Arthritis and knees.

Wear and tear = Osteoarthritis??? I was listening to Radio 4's Inside Health featuring Osteoarthritis, which has enhanced my understanding of the condition. Dr Mark Porter GP come journalist presents a seemingly bipartisan radio series covering many and varied health issues. Dr. Porter set the scene with the current medical beliefs that arthritis is also known as wear and tear and unfortunately can often lead to joint replacement surgery! This then is not the case, apparently when people hear “wear and tear” they imagine both ends of the bone rubbing together. Arthritis is not where the ends of bone grind together. It is the natural and normal degeneration of the cartilage that reduces the friction at the end of the bone. According to Inside Health and this where my ears pricked up, rest is definitely not the solution to arthritis. The pain, heat, redness and loss of function that you feel are a healthy inflammatory response by your body summoning immune troopers and a wrecking crew to gobble up damaged cells, allowing new chondrocytes to flourish and build new tissue. Inside Health, and NICE are kicking some old myths into touch. 1.) Arthritis needs rest. 2.) Cease exercise.

Exercise then promotes the imbibition of synovial fluid and the laying down of new tissue. This is especially the case in the knee joint where the knee cartilage is the premium hyaline type which is mostly likely to revive. Excessive and inappropriate exercise can be damaging, but a useful rule-of-thumb is to exercise in a pain free and poised manner. If your leg extensions hurt your knees then reduce the weight! Strengthening the muscles that bend and straighten the knee improves the function of the knee by improving knee stability, muscular efficiency and increasing venus and lymphatic return.

Dr. Porter discussed the research that shows good evidence for the use of physiotherapy, osteopathy and chiropractors in the treatment of arthritis.

Chondrocytes are cells that build connective tissues like cartilage.

Imbibition is how synovial fluid is absorbed into connective tissues.

Neck cracking, to do or not to do

Letting a chiropractor `crack` your neck to relieve pain could trigger stroke. I was recently presented with the Daily Telegraph article concerning neck cracking. (June 8, 2012) I was worried that anyone denied all of the details might read the article and draw the conclusion that osteopaths induce strokes in their patients. To induce a crack in someone's neck is not that difficult to achieve. Simply rotate their neck quickly beyond the normal range of motion, then behold the tell-tale click can be heard. Please do not try this at home. Clicking is not the point of the technique, rather it is a by-product. 

Why would an osteopath or chiropractor perform such a technique? Hollis King PhD in, The Science and Clinical Application of Manual Therapy, 2011 discusses the modification of muscle tone, reduction in local tissue strains and to encourage better postural positions. This means tight muscles relax around the joint and tissues held in strained positions adjust. Happily osteopaths deliver these techniques  with the minimum of rotation, as it is excess rotation of the neck which often causes the trauma in the vertebral artery. Osteopaths are trained to use as well as rotation, side bending, side shift, traction and compression to avoid the need to wrench the neck around! 

 
The vertebral arteries travel up and through the little bones on the side of your neck, then a weakened artery in combination with a neck crack could occlude the artery or allow a blood clot to be dislodged and cause stroke. Doing a head stand in yoga, arching your neck over a wash basin to have your hair washed at the hair dressers, being hit in a rugby tackle or scrum incident, or other traumatic incidents could also cause such a traumatic ischemic accident. People who don't visit osteopaths also suffer strokes. perhaps a better discussion would be what percentage of the normal population suffer strokes compared to those who visit osteopaths. (20.0 strokes per 100 000 normal population.Those receiving neck cracking have a greater risk of suffering strokes. This reality makes the exhaustive screening of patients all-the-more important. At my osteopathy practice I discuss and use an up-to-date NHS VBI checklist. )

Given the extreme consequences of such a technique it would seem logical then to limit the use of this technique to only persons whom are safe to treat and where treatment is not contraindicated. Osteopaths will ask questions to illicit that the patient does not demonstrate signs of VBI, ( Vertebrobasilar insufficiency ). 

Given the real improvements in patient's expressed symptoms the conservative use of these techniques once NHS clinical screening methods have been applied is safe and appropriate. The fearful views expressed in the article need to be weighed up with the counter arguments. 


 Daily Telegraph article. 

Visceral pain and osteopathy

When is low back pain not from the back?

Occasionally patients come along complaining of pain in the low back, with seemingly plausible physical examination findings who do not feel the benefit of treatment long term. They feel a couple of day’s relief from their pain which then returns.

Three possible reasons present themselves for this. Firstly their pain is chronic in nature and their muscles, tendons, ligaments and connective tissues have adapted over time to avoid the pain. Such long term discomfort takes time to unravel. Secondly the diagnosis is simply wrong! Thirdly the pain is referred pain, felt in the body away from the cause. The most well known example of this is Sciatica, where the inch thick Sciatic nerve is irritated as it emerges from the spine, where this irritation that is often caused by a combination of compression and inflammation. The nerve relays bogus nerve signals back into the spinal cord and up into the brain. This bad signal makes you feel that you have pain, typically lancing or stabbing in nature down the back of your thigh and lower leg.

