for DOMS (delayed onset muscle soreness) for people who have worked out the day before.
This move is a combination of elevation and activity. It was inspired by ‘legs up the wall’ in yoga and the ‘prancing’ moves that you do on a reformer in Pilates. It gets people on their backs, relaxing for five minutes or more, it empties the legs and mobilises the feet and ankles. It promotes the normal drainage of lymph and is different to manual lymph drainage, which is a specialised massage technique.
Legs up the wall/elevated with Prancing
This can be completed once daily, especially after a long period of sitting or standing or walking. Most likely at the end of the day.
Lie on the floor with your legs and feet up the wall or elevated on the couch.
You should be comfortable so it's not about getting a stretch behind the leg.
Alternately, point and flex your toes and knees - prancing!
Complete about ten times and then have a rest and complete again and again over a period of around five-ten minutes. You can separate your toes on/off through the process. You can also push your heels into the wall/ottoman/couch to work the big muscles behind the legs.
In your breaks take some slow, deep breaths *
Your legs might feel tingly, this is a signal to move out of the position.
Bring your feet slowly down the wall
(PAUSE PAUSE PAUSE)
Roll to your side
PAUSE as your blood pressure will have changed.
Come to sitting
(PAUSE PAUSE PAUSE)
Then come to standing
* Breathing also propels lymph up and out of limbs due to the suction pump like affect created by the lungs and diaphragm.
Is that a knot in my muscle?
54 year old Barbara has pain extending across the top of the shoulders, frequently extending into the neck. Is it a muscle? Is it a trapped nerve? Or is there something more complex going on? Why didn’t it hurt six months ago?
Surely, the muscles are tight?
They may actually be a bit wound up actually, especially with a little bit of stress in your life. Most of us have experienced a rush of adrenaline in the work place, at home or even crossing the road. Adrenaline is great; it prepares your body to get moving by increasing your heart rate and your breathing so you can send more oxygen to your muscles. The free-floating adrenaline also binds to your muscle spindles, increasing the resting tension so your muscles can burst into action.
Most of the time though, we’re left not bursting into action but taking a deep breath and getting on with not moving.
But is all that tension going to make a knot?
One study specifically found there is no clear evidence of a strong relationship between increased electrical activity of muscles and the development of musculoskeletal disorders (2). Keep in mind this was one study, and the definition of a musculoskeletal disorder might not include Barbara and her sore muscles across the top of her shoulders.
I can definitely feel a knot in there.
There is zero consensus about what that hard lump in the muscle actually is and ‘knot’ seems like a fairly innocuous word to all those other than knitters and sailors. And just like knots in the real world, most are amenable to unwinding given the right intervention.
Bio (Body) Psycho (Brain) Social (Environment/Interaction)
Like many things in the body and pain, the pathophysiological mechanisms remain unclear. We are always more than the sum of our parts and if we look at the risk factors above, you need to find out whether Barbara has stress in the workplace, disappointment in her job, her relationship, whether she has a cold, whether her dog just died and she’s stopped walking, whether her children left her with five grandchildren on the weekend? And then what is her ability to control any or all of these aspects of her professional and personal life?
See the problem? This is why a medical history is important, why Osteopaths ask a lot of questions, why we need to spend more than seven minutes with you to grasp how to help you out of pain. We need to find out what’s tipped you from not even noticing that you’re a bit tight, to not being able to tolerate your shoulder discomfort a moment longer.
Hopefully, it’s as simple as softening off the muscles, turning a computer to a better angle, taking some micro breaks in the workplace and heading out for a daily walk.
Let’s get back to Barbara...
Step One:
take a slow deep breath
drop your shoulders
release the tension
Step Two:
get up from your desk occasionally
wave your arms around or run them quickly on the spot for ten seconds
smile at your colleagues and let them know you’re not crazy
Step Three:
Find some daily exercise that you love
Step Four:
Advise your children you can no longer care for all five grandchildren at once for an entire weekend.
References:
Ratey, John J.,Hagerman, Eric. (2008) Spark :the revolutionary new science of exercise and the brain. New York : Little, Brown,
Westad C, Westgaard RH, De Luca CJ. J Physiol. 2003 Oct 15;552(Pt 2):645-56. Motor unit recruitment and derecruitment induced by brief increase in contraction amplitude of the human trapezius muscle.
Surviving breastfeeding
I saw a lovely new mother yesterday who asked me “So how exactly do you survive this breastfeeding palaver?”
Aside from the obligatory tender nipples and general exhaustion, her experience of pushing a baby out, her subsequent recovery and breastfeeding on the whole had been positive. Her comment on the downside of breastfeeding was, ‘…there is just so bloody much of it’.
When you’re in the midst of the first few weeks, it’s hard to foresee that the frequency of feeds in the early weeks doesn’t continue forever.
What is rarely acknowledged is the additional stress on every new mother’s body, especially if things are going well. All that sitting, holding, squeezing, loving, staring, and connecting constantly to a needy, small human attached to your breast, can mean your neck, shoulders, arms and wrists can take a bit of a battering.
I asked this lovely mother to demonstrate some of the mobilisations she was doing to combat these behaviours.
Neck mobilisations when feeding
Bear Hugs - good for the chest, shoulders and upper back
Bow and Arrow - great for shoulders, thoracic spine and neck
Do mobilisations help?
They certainly won't hurt and they'll remind you to commit just a small amount of moving and thinking time to your own body every day.
I'm still feeling a bit broken.
Sometimes you need a helping hand to maintain the energy needed to nurture new humans. The osteopaths or massage therapists at Fairfield Osteopathic Clinic can work with you to mange any post-pregnancy, post-labour, excessive baby-carrying, or breast feeding aches and pains.
You can book online or call 9489 0981 to schedule an appointment.
Morning, I'm Broken!
We all know we feel better physically, emotionally and psychologically if we’ve taken the time to exercise in the morning but how do we reduce the general ache and stiffness that many of us feel before we even get out of bed?
The main thing people consult an osteopath for is pain. Pain in their low back, between their shoulder blades and in their neck.
But a frequent complaint in practice is people reporting a general feeling of stiffness or ache in all sorts of places when they try to leave their beds of a morning. So while the good news is you aren’t woken with pain in the night, the moans and groans start when you haul yourself out of bed. And it can be enough to wake your partner, or the dog.
Is there any research on this?
There was nothing focused in the literature about whether stiffness improves with exercise, and certainly nothing as specific as morning stiffness. Although this may be because no one asked the question in an original study (i.e. it wasn’t set as a specific outcome for the population being studied).
An educated guess…
Waking with stiffness would be due mostly to your body trying to adapt to new behaviours or resting postures you’d get out of given the chance if you were awake.
Examples of the types of things that might cause stiffness in your neck:
Stomach sleeping
Bingeing on Netflix in bed with a laptop
Long long hours at a computer
Long drives on straight roads
Examples of the types of things that might cause stiffness in your low back:
See above
Examples of the types of things that might cause stiffness in your feet and achilles:
Standing for long periods (cooking, ironing, gallery walking)
New exercises or an increase to new exercises (skipping, golfing, new shoes)
Or just good old DOMS the day or two after a workout at the gym
What exactly will you be mobilising?
There is no exactly about it….you’ll be mobilising nerves, muscles, tubes, connective tissue, all manner of fluids including sparking up your brain juices.
A word of caution in the mornings.
Your nervous system is a bit protective of itself when we first wake up, as anyone who has ever done yoga before 6am will attest. That burning tightness behind your knees is not your hamstrings it’s actually your sciatic nerve letting you know it does not appreciate being pulled quite so aggressively before the sun has even risen.
Give it a fortnight.
It might take a while to tell if your body is going to love a new regime but in the meantime you can reward your mornings with these mobilisations:
ACHILLES and FEET stiff when you stand on them in the mornings?
Prancing with straight legs
Heel to toe
Holding onto the door frame squat
If your low back stiff in the mornings?
