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Surgical Options for Slipped Disc

In our earlier post on Herniated Disc or ‘Slipped’ Disc, we looked at the structure of an inter-vertebral disc and what a herniated disc is. Here, we will discuss when surgery is indicated in people with herniated disc(s) and what are the various surgical options available. Read more

Belt Up Your Unstable SIJ

An unstable Sacro-illiac Joint (SIJ) can cause pain in the lower back and pelvic region. This happens when the core muscles surrounding it are too weak to support the SIJ. A sacroiliac support belt can help to provide support and stability to the joints during the initial stages of core stability training. Read more

Whiplash - Part I

In this article, we will be looking at the three most commonly asked questions:

1. What is a whiplash?
2. What are the signs and symptoms of a whiplash injury?
3. What are the common treatment techniques available?

What is a whiplash?

Whiplash is a common term for sudden acceleration-deceleration forced on the neck. This is usually as a result of rear-end or side impact motor vehicle accidents or any other mishaps. The acceleration-deceleration forces cause the head into forward flexion (head down position) and very quickly the head gets whipped back into extension (head in a looking up position).

When this occurs, the forces may result in bony or soft tissue injuries such as in the disc, ligaments, tendons, neck muscles and nerve roots.

There are several grades to the severity of whiplash associated disorders (WAD).

Grade 0: No pain or discomfort. No physical signs of injury.

Grade 1: Neck pain, stiffness or tenderness. No physical signs of injury.

Grade 2: Neck pain, stiffness or tenderness. Some physical signs of injury such as point of tenderness or trouble turning the head.

Grade 3: Pain, stiffness or tenderness and neurological signs of injury, such as changes to the reflexes or weakness in the arms

Grade 4: pain and fracture or dislocation of the neck.

What are the symptoms?

The most common symptoms after a whiplash injury are neck pain or stiffness. This can occur immediately after the injury or even after a few days.

Other symptoms may include

• Headache
• Pain in the shoulders and arms
• Dizziness
• Altered sensation, pins and needles, numbness in the arms
• Weakness
• Visual and auditory symptoms
• Difficulty concentrating
• Difficulty in swallowing

What are some treatments available for treatment of whiplash?

There are many treatments available for the treatment of a whiplash injury. In this article, we will only list what is available but not grade the quality of each treatment techniques. This will be done in the next article.

Some of the treatments include:

Treatment	What it means
Act as usual	Staying as active as possible within tolerable levels.
Active treatment	Actively perform repeated movements of the neck in a pain free range.
TENS machine	The current from the TENS (transcutaneous electrical nerve stimulation) machine may inhibit pain in the tissues surrounding the electrodes. It works by distracting your nerves and brain from the pain sensation.
Exercise	Exercise improves pain, range of motion, flexibility, function and physical fitness. It is thought that exercise promotes the production of endorphins, naturally occurring hormones by the brain that can help with pain control.
Manipulation	Also known as ‘adjustment’ or ‘cracking’. It is thought that manipulation of a spinal joint may provide temporary increase in joint range of motion. It also corrects spinal alignment which gives relief from musculoskeletal pain.
Mobilization	A technique that entails gentle, controlled movements of the joints affected. This aims to improve mobility in areas of the spine which leads to a decrease in restriction. Hence, removes a source of pain and provides symptomatic relief.
Pilates	Aims to selectively increase the strength and endurance of the deep core muscles of the torso. By doing so, posture and stability is improved, reducing the amount of pressure on the spine.
Acupuncture	A treatment modality of Traditional Chinese Medicine (TCM). Acupuncture influences the nervous system and neurotransmitter which respond to needling stimulation and electro-acupuncture, which in turns influences pain relief. From a TCM perspective, acupuncture is thought to restore the flow of “chi” through the body.

