Posts tagged physiotherapists
Chronic Segmental Low Back Stiffness
When we have our first episode of low back pain our back is rarely stiff unless we are just like that, having a tendency towards stiffness. Mostly our back moves like the well designed machine it is. The discs separate the vertebrae and allow movement to occur, with thicker discs in areas of greater movement. The facet joints control and limit movement of the segments and prevent abnormal displacement of the spine under the shearing loads it must cope with. The muscles are all in good condition and working in the most functional patterns. Until, at least, an episode of back pain occurs and it all changes.
Initially back pain causes an inhibition and a wasting of the core muscles which provide stability to the segments and to the whole back. This allows instability to occur which may predispose to future back pain episodes if nothing is done to correct it. With time and repeated episodes of pain and degenerative changes which occur in the discs and facet joints, the back can become stiff and develop chronic back pain. Gravity tends to force fluid out of the disc under load and is counterbalanced by an absorbing force which is more active when lying.
Discs will narrow and lose part of their hydration under the forces of compression which occur in normal life, the disc becoming stiffer and narrower. X-rays can show up this narrowing when it reaches a certain level, but many discs will be troublesome long before this stage. The intervertebral disc and the two vertebrae each side of it are referred to as a vertebral segment and an abnormal stiff segment will move in such a way as to impose inappropriate levels of load upon structures not adapted to take them. The stiffness of individual spinal segments can be felt by a physiotherapist palpating the spine.
Muscle spasms are a typical reaction to an acute injury and has a protective function, stopping the damaged segment from moving while it is so inflamed and thereby giving it some freedom to heal. As the pain settles and the injury heals the back spasms should gradually settle and allow normal movement to be restored. Unfortunately this does not always happen, with some muscles remaining over protective and eventually forming a contracture, an abnormally shortened tissue structure which maintains an abnormal joint position.
Sitting for extended periods can increase the likelihood of suffering from increased compression of the lumbar discs with consequent fluid loss. Repeated flexion maintains the regular cycle of fluid uptake and avoidance of this movement interferes with this important process for disc health. The maintenance of abnormal posture and lack of strength in the abdominal muscles are also important factors.
Chronic segmental stiffness is usually indicated by a history of back pain and general backache with some leg referral also possible. Since many and variable areas of the spine can be stiff or mobile, the stiffness which contributes towards the painful problem might have been present for some time. The pain is worse on sitting for long periods or doing bent over activities, anything which stresses the stiff segment towards the end of its available range of motion. The facet joints become stuck in an extended position and the segment tightens up by adaptive shortening, losing its ability to flex or maintain flexion comfortably. My back problems are like this and can be quite troublesome on stressing, leading me to avoid heavy work such as lifting objects of any weight.
Sarah Key, a physiotherapist who is well known in the UK, has produced the Sarah Key's Back Sufferers Bible, a book in which she sets out her views of what is going on in this most common of musculoskeletal syndromes. She does acknowledge that it is hard to bring solid evidence for many of her interpretations but seems to have many good and practical therapy ideas to approach the back pain problem with. She covers the main syndromes which typically occur, giving treatment routines for self management of each one, all of which I have found very useful for my own lower back pain. Now I have something I can do about it rather than accept it as a fact of life.
Physiotherapy Assessment of Muscle Strength
Muscle strength is very important for all of our functional activities, from heavy work such as climbing stairs or a hill to fine work such as sewing or typing on a keyboard. While losing feeling in a part of the body can be more disabling, losing muscle power always has consequences for our function and our independence, especially as we get much older when our power levels decline anyhow. We may lose muscle power for a wide variety of reasons: disuse; pain; injury; disease or neurological illness. Physiotherapists are skilled at the assessment of muscle power and in progressive strengthening techniques to restore power within the patient's capacity.
The Oxford Scale is the rating system used by physiotherapists for the assessment and recording of muscle power when required. Knowledge of muscle anatomy is vital so that the joint can be positioned correctly and the tendon and muscle palpated so whether there is any muscle action can be judged. The muscle is rated on the Oxford Scale from one to five and written down as 2/5 or 4/5, at times with a plus or minus sign to show the muscle has more or less strength but not enough to go down or up the scale. The physiotherapist ensures the joint is in the optimal position to enable the muscle to function easily and for easy visualisation of the tendon and muscle.
The physiotherapist will ensure the joint is positioned best for good visibility of the muscle, easy manual palpation of the tendon and muscle belly and the correct alignment for the expected strength of the muscle. Palpating the tendon and muscle, the physiotherapist will ask the patient to perform the muscle action desired, feeling for any contraction or movement. If there is none then the score is 0/5 and 1/5 if there is a just discernable contraction or a twitch, without apparent joint movement. If the joint can be moved through its whole motion but only without gravity resisting then the grade is 2/5, for which the joint needs careful positioning. 3/5 grade would be recorded when the joint can be moved through its range against gravity, an example being straightening the knee from bent in sitting.