Try this series of movements:
LB twist
Knees to chest
Cat/Camel
Child Pose with Lateral Flexion
UPPER BACK and NECK stiffness in the mornings?
Sidelying bow and arrow
Neck slider/shoulder shrugs
All our mobilisations will be available on our BLOG this month.
So make yourself a morning routine that suits you.
Share these tips and tricks to put some spring in someone else’s step this August.
Turmeric: The Golden Spice
Turmeric (curcuma longa) has been making an appearance in health food magazines and in the hot beverages of the Fairfield and Northcote hipsters. So what is all the hype about? Are there real benefits in replacing our lattes or in a more substantial dose in a therapeutic sense? Is there any evidence that it’s effective?
Resident naturopath, Vicki van der Meer, and osteopath, Catherine Burns looked to the science for information.
History
Turmeric has been used for centuries in Traditional Chinese and Ayurvedic medicine, and it’s eaten in abundance in many Asian cuisines. In Western households a (probably outdated) packet of turmeric was often kept to throw in the occasional curry, but in the past few years the benefits of turmeric have been investigated by both mainstream and complementary medicine.
What does it do in our body?
Turmeric contains compounds called curcuminoids, the most important of which is curcumin. Most of the studies on turmeric are based on extracts that contain a high level of curcumin, and it’s thought that many of its actions are due to curcumin.
Turmeric’s benefits are purportedly widespread and many, but most of the research suggests it is has anti-inflammatory, antioxidant and immune-modulating properties (1). There is emerging evidence that turmeric can help in cancer prevention and can be used as adjuvant in cancer treatment (2). Epidemiological data suggests a correlation between turmeric and lower rates of colorectal cancer in Asian countries. (15)
Antioxidant
Oxidative stress can lead to tissue damage and contribute to chronic disease development. It plays a role in arthritis and inflammatory diseases. As an antioxidant, turmeric can protect against the potentially harmful effects of oxidation. (16)
Anti-inflammatory
As an anti-inflammatory, turmeric inhibits the production of inflammatory chemicals, such as leukotriene and prostaglandins. It has shown promising results in the treatment of multiple chronic inflammatory diseases (3) including:
- Osteoarthritis (4,5,6,7)
- Rheumatoid Arthritis (8,9)
- Cardiovascular disease (10)
- Type 2 Diabetes Mellitus (11)
- Inflammatory bowel disease - Crohn’s Disease & Ulcerative Collitis (1)
- Irritable bowel syndrome (1)
- Anxiety & Depression (14)
Osteoarthritis
A number of studies support the use of turmeric for osteoarthritis. Turmeric has been shown to decrease pain levels, improve morning stiffness and joint movement, increase walking distance and decrease inflammatory proteins on blood testing. (4,5,6,7) The participants in these studies used less over the counter anti-inflammatories and experienced fewer medication side effects.
The research indicates that turmeric may have similar efficacy as over-the-counter pain medications such as ibuprofen and voltaren (5) for osteoarthritis.
Rheumatoid Arthritis
Turmeric was found to be effective in improving morning stiffness, walking time and joint swelling, either similar to or to a lesser extent than other over-the-counter anti-inflammatory drugs (8,9). Whilst the results for rheumatoid arthritis (RA) aren’t incredible, turmeric was well tolerated by all participants, in contrast to the side effects of other anti-inflammatory medications. It’s important to note that RA is a multi-system autoimmune inflammatory condition, so to get real improvements a multi-system approach is needed.
How does it compare to Non-steroidal anti inflammatories (NSAIDS)?
NSAIDs, such as Diclofenac (e.g Voltaren) or Nurofen (e.g. ibuprofen), which are often used for pain relief and to decrease inflammation, can cause gastric ulceration. Turmeric has the benefit of not causing ulceration at therapeutic doses.
The research suggests that turmeric is effective in chronic inflammatory conditions, rather than for use with an acute headache or injury.
How to take Turmeric
Most of the studies on turmeric are based on extracts that contain a high level of curcumin. Therefore, although consuming turmeric in beverages and everyday cooking has many benefits, if you have an inflammatory condition, and are using turmeric therapeutically, you need a turmeric supplement that has high levels of curcumin to get real anti-inflammatory effects.
Supplements
There are many different products available, and as is the case with many herbal supplements, they vary in terms of quality. Turmeric is poorly absorbed through the gut wall, so good quality products have been formulated to optimise absorption. Don’t choose a turmeric based product without it being recommended by a health professional.
As a spice
Consuming turmeric in home cooking or as a beverage in the form of a latte, provides many health benefits, as you are having a warming, antioxidant, anti-inflammatory food. You can certainly do this as well as taking a more concentrated supplement. When consuming turmeric at home there are some things you can do to help the curcumin become more available. It should be consumed with black pepper, and as it’s fat soluble, having it with a meal helps its absorption
Safety
Turmeric is considered very safe at normal dietary or therapeutic dosages (2). Trials have demonstrated doses up to 8000mg/day are non-toxic to humans (12) which is well above the recommended therapeutic dosages.
Small warnings
High doses are generally not recommended during pregnancy or for those wanting to conceive (4).
Little research has been performed on interactions between turmeric and other medications. Theoretical and speculative data suggests turmeric should not be used in combination with antiplatelet drugs, anticoagulant therapy or cyclophosphamide (a chemotherapy drug). It is best to stop taking turmeric within 1 week of major surgery (2).
A Final Word
It’s exciting to see a humble spice garner so much scientific and medical attention. As more people seek alternatives for pain relief, turmeric is proving to be a safe and effective option. Check with your health professional if turmeric would be of benefit of you. Our naturopath, Vicki, is able to guide you on the most appropriate dosage and type of turmeric for your complaint.
References
(1) Dulbecco P. & Savarino V. (2013). Therapeutic potential of curcumin in digestive diseases. World J Gastroenterol, 19(48):9256-70
(2) Braun, Lesley, and Marc Cohen. Herbs and Natural Supplements, Volume 2, Elsevier Health Sciences, 2015. ProQuest Ebook Central
(3) Henrotin Y, Priem F., Mobasheri A. (2013). Curcumin: a new paradigm and therapeutic opportunity for the treatment of osteoarthritis: curcumin for osteoarthritis management. Springerplus, 2(56)
(4) Pergolizzi, J.V., Eke-Okoro, UJ., Breve, F., Taylor, R., Raffa, R.B. Postgraduate Medicine. Conference: 2016 Pain Week Conference. US. Turmeric: Its potential role in analgesia.
(5) Daily, J.W., Yang, M., & Park, S. (2016). Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. Journal of Medicinal Food, 19(8): 717-729
(6) Belcaro G., Cesarone MR., Dugall M., Pellegrini L., Ledda A., Grossi MG., Togni S., Appendio G. (2010). Product-evaulation registry of Meriva, a curcumin-phosphatidylcholine complex, for the complementary management of osteoarthritis. Panminevera Med, 52(2 Suppl 1):55-62
(7) Belcaro G., Cesarone MR., Dugall M., Pellegrini L., Ledda A., Grossi MG., Togni S., Appendio G. (2010). Efficacy and safety of Meriva, a curcumin-phosphatidylcholine complex, during extended administration in osteoarthritis patients. Altern Med Rev, 15(4):337-44
(8) Deodhar SD, Sethi R, Srimal RC. (1980). Preliminary study on antirheumatic activity of curcumin (diferuloyl methane). Indian J Med Res, 71: 632-4
(9) Chandran B & Goel A. (2012). A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis. Phytother Res 26.11: 1719– 1725
(10) Jiang S et al. (2017). Curcumin as a potential protective compound against cardiac disease. Pharmacol Res, 119:373-383
(11) Zhang DW et al. (2013). Curcumin and Diabetes: A Systematic Review. Evid Based Complement Alternat Med. 636053.