9 Things To Take Pressure Off Your Back

Pressure Relievers	Why They Work
While standing to perform ordinary tasks like ironing or folding laundry, keep one foot on a small stepstool, shifting between feet occasionally	To reduce the excessive lordorsis (inward curvature of a portion of the spine) that some people may have especially in standing. Particularly those with weak abdominals. The foot on stool will take the pelvis into posterior pelvic tilt, hence reducing the lordosis
Don’t sit or stand in the same position for too long. Stretch, move about or take a short walk when you can.	Allows the different postural muscles to have a little rest. The spine is made of many vertebrae stacked on top of each other, allowing each segment to move. Therefore, our spine is built for movement and not to be in one position for a prolonged period of time
When bending from the waist, always use your hands to support yourself.	Reduces torque on the lower back.
Because vacuuming can take a toll on your back, tackle rooms in chunks, spending no more than 5 to 10 minutes at a time doing this task.	Offers the back a chance to rest after a period of sustained bending. Muscles can get strained and fatigue, thus compromising the support to the lumbar spine
Choose an office chair that offers good back support (preferably with an adjustable backrest, lumbar support, armrests, and wheels) and set up your workspace so you don’t have to do a lot of twisting.	Allows the spine to stay in an optimal position as you work, without having the back muscles constantly supporting you. It also facilitates the neck to be aligned properly
Try not to overload briefcases or backpacks (see “Lighten your load”).	Reduces loading of the back muscles and disc pressure. As the muscles fatigue, our bodies will adopt a rounded upper back posture to compensate, resulting in poor posture and associated injuries
Make frequent stops when driving long distances.	Prevents fatigue mentally and physically to allow some mobility in the spine and stretch out muscles that are placed in the shortened position as we drive
While driving, sit back in your seat, and if your seat does not provide sufficient support, place a rolled blanket or some towels behind your lower back. Try to shift your weight occasionally. If you have cruise control, use it when you can. Also consider using a foam seat cushion to absorb some of the vibration.	Allows the back to be in a proper posture. Weight shifting offers pressure reliefand cruise control allows the foot to rest and not sustained effort on the accelerator Vibrations can cause injury to the back
Sleep on your side if you can, and curl your body up a bit, and if possible, with one knee bent and the other straightened. Also, choose a pillow that keeps your head level with your spine; your pillow shouldn’t prop your head up too high or let it droop. Choose a mattress that’s firm enough to support your spine (so that it doesn’t sag into the bed) and that follows your body’s contours.	The spine will be well supported when it is in the neutral position

Lumbar Spinal Stenosis

Lumbar spine stenosis is a condition where the space in the lower spinal canal narrows. The spinal canal houses the spinal cord along the back. Narrowing of this space causes pain, numbness to weakness in the legs in more serious cases. In extreme cases, loss of bladder and bowel control. This condition typically affects adults over the age of 50. Read more

Pain Relief Medications: An Overview

Sometimes we are told to take something for the pain. There are quite a number of options out there in the market. Here is a summary of the major categories of pain relief medications available. Read more

Myofascial Release

Myofascial Release is a form of hands-on therapy used to relieve pain and to relax muscles and tissue. “Myo” refers to the muscle, and “fascial” refers to the smooth tough tissue that covers all the muscles.

In a normal healthy body, the fascia is relaxed and soft. It can stretch and move without restriction. However, it becomes tight and restricted when our body experience physical trauma or inflammation of the fasica. Trauma such as a fall, whiplash or habitual poor posture can have a cumulative effect over time to tighten the fascia.

Myofascial release is applied directly on the body and uses slow and sometimes deep pressure to restore the proper health of the fascia. Myofascial release has been used effectively in the treatment of:

• Low back pain
• Headaches
• Neck Stiffness
• Sports injuries

Manual Therapy - Spinal Vertebra Mobilisation

One physiotherapy modality is fast becoming de rigeur in the treatment of referred pain cause by stiff joints is manual therapy. Today, manual therapy is the main stay of modern physiotherapy moving away from the dependency on Electro Therapy Agents such as Ultrasound, Short Wave and TENS as the primary treatment modalities.

 

Referred pain is a very unpleasant sensation localised to an area separate from the site of the causative injury or other painful stimulation. Often, referred pain arises when a nerve is compressed or damaged at or near its origin. In this circumstance, the sensation of pain will generally be felt in the territory that the nerve serves, even though the damage originates elsewhere.