Less known and therefore more difficult to diagnose is visecerosomatic pain, or pain from the organs that are not felt in the abdomen, but rather experienced as pain in the low, mid, upper back pain, shoulder pain, chest or groin pain to name a few. The physiological mechanism whereby pain from one of your kidneys is felt in your lower back has its beginnings when you were an embryo. Then as you grew and developed as an embryo, cells that were embryologically together later took on specialist roles and became separated from each other as they diversified. Now as a fully developed organism if your kidney is damaged, rather than feel the pain in the kidney, which has no pain sensitive nerve cells, you feel the pain into the low back, flank or groin.

How can physical therapists avoid misdiagnosing such referred pain? The correct taking of the case history will supply information about trauma, illness or symptoms of diseased organs. Kidney problems can give pain on urination, nausea, blood in the urine, tiredness and swollen ankles. This process is made further complex when symptoms overlap. Impaired kidney function can allow increased fluid retention and consequentially swollen ankles, that also occurs in right heart failure!

Why osteopathy?

Why osteopathy? It is a question that I often follow with, if I had a pound every time somebody asked this question. At age 15 I started a love affair with wearing white pyjamas, kicking, punching, throwing and feeling very sore after training. In 1994 I took and passed my 1st degree in Tae Kwon Do. I could kick hard enough to break a house brick. In all honesty I cut my foot on the brick! My turning kick was fast and powerful, even above my own head height. We all stretched to increase our flexibility and avoid injuries. Aside from some occasional episodes of low back pain and stiffness I was free of pain until at age 31 I ceased martial arts training and gained about 15kilogrammes of body weight, mostly on my love handles. I ballooned up to 106 kilogrammes. To get back into shape I joined David Lloyd in Derby and took up heavy weight training, (well heavy for me!) Over three years I lost 6 kilogrammes and gained awful, lower back, shoulder and neck pain.


Osteopathy was kindly recommended to me after I attempted to front squat 80 kilogrammes, pressed the weight up, reached the point where the weight was to much for my strength, where I let my shoulders roll forward, (see the 3rd drawing above for how not to front squat.) pushed up once more, when pain hit me in my low back! On reflection the pain was a combination of bad diet, red wine, poor lifting technique, absent core stability and mild body dysmophic disorder BDD.

The osteopath helped me but I needed to know more about this science. What are these strange sounding muscles? Why do joints pop or crack, then feel much better? How are osteopaths different from Physiotherapists? Two years later and I was studying part-time with the College of Osteopaths. This lead me down a 5 and a half year life changing path of enlightenment and tiredness!

I received with eager hands my Keele University certificate making official my BSc in Osteopathy, with a fair 2.2 or Desmond Tutu. Alas my registration as an osteopath will now be set back at least a fortnight as my latest CRB has just expired. But what about my working as an unregistered osteopath? Or put another way how is treating people using the osteopathic diagnosis approach?

It still impresses me when people get of my treatment table and exclaim their delight at how different they feel! Occasionally people do not respond, which is really irritating for both parties. Fortunately unresponsive patients are few and far between. Still people who do not feel improved do not re-book, and therefore my desire to learn new approaches, ask more precise questions, test my patient's pain presentation more accurately and  figure out what is causing the patient their pain. So in conclusion working using the osteopathic screen is challenging and rewarding!

Osteopathy on the eve of registration..

Someone once said that the job is not finished until the paperwork is done. Like many old sayings there is a nugget of truth hidden away in that saying. I passed my osteopathy finals on the 8th of February and have waited fairly patiently to be registered since then. Until I am registered, I cannot call myself an osteopath. Five and a half years later,  in exchange for a second degree I have given up one good job, my house, too much money to even begin to think about and at least one cherished friendship.

Has it all been worth it? YES it has. Being a student while working as a school teacher has given me a clearer view of what is important in life. (Friends and family) Having to learn a whole new skill-set while unlearning some unhelpful attitudes has meant a lot of self doubt and tears but fortunately much patience from my osteopathic tutors at Staffs Uni osteo programme. Link Excessive pressure applied makes me learn but suffer. Babies need to pushed out of the nest at some point, its how you push people that matters, not what is in your heart.

I am about to change the sign over my clinic door, update my website Link2, add a new website and further insist that I justify the treatments that I do. If osteopathy is that which osteopaths do, then this osteopath has got to avoid taking the easy route. My view of how osteopaths treat their patients has changed, and will continue to change as my experience grows.