(12) Cheng AL et al. (2001). Phase I clinical trial of curcumin, a chemoproventative agent, in patients with high-risk or pre-malignant lesions. Anticancer Res 21.4B: 2895-900
(13) Prasad S, Aggarwal BB. Turmeric, the Golden Spice: From Traditional Medicine to Modern Medicine. In: Benzie IFF, Wachtel-Galor S, editors. Herbal Medicine: Biomolecular and Clinical Aspects. 2nd edition. Boca Raton (FL): CRC Press/Taylor & Francis; 2011. Chapter 13.Available from: https://www.ncbi.nlm.nih.gov/books/NBK92752/
(14) Ng QX, Koh SSH, Chan HW, Ho CYX. (2017). Clinical use of curcumin in depression: a meta-analysis. J Am Med Dir Assoc. 18(6):503-508
(15) Plummer SM (2001) Clinical development of leukocyte cycloxygenase 2 activity as a systemic biomarker for cancer chemopreventative agents. Cancer Epidemiol Biomarkers Prev 10,12:1295-1299
(16) Menon VP, Sudheer AR (2007) Antioxidant and anti-inflammatory properties of curcumin. Adv Exp Med Biol 595:105-125
Get Your Body Moving - 30 mobilisations for everybody
Let’s be honest people. We can’t always be as active as we want.
We find it inconvenient and at times impossible to answer the call for natural movement*. It’s hard to run across the grassy plains when we’ve only got a concrete path or it takes a two-hour train ride to get to a wilderness trek up the side of a mountain. And we have to be dedicated in searching out opportunities to squat, throw something, wrestle, dance, run, leap, climb or hang upside down off a branch.
We need to do these things, but when we can’t, you can offer something else to your beautiful body. Something to nourish, so it can flourish! And so comes the concept of 30 ideas to mobilise your body.
WHAT THE HECK ARE MOBILISATIONS?
Mobilisations are like dynamic stretching. They sit somewhere in between rehab and lifting weights. It’s difficult to get any specific research to support this kind of movement but we can draw some conclusions based on evidence supporting early movement after surgery for hip and knee replacement (1) daily movement for acute low back pain rather than bed rest (2) safe movement following a car accident instead of a neck brace (3) and a long history of committed movement in multiple cultures (tai chi, qi gong, ceremonial dancing, prayer and worship).
We might even want to throw it out there that mobilisations might be useful for:
- pain relief
- early healing
- micro breaks
- preventing pain
- preventing injury (I said maybe!!)
the dip in the couch
We can get attached to not moving. You know the feeling when you’ve succumbed to the dip in the couch or you’ve shaped your body to the back of your ‘ergonomic’ chair. Our bodies sometimes try to get us to move out of desperation before the thinking part of our brain even gets a say. We crack our neck, stretch our back over the back of the chair or twist forcefully to one side. Take charge of your runaway body and acknowledge that alarm bell for what it is.
Convert that animal instinct into something to nourish your cells in all your tissues, including your brain. Pump and stretch those clumping cells and provide them with the nutrition they need via blood supply using the mechanics of your own body. Help juice up your joints, tendons, skin, brain cells, muscles, nerves, ligaments, organs and move those tubes that string them all together.
we've put together 30 great ideas to inspire the modern human to combat physical stagnation.
The rules to follow:
- easy and painless
- lots of repetitions (i can do it i can do it i can do a little bit more) 25-75 repetitions (1-3) sets/day
- joyful, fun, no protocol, no commitment beyond maybe a few days
- if you’ve tried to make it easier and it still feels bad (or pointless) then STOP
INSTA VIDEO SERIES
SEATED ROTATIONS
hip and back tightness/pain, neck stiffness, excessive sitting
STIR THE POT
neck stiffness/pain, upper back pain, shoulder pain
FOREARM MOBILISATIONS
arm and shoulder tightness and pain, desk worker
SIDE RAINBOW
side stiffness, hip and back tightness, shoulder pain
HIP RELEASE - KATY BOWMAN STYLE
hip and buttock tightness/pain
STANDING ROTATIONS
stiffness everywhere, excessive sitting
SEATED GLUTE STRETCH
hip pain , low back pain , improve hip mobility
CHEST OPENING AND CLOSING
upper back, chest and shoulder tension
ALPHABET EXERCISE - ARM SWINGS
thoracic and shoulder tension, low back too
BEAR HUGS
more dynamic than chest openings, more arm wrap around, good for shoulder and upper back tension
ASSISTED SQUATS
low back, hips, knees and ankles
ANKLE TWIRLS
stiff ankles, fluid congestion, motion is lotion
CAT AND CAMEL
good for spinal mobility, ask practitioner if this is right for you
THREAD THE NEEDLE
thoracic and shoulder mobility, low back stiffness
THREAD THE NEEDLE (V.2)
thoracic and shoulder tightness, standing at the desk version
CATH A BUTTERFLY
shoulder, hand, forearm and elbow
HIP DROPS
low back hips and pelvis
LOWER LIMB AND GLUTES
glutes, hips, hamstrings and calf
WAG THE DOG
lower back, hips and pelvis
LEG SWINGS
hip stiffness, low back, balance, positional awareness
DO THE SWIM
shoulders, upper back and neck
LEG SWING V.2
hips and low back
THE LAWNMOWER
Upper back, lower back and shoulders
NECK MOBILISATION
write out no. 1-10 with your nose, for general neck stiffness
SHOULDER SWINGS
good for stiff shoulders - who would have thought!?
BOW AND ARROW STANDING
shoulders, upper back and chest
FOOT AND ANKLE MOBILISATION
foot and ankle mobility
CHEST OPENINGS
chest, shoulders and upper back
THE SHOVEL
general back and shoulder - better without a real shovel!
DISCO TIME
looking good ladies - dance your way to better movement!
THAT'S 30! PHEW!
References
(1) Guerra, Mark L., Parminder J. Singh, and Nicholas F. Taylor. "Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review." Clinical rehabilitation 29.9 (2015): 844-854.
(2) Hagen, Kåre B., et al. "The Cochrane review of bed rest for acute low back pain and sciatica." Spine 25.22 (2000): 2932-2939.
(3) Teasell, Robert W., et al. "A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 2–interventions for acute WAD." Pain Research and Management 15.5 (2010): 295-304.
(4) Chan, Roxane Raffin, and Janet L. Larson. "Meditation interventions for chronic disease populations: a systematic review." Journal of Holistic Nursing 33.4 (2015): 351-365.
thank you for your inspiration:
How to do Joint mobility drills - Todd Hargrove
Mobilize! Dynamic joint mobility drills are an alternative to stretching - Paul Ingraham
Therapeutic Stretching - Eyal Lederman
Nutritious Movement - Katy Bowman
Daniel Wolpert - TED talk
There are devoted proponents for natural movement who have wonderful websites. Check them out:
Mark Sisson, Katy Bowman, Phillip Beach
"I get knocked down but I get up again! You're never gonna keep me down!"
Why do people fall over?
There are multiple reasons that people fall. If we’re young and healthy it is generally to do with misadventure, sport or intoxication. As we age, risk factors for falling are varied and are linked to factors such as advancing age, sensory decline (think vision and bifocals), reduced lower limb strength and co-morbidities (e.g. obesity, cardiovascular disease or cognitive impairment) (1).
There has been a stack of research into implementing strategies for preventing falls in an ageing population and at the top of the list is exercise.
Fall preventions strategies
There is no doubt that exercise interventions reduce falls (2). There is recent Cochrane systematic review (3) that has even summarised the most effective programmes to help reduce falls. They involve dynamic exercise, three times per week for three months. No surprises there.
Okay - now I can't get up!
What is surprising is the startling statistic that up to half of non-injured fallers are unable to get up again (4,5) and to put it rather bluntly if you can’t get up again, you are at greater risk of falling again (6,7) and more likely to die if you do (8). If you’re stuck on the floor for greater than 60 minutes, you’re also at risk of pressure sores, hypothermia, dehydration and someone may suggest that you shouldn’t be in your own home (8).