Manual therapy consists of a range of interventions, including hands-on techniques such joint mobilisation. Joint mobilisation is thought to help maintain or improve extensibility and tensile strength of the articular tissues, reduce the effects of mechanical limitations, elongate hypomobile capsular, ligamentous and connective tissue. It also stimulates mechano-receptors and therefore may be responsible for inhibiting the transmission of nociceptive stimuli and in doing so, reduce pain perception. (Kisner and Colby 2002).

In Singapore, there are two common concepts of manual techniques used for spinal mobilisation– the Maitland Concept and the Mulligan Concept.    

Maitland Concepts

Maitland’s Concepts (often also referred to as the Maitland Technique) involve the application of passive and accessory oscillatory movements to spinal and vertebral joints to treat pain and stiffness of a mechanical nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude.

Grade I is a small amplitude movement performed below the range of resistance and is suitable for treating highly irritable conditions. Use of Grade I enables the slack in collagen to be taken up when connective tissue is not under load and can relieve pain by working on neural structures (Threlkeld). 

A Grade II mobilisation is wider in amplitude but still below resistance. Use of Grade I and II are appropriate when palpation elicits pain before restriction of movement.

Grade III and IV are used when resistance to movement is encountered before pain. A Grade III is a large amplitude movement performed within resistance and generally used to improve range of motion.

Grade IV is a small amplitude movement performed within resistance used for chronic aches of low irritability. 

Grade V is a high velocity thrust used in manipulation.

Application of Maitland techniques to the vertebrae is along an anterior-posterior axis or transverse irrespective of the angle of the joint. Peripheral joints are similarly treated with Maitland techniques on planes appropriate to the condition, usually on the plane where there is pain or restriction. These may be anterior- posterior, transverse or longitudinal.

Mulligan’s Concept

Maitland argues that the comparable pain response “is nearly always found with the unphysiological movement rather than the physiological movement”. Conversely, Brian Mulligan applies movement in sympathy with physiological movement. Mulligan is guided towards restoration of correct physiological tracking by the absence of pain. His techniques are designed to deal with problems of restricted or painful movement but are not highly irritable. These techniques are therefore used for conditions that are not acute when the biomechanics of the joint may be altered without inducing pain. The appropriateness of the technique is judged against Maitland’s criteria of severity, irritation and nature of the condition.

Mulligan does not prescribe grades of movement or oscillatory movements. He prescribes taking the joint through its full range of movement and this entails taking it into resistance. The physiotherapist superimposes an accessory movement onto the patient’s active physiological movement with the aim of over-riding the obstruction and re-establishing correct alignment. The accessory movement takes the joint through what would be the normal physiological movement of the joint. The pre-injury joint tracking is re-established reasserting the ‘joint memory’ or prior conditioning of the healthy joint.

Mulligan’s principle techniques are NAGS, SNAGS and MWMs. NAGS are Natural Apophyseal accessory Glides applied to the cervical spine with the patient passive. SNAGS are Sustained Natural Apophyseal accessory Glides whereby the patient attempts to actively move a painful or stiff joint through its range of motion whilst the therapist overlays an accessory glide parallel with the treatment plane. MWMs are Mobilisations With Movement and are applied to the peripheral joints.  The underlying principle to MWMs is derived from Kaltenborn (1989 in Exelby 1995) who argued that joint surfaces are not fully congruent, physiological movements are a combination of rotation and glide, and glide is essential to pain free movement. Glide occurs in the direction of bone lever movement where its articulating surface is concave and in the opposite direction when convex. The treatment plane lies at a ninety-degree angle to the concave articulating surface of the bone and treatment is applied parallel to the treatment plane. The anterior-posterior and posterior-anterior movements used in Maitland’s techniques follow the same planes in peripheral joints.

However, in treating the spine Maitland will follow the planes of the intervertebral body joints whilst Mulligan techniques follow the plane of the zygapophyseal joints.

Exelby argues that the zygapopheseal joints guide the spine and so improving their glide by applying NAGs and SNAGs will improve the range of spinal movement. Applying treatment on the plane of the intervertebral body joints results in compression on the zygapopheseal joints and will not promote glide.

Language Translation




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It is increasingly common for organisers of long-distance endurance events to have ‘massage areas’ set up at the end of the race. Generally, at Strong... Read more »



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Musculoskeletal Consumer Review © 2007 - 2009 by Core Concepts Pte Ltd