To be rated as 4/5 on the Oxford Scale a muscle must be able to move its joint through full range against resistance and gravity. The physiotherapist will decide what degree of resistance is reasonable for this test, bearing in mind the characteristics of the patient such as age, sex, activity levels and medical status. The normal rating of 5/5 is given only when the muscle can move the joint painlessly to the extent that the tester feels is entirely adequate, given the personal status of the patient. Full power for a younger, strong man will be very different for a child or old person.
Grade three out of five for the shoulder muscles might be the ability to lift the arm above the head, but if this cannot be easily done or to full range then the muscle can be graded as three minus to indicate its inability to be fully grade three. If the physiotherapist can resist the muscle firmly but it still doesn't seem to be strong enough for a five, then the rating can be four plus. Physiotherapists go through all the muscles to be tested and rate them all on a muscle testing chart as a record of the muscle strength, which can be retested over time to chart recovery.
Physiotherapists begin muscle strengthening techniques in a position where gravity is eliminated, allowing a weak muscle to be repetitively exercised. As the patient's ability increases they can perform more functional activities of daily life which strengthens the muscles in a co-ordinated way which reflects normality. Next, resistance against muscle action is increased as muscle strength improves in response to the level of intensity of resistance and not just repetition. High intensity causes muscle fibre breakdown which repairs with increased size and power until the next intensity workout repeats the process. Progression is then moved to functional exercise with bodyweight resistance as dynamic movement is more useful.
The Treatment of Sciatica by Physiotherapists
Sciatica results from a structure impinging on a lumbar nerve root, causing compression and/or inflammation enough to cause neurological changes in the skin, reflexes and muscles served by the affected nerve. Not a common syndrome, it is estimated that 3-5% of the population suffer this kind of problem at some time. It affects men and women equally with men most susceptible in their forties and women in their fifties. Up to a quarter have symptoms which last more than six weeks and referral to physiotherapists for acute management is routine.
Disc prolapse can result in the internal nuclear material being extruded past the outer disc wall, physically compressing the nerve root which runs nearby. The nuclear material is also chemically irritating to the nerve structure and these irritants make the nerve and nearby structures swell, partly blocking the local circulation and the nerve's message transmission. Disc prolapse is typically the cause of proper sciatica but the size of the prolapse is not closely related to the amount of pain the person suffers.
The great forces which we impose on the low back mean the lumbar intervertebral discs suffer structural changes and prolapses. Many activities involve a significant level of leverage, such as flexing over, performing movements in an upright position and lifting with the arms away from the body. This greatly magnifies the forces on the discs and due to their fluid mechanics they suffer 3-5 times the loads on the skeleton. This can cause the disc walls to degenerate, giving weak areas and predisposing to prolapse at some time.
The onset of lumbosacral radiculopathy is often sudden with low back pain and any back pain may disappear at the start of the leg pain. Worsening factors are sneezing, coughing and sitting with lying down or standing up common easing factors. Sciatic pain typically occurs in the buttock, back or side of the leg and calf and into the foot. If the disc prolapse is higher up (prolapses at disc levels L1 to L3 are 5% of the total) the pain may be in the front of the thigh no further than the knee. A patient may have an isolated area of pain and still have a prolapse.
A thorough history performed by the physio will uncover any red flags, an indication of a possibly serious underlying medical condition responsible for the pain. Loss of weight or appetite, severe pain at night, a history of cancer, unwellness or fever, bowel or bladder control difficulties, young or older patients, all these things ring warning bells and the physio will refer the patient on to a medical specialist for evaluation. The location, nature and response to activities and postures of the pain will be noted by the physiotherapist.
The physiotherapist begins with postural observation of the patient which can show an inability to stand up or a thoracic shift to one side. Spinal movements are performed and the pattern of movement limitation noted, with a full neurological examination of the lower limbs. The physio is looking for deficits in muscle power, reflexes or feeling which are related to the specific nerve root involved. The straight leg raise may be performed to check the stretch reaction of the spinal nerve.
The McKenzie technique works on pain centralisation, the tendency for pain to move towards the back from the legs, suggesting a disc problem, and many physios use this technique. Pain in the front of the thigh and over the knee can be referred from the hip joint, so the physiotherapist will assess the lower limb joints to check the diagnosis. A thorough examination informs the physiotherapist of the likely diagnosis and how they might treat the syndrome, or that the patient needs to be referred to a medical practitioner for a consultation and investigation.
Treatments for sciatica due to disc prolapse are many and physiotherapists can choose to use mobilisations and manipulations, lumbar stabilising exercises, the McKenzie treatment path, soft tissue mobilisations such as massage and myofascial release, using analgesics, education about the condition, advice on resting and the best position to relieve extreme sciatica pain. Sciatica naturally settles in time in the vast majority of cases and physios would encourage patients to establish an exercise regime over the long term.