Data from the UK suggested that only 4% of fallers were taught how to get up again (9). So I’m here to suggest that if you don’t know if you can get up and down off the floor then you need to get down there and see if you can. Once you’ve done it, keep doing it. Practice to prevent and reduce the fear of falling.
No more excuses
Remove any excuses “I’ve had a knee replacement” “My belly gets in the way” “What if I can’t get up again - how embarrassing”.
Don't panic!
The best way to reduce panic about being on the floor is if you know you can get up because you’ve been doing it every day. It’s also good to know 1) how to keep warm on the floor if you are stuck there due to an injury, and 2) how will you get help if you are stuck?
What became apparent when searching sources for this BLOG was there seems to be a fairly prescriptive way of getting up off the floor. This was challenged when I asked my own parents (both in their mid-70s) to show me how they get up off the floor. And then in support of my anecdote is a 2000 study (10) that videotaped and compared young, healthy adults with older, healthy adults and how they rose from the floor. They concluded with increasing age and physical deconditioning, multiple body positions were used during rising from the floor (FIGURE 1). There was a tendency to use both the hands and knees on the floor to presumably minimize the lower extremity strength required and maximize stability and postural control.
THere ARE MULTIPLE WAYS TO GET OFF THE FLOOR
Figure 1 (10)
Scroll through for half kneel (my mum found this really difficult)
Scroll through for Bearwalk (my mum's preferred version)
Take away points:
Practice getting up and down off the floor every day.
If you do fall down “Don’t panic”.
When you're ready to try getting up “Don’t rush”
References
(1) Campbell, A. John, Michael J. Borrie, and George F. Spears. "Risk factors for falls in a community-based prospective study of people 70 years and older." Journal of gerontology 44.5 (1989): M112-M117.
(2) Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull 2011; 22(4):78-83.
(3) Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance in older people. The Cochrane Database of Systematic Reviews 2011;(11). )
(4) Skelton D, Dinan SM, Campbell M, Rutherford OM. Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34(6):636-639.
(5) Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls among elderly persons. Journal of the American Medical Association 1993; 269:65- 70.
(6) Bergland A, Wyller FB. Risk factors for serious fall-related injury in elderly women living at home. Injury Prevention 2004; 10:308-313.
(7) Bergland A, Laake K. Concurrent and predictive validity of "getting up from lying on the floor". Aging Clinical and Experimental Research 2005; 17:181-185.
(8) Fleming J, Brayne C. Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. BMJ 2008; 337.
(9) Goodwin V, Martin FC, Husk J, Lowe D, Grant R, Potter J. The national clinical audit of falls and bone health - secondary prevention of falls and fractures: a physiotherapy perspective. Physiotherapy 2010; 96(1):38-43.
(10) Ulbrich, Jessica, Aarti Raheja, and Neil B. Alexander. "Body positions used by healthy and frail older adults to rise from the floor." Journal of the American Geriatrics Society 48.12 (2000): 1626-1632.
Take a breather.
There is growing evidence supporting a wide range of benefits for mindfulness and mediation but there remains uncertainty as to whether consciously interfering with our breath is of equal standalone benefit.
I don’t think anyone would disagree with the basic premise that breathing is essential for life. Breathing maintains tissue homeostasis, and responds in a timely fashion to increased carbon dioxide (CO2) levels (1).
What happens in the body when we breathe?
I apologise for not even trying to explain the mechanisms of breathing. Even the simplified version of how breathing is triggered and maintained involves a complex series of whole body and brain events. In fact, the underlying mechanisms that control breathing movements and neuronal pattern generation are under debate (2).
The bottom line is the complex, coordinated efforts of our brain and body adjust our breathing to the demands placed on the body by different activities, such as sleeping or exercising.
What happens to our breath when we're stressed?
Our breath can reflect our emotional state. If we are nervous or upset, we don’t consciously start to breathe quickly, it just happens.
In a whole series of events, our heart rate goes up, we start to breathe faster, blood diverts from our gut and is sent to our muscles so we can run away.
It constricts the pupils of our eyes so we can focus on our attacker. It dilates the bronchi of the lungs to increase blood oxygenation, and converts energy stored in the liver into fuel for strength and stamina.
Interestingly, a similar series of events happens with the cardiovascular effort of exercise and for some individuals, this body process can induce a sense of panic.
Does it work vice versa? Can we use our breath to influence our emotional state?
Our rate of breath can change the neurochemistry of the brain quickly with a subsequent affect on the body. But can it impact on the sort of emotions we are feeling? It is thought that deep and slow breathing facilitates emotional regulation, relaxation and a level of distraction (3)
If we breathe quickly will that induce panic? Does something special happen when we consciously breathe slowly? Can we induce calm, can we induce sleep? (4)
Can we use our breath to modulate pain?
A study on the effect of relaxing deep and slow breathing found that pain thresholds were increased and sympathetic activity was reduced from only six weeks of practice of deep slow breathing. (3)
Deep slow breathing reduced pain ratings and pain unpleasantness in healthy subjects (5)
However, there was little change to pain ratings or unpleasantness if the subject had been diagnosed with fibromyalgia. This is thought to be due to complex and altered thought processes. In fibromyalgia subjects there seemed to be a decreased ability to sustain the positive effects of deep slow breathing.
As I mentioned even breathing is a fairly complex thing to explain and the neurophysiological explanation for deep breathing reducing pain is even more complex and comes under the category of hypothesis*.
Breath therapy is safe
Whilst there may not be a water tight answer regarding the effectiveness of breath therapy, a randomized control trial for chronic low back pain, breath therapy was declared safe (6).
Also, in the early stages of the trial, breath therapy compared to physical therapy alone showed improved function, and improved physical and emotional state. At six months: physical therapy showed a greater improvement across all measurements, including vitality (6).
The right tool for the job
The answer, as always, is choosing the right tool for the job, at the right time, and in the right context. Using breath as a treatment tool together in different measures with other types of therapies in early and latter stages of recovery should help influence positive outcomes for most people.
You can start right now….
Here are some links to determine whether concentrating on your breathing might be another tool for your coping belt.
Great for kids:
http://annakaharris.com/mindful-breathing/
For the visual app loving learners among us:
Some apps attempt to enrich audio instructions with interactive visualisations. There has been one study looking at the the potential benefits, distractions, participation and ease of use by using visualisations in an app to obtain an optimal breathing pattern with resultant systemic changes (7).
My Calm Beat https://www.mybrainsolutions.com/mycalmbeat
Tactical Breather http://t2health.dcoe.mil/apps/tactical-breather
Breathe2Relax http://t2health.dcoe.mil/apps/breathe2relax
BreathingZone http://www.breathing.zone/
References:
(1) Guyenet, P.G. and Bayliss D.A., 2015 Neural Control of Breathing and CO2 Homeostasis
(2) Jasinski, P. E., Molkov, Y. I., Shevtsova, N. A., Smith, J. C. and Rybak, I. A. (2013), Sodium and calcium mechanisms of rhythmic bursting in excitatory neural networks of the pre-Bötzinger complex: a computational modelling study. Eur J Neurosci, 37: 212–230. doi:10.1111/ejn.12042
(3) Zunhammer, M., Elchhammer, P., & Busch, V. (2013). Do cardiorespiratory variables predict the antinociceptive effects of deep and slow breathing? Pain Medicine, 13: 843-854
(4) Zautra, A.J., Fasman, R., Davis, M.C., & Craig, A.D. (2009). The effects of slow breathing on affective responses to pain stimuli: an experimental study. Pain, 149: 12-18
(5) Bushc, V., Mageri, W., Kern, U., Haas, J., Hajak, G., & Elchhammer, P. (2012). The effect of deep and slow breathing on pain perception, autonomic activity and mood processing - an experimental study. Pain Medicine, 13: 251-228.
(6) Mehling, W.E., Hamel, K.A., Acree, M., Byl, N., & Hecht, F.M. (2005). Randomized controlled trial of breath therapy for patients with chronic low-back pain. Alternative Therapies in Health and Medicine, 11(4): 44-52.
(7) Chittaro, Luca, and Riccardo Sioni. "Evaluating mobile apps for breathing training: The effectiveness of visualization." Computers in Human Behavior 40 (2014): 56-63.
*Breathing increases bronchiopulmonary afferent activity. This increases left insula activation and increases left anterior cingulate cortex activation (correlating with a shift in vasosympathetic tone). Painful stimulation activates the right insula, so the activation of the left insula directly opposes this. At baseline, if respiratory rate was high a significant decrease in pain intensity and pain unpleasantness was observed with deep and slow breathing.
Jaws 42 - The Curse of TMD (Temporomandibular Joint Disorder)
All credit of this image go to Steven Spielberg and novelist Peter Benchley. Also to Zanuck/Brown Productions and Universal Pictures.
It has been nearly 42 years since the legendary movie "Jaws" was released. It was a cinema masterpiece of its time with bucket loads of suspense and horror that managed to scare everyone from swimming in the ocean for years afterward. Well, so I'm told. With the clever use of animatronics, images of bloody big dorsal fins and spooky music it left movie goers nursing tense and sore jaws from clenching their teeth through anxiety and fear. Segue complete. See that? Jaws and jaw pain?
Jaw pain is a pretty common issue affecting 33% of the general population at some time in life (1). Of that population there seems to be more significant spike in the age range of 20-40 year olds, with a significant portion of that number needing to seek treatment from a health professional. Anxiety is a key contributor to jaw pain but it is not the only reason people experience pain in/around the jaw or temporomandibular joint (TMJ). We commonly refer to pain around the TMJ as Temporomandibular Joint Disorder or TMD. It is actually not one single disorder but representative of multiple sub groups of issues. They are typically categorised as muscle problems or joint problems.
WHAT CAN YOUR OSTEOPATH DO?
At Fairfield Osteopathic Clinic we take into account the whole person when dealing with the treatment of TMD. In other words we need to understand the underlying causal factors, which may range from mechanical joint factors, emotional stress or functional overuse issues (think Australian gum-chewing cricketer). There are also direct links between neck pain and TMD and any assessment will recognise the connection. There is plenty of evidence both clinically and through peer reviewed research to suggest that the neck and jaw are pretty tight in their relationship with one another (pardon the pun). One paper suggesting that 70% of TMD sufferers also experience neck pain (2).
A worthy TMD assessment will always encompass an actual physical assessment of the muscles around the jaw and the joint movement itself. This will guide treatment options. As osteopaths we use lots of direct and indirect techniques to modulate pain, but without addressing underlying causal factors that impact the jaw then relief may not last for long. These irritating causal factors might include chewing gum, chewing meals on one side of the mouth, specific dental issues, night time bruxism or teeth grinding and habitual jaw clenching (a lot of people don't realise they clench until they actively relax their jaw muscles). There are simple relaxation exercises for the jaw that are easy to practice and master. Head down to the end of the BLOG for some ideas.
SELF MANAGEMENT
Self management strategies are essential in dealing with any long term TMD. A large study published in November 2016 attempted to collate as much data on self management strategies and form a best practice management strategy for longterm TMD. These strategies include:
1. Education - a bit of positivity is a good start as pain is usually self-limiting. Understanding the anatomy and usual function of the TMJ complex and associated musculature can be helpful too. Other ideas include improved sleep hygiene (don't watch Jaws before bed), sensible and time-limited use of analgesia, avoidance of OTC splints bought without consultation with a dentist, limit caffeine usage, ‘doctor shopping’ won't help.
2. Self exercise therapy - gentle stretches for the jaw muscles and relaxation exercises, which are best explained by your osteopath.
3. Heat treatment - usually heat for sore jaw muscles is best. Ice treatment is best avoided due to the sensitivity of the nerves that innervate the area (remember ice-cream headaches)
4. Self massage therapy - there are very simple self massage techniques for the main jaw muscles and upper neck muscles. Again these are best explained in person as a little goes a long way.
5. Diet and Nutrition - it's important to establish a pain-free diet for at least three weeks. That means avoiding excessive chewing or hard-to-chew foods. In other words TMD sufferers may need to establish a "soft diet" until sensitivity decreases.
6. Parafunctional behaviour - this is the tricky one. There are often habits that irritate the jaw that we seem to not have as much control over e.g. grinding teeth or jaw clenching during sleep, which is called nocturnal bruxism. This may require some other modalities of therapy or medication to help. Reflecting on coping strategies for stress and anxiety may be pivotal to changing some of these nocturnal habits (3).
EASY EXERCISE
Stand in front of a mirror.
Hold your palms gently on the side of your face - covering your cheeks.
Let your lower jaw fall into your hands. In other words relax it and let it go all loose.
Now practice that again without using yours hands on your face. Make as long a face as possible.
If you are having trouble mouth the sound "Bah". It lets your lower jaw fall open. Repeat that until you get a sense of your jaw relaxing.
If you practice this in the mirror then when you are at work throughout the day you can put your hands on your face and use that as a trigger for your face and jaw to relax. You are creating awareness around the difference between tension and ease.
Good luck and don't hesitate to make a booking to see us if things are a bit out of control.
References
1. Wright, Edward F., and Sarah L. North. "Management and treatment of temporomandibular disorders: a clinical perspective." Journal of Manual & Manipulative Therapy 17.4 (2009): 247-254.
2. Silveira, A., et al. "Jaw dysfunction is associated with neck disability and muscle tenderness in subjects with and without chronic temporomandibular disorders." BioMed research international 2015 (2015).
3. Durham, Justin, et al. "Self‐management programmes in temporomandibular disorders: results from an international Delphi process." Journal of Oral Rehabilitation 43.12 (2016): 929-936.
What’s RIGHT with me?
A colleague recently posted a link to a study that focused on spousal bereavement, or in layman’s terms, the feelings we experience when we lose a loved partner. There are multiple studies on the impact of health after the death of a partner and there is a resultant increase in GP visits for both physical and mental ailments (1).
With all those increased visits to the GP, there comes with it the potential for the GP themselves to feel helpless as a caring health practitioner. Having a sad and bereft person sitting in front of you may not be the regular focus of their practice and there are always time pressures involved. Hence the potential for patients being offered a ‘diagnosis’ of depression (2) and anti-depressants are prescribed as a relatively cheap intervention for people’s suffering. Albeit, with only a small benefit (3). Importantly, in this interaction, we need to acknowledge that most people visiting the GP don’t want to keep feeling the way they feel and are pleased with a label and a solution.
AND THE MORAL OF THE STORY IS?
My long-winded point is that we can be prone to pathologize* something that is completely, whilst unfortunate, normal. It is normal to feel anxious, sad, etc. and the question arises when does this cross over into something abnormal or into a ‘diagnosable’ condition? Perhaps the practitioner is relieved to give it a name, or equally, perhaps the patient is? Either way everyone’s intention is to ease suffering.
Over diagnosis and over prescription for depression is concerning, but what’s the link to pain?
PAIN IS NORMAL
Pain is normal. It might be irritating, confronting or downright awful but it’s infrequently insufferable. And on most days, pain is essential for our survival. It protects us from touching hot things that will burn us, it causes us to stop the flow of blood when we cut our finger, it makes us stop and rest when we’ve torn a ligament in our ankle and it stops us overloading to the point of heatstroke in an Ironman competition.
We are all at risk of pathologising something that is normal and it worries me when this message comes thick and fast from the medical voice of authority:
there is something (or everything) wrong with your posture
there is something wrong with your bones, ligaments, muscles, nerves, etc
there is something wrong with your desk, your shoes, your style etc.
there is something wrong with your running style, your swimming style, etc
there is something wrong with the food you eat, etc
there is something wrong with you!
And now, let’s fix that, with corrective exercises, corrective food, corrective supplements, corrective treatment (I know that’s my bit). There is a place for some of these things, we could all move more, eat better, sleep more, wear better shoes, be more mindful, hug more and take deeper breaths. But there is no getting away from the fact that pain is normal.
I’ll admit I’m as intolerant of pain as the next person. I’ll frequently reach for ibuprofen at the onset of a migraine or ask a colleague for a treatment when I have an aching low back. But I know that what I’m experiencing is normal. I listen to what the pain is trying to tell me (don’t drink red wine or lift mattresses by myself) and I take measures, where possible, to alleviate any predisposing factors.
SO LET'S FIND OUT WHAT'S RIGHT WITH YOU.
Disclaimer: there are times when pain isn’t normal and becomes the alarm bell that won’t stop ringing, and if all sinister reasons have been ruled out then we are left only with complex uncertainty, but that story is for another BLOG.
1. Charlton R, Sheahan K, Smith G, Campbell I. Spousal bereavement – implications for health. Fam Pract 2001;18:614–8.
2. Stroebe M, Henk S, Stroebe W. Health outcomes of bereavement. Lancet 2007;370:1960–73.
3. Kirsch I. (2009). The emperor’s new drugs: Exploding the antidepressant myth. London, UK: Bodley Head.
This is a link to the article that sparked my BLOG:
http://www98.griffith.edu.au/dspace/bitstream/handle/10072/40154/70829_1.pdf?sequence=1
* Pathologize = to take some way of reacting, feeling, or being and to treat it as a disease.
Flourless Chocolate Almond Cake
Ingredients
200g dark bitter cooking chocolate (Nestle Plaistowe), chopped
3/4 cup castor sugar
150g unsalted butter
200g ground almonds
5 eggs, separated
Icing sugar to dust
1. Grease, flour and line base of 20cm round springform tin
2. Heat oven to 160`C (careful - it burns easily at 180`C)
3. Melt chocolate, sugar and butter in a bowl over simmering water or in the microwave.
4. Add butter and sugar. Stir as it continues to melt. Remove from heat.
5. Add almonds. Mix well
6. Beat in egg yolks one by one with a metal spoon
7. Beat egg whites until peaky and fold into the cake mixture
8. pour mixture into cake tin and bake for 40 minutes
9. Allow to cool before removing from tin. Dust with icing sugar to serve
Bridging the Gap on Men's Health
If you hadn't noticed it's Movember and Men's Health is in the spotlight. In particular Mental Health, Prostate Cancer and Testicular Cancer. Three aspects of Men's Health that contribute significantly to men's mortality. The saddest part of this statistic is that they are, to a great extent, preventable causes of death with early intervention.
In the course of my career I have taken many a phone call from the wife or partner of a man to make a booking on their behalf. Often unbeknownst to the man! This gives a small insight into men's health behaviour that is quite curious. Men will often avoid seeking attention for health related issues.
Why don't men ask for health help?
A study from the International Journal of Consumer Behaviours (1) found some interesting reasons why men do not seek health care assistance when they clearly should. These were broken down into broad themes that included:
1. Health-seeking behaviour was seen as a more female trait and not one associated with male self-reliance (I think this might be code for "I'm too scared to find out what's wrong with me")
2. Expressions of underlying fear and fatalism (at least they're being honest!)
3. Feelings of disconnection from health providers (talking about how I feel with a stranger is just not cool)
There is no good age to be a man
At the pointy end, the life expectancy of a man is on average 4.5 years less than a woman.
Perhaps more alarming, across the lifespan, just being a man means you're more likely to die than a woman. And that's in all major age groups! This is in part due to men being biologically driven to partake in more risky behaviour (with sometimes devastating consequences). However the stark difference across the lifespan points more directly at men's lack of attention to detail in maintaining their own health and well-being (2).
Health behaviour change and the time it takes
One of the major benefits of seeing an osteopath at Fairfield Osteopathic Clinic is the time we take with our patients. An initial consultation is usually around one hour and all subsequent consults are around 30mins. There is always opportunity to get to know the patient in front of us. Of course we'll take a detailed medical history and perform the appropriate physical examination. But more than that it is chatting to the patient about their life, family, work, hobbies, exercise routine, friendships - all the stuff that makes them who they are. Obviously this doesn't all happen in one consultation, it will often take a while to build a therapeutic relationship with a patient and trust is not something that can be afforded lightly. Often this chat can reveal something about them that needs a little more attention. This might work a little better with men who are more reserved about revealing too much about their health history.
So a shout out to the men out there. Don't put that appointment off with the osteopath because you think that it's not "manly" to see someone about your aches and pains. This goes double for those things that you should see the GP about e.g. a spot that has changed on your skin, a lump that has developed somewhere it shouldn't, or you just aren't feeling your "manly" self.
Taking ownership of your health
Influencing health behaviour's is usually a pretty subtle science, even as a health professional. In recent times initiatives like Movember have done terrific work in highlighting the need for men to take ownership of their health. Likewise the RUOK group have done great work in clearing the lines of communication to help men (and women) open up about struggles with mental health. Always keep in mind that your health professional is a confidential source for anyone to talk about their health problems. As osteopaths we always are aware of our professional boundaries and scope of practice and will refer you on as necessary.
(1) Buckley, Joan, and Seamus Ó Tuama. "‘I send the wife to the doctor’–Men's behaviour as health consumers." International Journal of Consumer Studies34.5 (2010): 587-595.
(2)http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/LookupAttach/4102.0Publication30.06.104/$File/41020_MensHealth.pdf
SHOULD WE BE PERFORMING SELF BREAST EXAMINATIONS?
Like many things to do with health and the human body, the evidence is muddy.
WOMEN SHOULD NOT ROUTINELY PERFORM BREAST EXAMINATIONS
An opinion article published in the Journal of Obstetrics and Gynaecology of Canada (1) recommends that breast self examination should not routinely be taught to women as they concluded there were risks of unnecessary biopsies being performed with no reduction in mortality rates. They drew their conclusions largely due to a gigantic randomised, longitudinal trial completed in Shanghai (2).
WOMEN SHOULD COMPLETE BREAST SELF-EXAMINATION
There is less robust evidence that supports breast self-examination. It suggests excellent physical examination practice, whether breast examination performed by a health professional or breast self-examination, may reduce mortality (3).
I’m firmly in the camp of giving breast self examination a red hot go. You might feel things but not know what they are and whether it’s normal but like all skills, the more you examine your breasts, the better you’ll get to know them and find any changes.
IS THERE A PERFECT WAY TO DO A BREAST EXAMINATION?
Probably not.
GET TO KNOW YOUR OWN BREASTS
What is important is to know the look and feel of your breasts’ various peculiarities. Has that blobby area changed from a few months ago? Does something stand out as different from the rest (like a rock on a sandy beach)?
A 2005 systematic review suggests women should look and feel their breasts and know what is normal. They should also know what changes to look for and know what to do if a change is found (4).
This is a step by step taken from the USA breastcancer.org site, which is about as simple and as complex as you probably need to be.
YOU’LL NEED A MIRROR
STEP ONE: Look at the shape and appearance of your breasts and nipples in the mirror with your hands on your hips
STEP TWO: Raise your arms above your head and look at your breasts. Look for any changes in the shape of the breasts.
STEP THREE: Look at your nipples to see whether there is any fluid coming out.
STEP FOUR: Feel for lumps in the breasts either standing up or lying down.
STEP FIVE: Feel for lumps in the nipple area and in the armpits (5)
WHAT CHANGES AM I LOOKING FOR?
Armed with some knowledge of what is normal for you, detecting changes should be easier.
You’re on the lookout for:
- New lumps
- Thickening in breast tissue
- Nipple sores
- Nipple discharge
- Nipples turning in
- Skin dimpling
- Rash
- Red swollen breasts (6)
If you notice any changes report to a health professional IN A TIMELY MANNER. Rushing off every month will probably leave you and your GP frustrated. Equally, don’t wait just because you don’t want to bother anybody with your weeping, red nipple.
HOW OFTEN DO I NEED TO CHECK MY OWN BREASTS?
Tricky. A slow progression may not be noticed if you undertake an examination every month. However, if you don’t complete it often enough then you won’t know what normal is.
An educated guess would be four times a year?
WHEN TO COMPLETE?
Choose a day that's easy to remember, such as the first or last day of the season. If you are still having your period, complete the check a few days after your period has ended.
SHOULD I KEEP RECORDS?
Many people find keeping records onerous and it might stop you from even peering at your boobs in the mirror. Another person might find it essential to set an alarm, and keep thorough notes on their phone.
You can download this PDF sheet to track your attempts and any changes or you can download this app from the McGrath Foundation http://www.curvelurve.com.au/
WE SHOULD BE MORE CONFIDENT TO CHECK
Learning how to undertake a breast self-exam is the first step as we spend far more time with our breasts than anybody else.
IF YOU’RE 50+
BreastScreen Victoria provides free mammograms to women over 50 as over 50% of women diagnosed with breast cancer are 50-69.
References
(1) Journal Obstetrics and Gynaecology of Canada 2006; 28(8):728–730
(2) Thomas DB, Gao DL, Self SG, Allison CJ, Tao Y, Mahloch J, et al. Randomized trial of breast self-examination in Shanghai: methodology and preliminary results. J Natl Cancer Inst 1997;89:355–65
(3) Harris R, Kinsinger LS. Routinely teaching breast self-examination is dead. What does this mean? J Natl Cancer Inst 2002;94(19):1420–1.
(4) McCready, Littlewood, Jenkinson. Breast self examination and breast awareness: a literature review. Journal of Clinical Nursing 2005 (14); 570-8.
(5) http://www.breastcancer.org/symptoms/testing/types/self_exam/bse_steps
(6) GETTING A GRIP A Report Into Breast Health Understanding Among Women In Australia Based on independent research carried out by AMR for the McGrath Foundation October 2016
Keeping abreast of your breasts.
At the mature age of 42 I’m long past worrying about how small my breasts are and how much padding I need to stuff in my bra if I want to wear a low cut top. And now the days of breastfeeding are over, my breasts are just another part of my body heading south.
I haven’t always been so ambivalent. I undertook my Master’s research on the potential impact of bras on breasts. There were no significant findings from our very small pilot study. And more significant research shows that wearing a bra is not a risk factor for breast cancer (yes - even underwire) (1). Like all good myths though, it doesn’t stop nearly 20% of women surveyed on this topic thinking they are harmful (2).
I think many women, once they’ve relinquished the vanity about what they think their breasts should provide for them, get on with the job of ignoring them. And that’s what I like about the Jane McGrath Foundation and what they’re trying to do with the pink QV cream. Make checking our breasts part of our hygiene routine and we might be inspired to play our part in preventative health.
Of course, whilst the cream is a good reminder to check and is also a lovely bit of advertising for breast cancer awareness month, you can most certainly check your breasts without the pretty cream
WHAT ARE THE MCGRATH FOUNDATION TRYING TO DO?
I applaud the McGrath Foundation’s serious attempt at some foundational research investigating whether women are breast aware.
They surveyed a cross section of 1,288 women to determine if women knew the risk factors for breast cancer, and how often and how confident they might be in examining their own breasts and detecting any changes that might be present.
WHAT ARE THE RISK FACTORS FOR BREAST CANCER?
The study reports there are six proven risk factors for developing breast cancer (there might be more but no one has done a study on every potential risk factor).
• Strong family history of breast cancer (however, according to Cancer Australia’s Recommendations for the management of early breast cancer in women with an identified BRCA1 or BRCA2 gene mutation or at high risk of a gene mutation, only around 5-10% of breast cancers are due to hereditary / genetic mutations) (2)
• Being a woman
• Being a smoker
• Growing older
• Drinking alcohol
• Starting menstruation earlier or menopause later
The one that I certainly didn’t know about was starting menstruation earlier or menopause later. The role of hormones in breast cancer is a complex one and the study notes that there was a lot of confusion from survey respondents.
A seventh risk factor, taking the contraceptive pill, was identified. Considering the role of hormones just mentioned, I think many younger women feel concerned. The recommendations are not clear on this topic, however, there may be an increased risk while a woman is taking the contraceptive pill depending the dose (3).
WHAT ARE SOME INCORRECTLY IDENTIFIED RISK FACTORS?
In other words what do we think will give us breast cancer but actually won’t. Things like sunbathing topless, having breast implants or reductions and sleeping in a bra do not increase our risk of developing breast cancer.
The study also showed women who consider themselves breast aware were more likely to identify the myths as risk factors. Questioning our intuition is always a good move.
DO WOMEN SELF EXAMINE?
Being armed with the correct knowledge is a great start but are women, even those identified at risk, self-examining their breasts? And do they feel confident that they could detect any changes?
Without breaking down what this sample of women actually undertake, a summary of this questions sums up the predicament:
“Approximately one third of those who don’t check their breasts regularly say that this is because it has never occurred to them to do so. One in five indicate that they don’t know how to, or they forget.”
And hence the problem. Do we need to change our behaviour? The study found that even having a friend or relation who has been diagnosed with cancer doesn’t improve our vigilance. Interestingly, having daughters makes us more likely to self-examine.
HEALTH BEHAVIOUR CHANGE
Health behaviour change has become an entire industry, in both private and public sectors. From an individual to an entire population it’s a big job.
Multiple studies look at teaching skills-based interventions combined with goal setting to improve health behaviours as an adult.
A PhD study looked specifically at educating 9th grade girls on a self breast-examination combined with goal setting as a preventative health tool. The rational is that the knowledge and skill base will be present as they age, and combined with a knowledge of the risk factors, they may even implement their skills. The study noted there was excellent compliance over the time of the study, however, the novel interest in breast self-examination may wane over time.
WHAT EXACTLY SHOULD WE BE DOING?
The next BLOG reviews what the research and the experts conclude about breast examination, whether we should be doing them and some handy advice on how and when to complete one if you want to and importantly, how to track your efforts.
REFERENCES
(1) GETTING A GRIP: A Report into Breast Health Understanding Among Australian Women in Australia (October 2016)
(2) Getting Youth to Check it Out!®: A New Approach to Teaching Self-screening Resa M. Jones, MPH, PhD; Ian J. Wallace, PhD; Alice Westerberg, BA; Kristyn N. Hoy, MPH; John M. Quillin, MPH, PhD; Steven J. Danish, PhD Am J Health Behav.TM 2015;39(2):197-203
(3) Recent Oral Contraceptive Use by Formulation and Breast Cancer Risk among Women 20 to 49 Years of Age Elisabeth F. Beaber, Diana S.M. Buist, William E. Barlow, Kathleen E. Malone, Susan D. Reed and Christopher I. Li DOI: 10.1158/0008-5472.CAN-13-3400 Published 1 August 2014
Slow and steady wins the race
The simple solution for the complex problem
When pain hangs around for longer than expected this can be immensely frustrating for patients. But when problems are complex and recalcitrant they can also be frustrating for practitioners.
A complex problem requires patience from both parties. If a patient has a story of brokenness, then it takes the right information, at the right time provided in the right way for that person to help turn that story into one of hope.
So many of us are pressed for time and aren't we all searching for the simple, immediate solution to any problem?
Often a simple and effective solution can be manual therapy. Good practitioners can be really good at providing an immediate relief for pain. Whether it lasts is another story and the transient relief for patients can be at once addictive and ultimately frustrating.
A good practitioner will combine manual therapy and education. Education comes in multiple forms, knowledge about why it hurts, and information about pain can help redirect the assumption of brokenness.
Education can also be advice about unhelpful behaviours, thoughts or beliefs. And it most certainly should involve having a discussion about the true
A good clinician will help find your baseline for activities and armed with good knowledge, your brain and body will know you're safe even if you experience some discomfort.
A fair amount of frustration exists around trying to increase physical activity, which as we know from the literature (and the media) is a magic bullet (1). But many people have the experience that simply increasing the amount they move increases their pain. Often, they'll take the weekend warrior approach. They join a gym and do a body balance class and end up crawling in for pain relief as their low back and neck are screaming at them. If the alarm bells are ringing and you're getting negative feedback from every part of you it's hard to make the connection that it's a) good for you, and b) we need to do more of it and finally c) do it forever.
A good clinician will help find your baseline for activities and armed with good knowledge, your brain and body will know you're safe even if you experience some discomfort.
I listened recently to a great podcast with Neil Pearson, who is a physical therapist in Canada, who uses graded exposure to therapeutic yoga to help people with complex pain problems. But it doesn't have to be yoga that gets you there. The simple and free option is walking.
What is graded exposure?
Graded exposure is a fancy way of saying that you need to start with a small amount of something that threatens you and as your brain and body tolerate it, add in a bit more the next day until you can participate in an activity you enjoy without a backlash.
So what does a graded exposure program to walking look like?
Start with a baseline of 10 minutes per day at around 65% of your maximum heart rate. In the range of comfortably carrying on a conversation. Up the benefits and go with a friend.
You need to assess how you feel afterward. If you have any adverse effects, ask yourself, do they last five minutes, five hours or five days? Depending on the answer, you need to increase or decrease the amount of time and effort you are making with walking. As a guide, anything more than a three hour increase in discomfort means you're overdoing it. Remember though to pay attention to your response AFTER your walk, not during, as this is a better indicator of how irritable your body and brain is.
If you don't overdo it, you'll improve so rapidly that after only a week you'll want to start increasing the amount of time, slowly now, to get to the point where you can walk for 45-60 minutes. It might take eight weeks or it might take six months, depending on how your body responds.
When you reach the 60 minute range, you'll be improving brain health, fighting Alzheimers, etc, you'll definitely be burning fat, if that's your extra goal achieved.
When you can comfortably walk in this time range with no negative repercussions, you can add in some moderate intensity exercise, like a 30 second jog, and then another 30 second jog later in the walk around 75% of your maximum heart rate. Once you've worked up to 6 x one minute jogs, then you're ready to add in some additional activities that take your fancy.
Strength work, flexibility and high intensity exercise come after all this preparation. You'll be so much more connected to what your body might want to achieve and what you might enjoy. If you enjoy being out in the sunshine, then there are myriad options at your disposal. Do something you like, do it with a friend and do it for your mental health, as well as to improve your pain.
1. http://www.canberratimes.com.au/act-news/exercise-could-be-the-answer-to-solving-one-of-australias-biggest-health-burdens-20160809-gqo8bi.html
HOW LONG UNTIL THIS STOPS HURTING?
Not all pain is caused by tissue damage but there are many occasions when an ‘event' has caused someone to present with pain. Pulling off a tight and sweaty crop top, lifting a heavy pot plant on a weekend clean-out, twisting an ankle during a netball match or landing awkwardly while trying to double bounce your kids on the trampoline.
Four weeks ago, a lovely mid-50s patient kicked a heavy box (that wasn't there before) on a night time bathroom break. She had an x-ray the next day and there was no indication of a fracture and now she is presenting with pain in her toe joint one month later. She is worried the toe may be fractured and the x-ray missed it and now her pain seems to expanding into other areas of her foot.
As students we all learn about how long a tissue injury may take to heal. But this information is infrequently passed on to the patients and I don't think we should underestimate the benefit in learning how long something might take to feel better. It is one of the active ingredients in therapeutic care that we can provide to patients with pain, along with reassurance. Sometimes people don't want to hear that healing and resolution will take 'time' but I'm afraid that's one of the first things we need to accept.
As an absolute minimum these are some common timelines for Tissue Healing:
Muscle Tear: between 2-12 weeks depending on the severity
Acute Tendinopathy: 4+ weeks
Degenerative Tendinopathy: 8+ weeks
Ligament: Between 2-12 weeks depending on the severity (and 12+ weeks if you've had surgical repair)
Internal Disc Derangement: 8+ weeks depending on severity and location
Bone fracture: 8+ weeks (depending on severity)
Bone bruising: 8+ weeks
Most Cartilage injuries: 4+ weeks
Bursa: 2-6 weeks (or on and on and on) depending on severity
Things that will impact tissue healing times (for better or for worse):
- Underlying bony change (age related or previous injury)
- Anti-inflammatories
- Progressing exercise too fast
- No exercise
- Sitting on your butt 9 hours per day
- Eating great or crap food
- Drinking alcohol
- Drinking caffeine
- Drinking sugary drinks
- Age
- Occupation
- Values (have you got a big game to play?)
- Beliefs (your father thinks you're weak)
- Sleep or lack of...
- Stress
Keep in mind we are talking about tissue healing times here and this is something completely different from whether you are experiencing pain or whether you have terrific or terrible function (read this entry here for more on the complexity of pain).
Back to our lovely mid-50s lady with sore toe. Potentially, when she kicked her toe into the heavy box, she didn't fracture the long bone but compressed the ends of two bones into each other essentially bruising the bone. This bruised bone takes a lot longer to heal than a bruise to the skin and the soft tissue just below it and this means it may also hurt for longer.
Finally, walking around with that sore toe can mean you may start to move through your foot differently avoiding the sore joint. You might weight bear more on the foot that doesn't hurt. Your whole body is invested in reducing the pain in your foot and so adapts to give your poor old toe the time and space to heal and recover. Learning about this can help your anxiety around your sore toe and even reduce pain levels. And of course manual and physical therapy provided by the Osteopaths at Fairfield Osteopathic Clinic can certainly diagnose, treat and provide education and advice to help reduce your pain and your anxiety about 'how long until this stops hurting'.
To make an appointment book online or call 9489 0981
Sitting at the desk can be a real pain in the %$*&
It's one of the most common questions we get in the clinic - what is the best sitting posture?
To be honest, it would be ideal if we didn't sit as much of the day as we do, but given the society we live in it's going to be a while before we all get to go primal.
We have all had a think about it and the overwhelming advice we give revolves around optimal sitting postures and reducing the amount of time you sit altogether.
So what can you do?
We all need to become big softies. Softening your neck, shoulders and upper back will go a long way to reducing pain and dysfunction around that area.
Start by dropping those shoulders.
Whether you sit, stand or kneel you're still going to get a sore neck and shoulders if those upper back, neck and shoulder muscles are working hard for hours on end. They have to work hard any time you have your arms out in front of you for long periods of time. For instance, when you are tapping at the keyboard, driving the car, crocheting, and then throw in the added tension that stress creates. A neat trick that seems to help is to tuck your elbows to your sides, this lets the shoulders relax a little more and keeps you mindful. Always try and rest the weight of your forearms on the desk or chair if you are sitting.
Some other good ideas to help you soften through your upper back neck and shoulders include:
1) Breathe and Release - most people find it easier to drop the shoulders, soften and release on an exhale.
2) Driving - hold the wheel on the two lower quarters and let your shoulders rest when you are in a more relaxed stage of a drive.
3) A Trigger - find a trigger during the work day to consciously soften through the trapezius and drop the shoulders, e.g. hanging up a phone call, sending an email, etc.
I'm sure you've noticed the recurring theme is 'letting the shoulders drop'.
If you are quite conscious of this over a period of three weeks, there is a sense of 'retraining' your brain to release your shoulders and neck tension automatically.
There are definitely more optimal sitting posture than others.
We have included some photos of the good, the bad and the plain ugly. Some sitting positions are extremely sloth-like but extremely comfortable, and that's ok. But always remember the more comfortable you are in the position the longer you can hold it - and that can be the problem.
The thing about maintaining good "posture" or sitting more upright is that the "better" your posture the more energy intensive and the harder it is to hold so then you move away from that position - therefore it’s better for you. Moving more is better for you - it is that simple.
Other simple tricks for the desk jockey:
1. Stand to talk on the phone wherever possible
2. Look out the window at something small and distant (like a bird in the tree) - this is good for your eyes.
3. Have walking meetings outside wherever possible. Who said a meeting had to be sitting down?
