Blog 3 from Lower Earley Osteopaths: Fibromyalgia; The Neurological Basis.

What is Fibromyalgia?

Fibro - fibrous tissues, myo – muscle, algos – pain: muscle and connective tissue pain.

It is a medical disorder characterized by chronic widespread pain and a heightened response to pressure. Common symptoms include fatigue (or brain fatigue) and sleep disturbances, frequent symptoms include Irritable Bowel syndrome and chronic headaches. It’s estimated 2% of the population is diagnosed with FM and a dominant female ratio of 9:1. There is not a routine blood test or x-ray that show abnormalities, it is diagnosed by a doctor who looks for a history of chronic symptoms, lasting over three months, with pain reported in all four quadrants of the body. They perform a physical exam of 18 specific points, diagnostic criteria includes 11 tender points or pain upon light pressure.

A large amount of my research consists of looking at Fibromyalgia from a neurological view point, to help explain fully lets explore the nervous system:

The nervous system is made up of: the central nervous system (consisting of the brain and spinal cord) and the peripheral nervous system (consisting of the nerves aka neurones and nerve cells). The neurones connect to each other as well as connecting the peripheral and central nervous systems. Neurons send signals to other cells as electrochemical waves, along fibres within called axons, they release neurotransmitter to cross junctions called synapses. There are two main types of neurones: sensory neurones (response to touch, sound light etc) and motor neurones (muscle contractions).

How nerves work:

A nerve is known as a transducer, it converts one form of energy into another. For example it converts temperature stimulation into an electrochemical impulse. It does this by developing something called an Action Potential which causes the nerve cell axon (a good analogy is a bit of wire in an electrical circuit) to conduct an impulse across synapses from the peripheral nervous system along to the central nervous system sending information to the brain.

When a nerve cell in the skin is stimulated sufficiently it sends an impulse to the spinal cord which, through a series of stages, directs the impulse upwards (the ascending tracts) to a part of the brain called the Thalamus (a sort of relay station). The Thalamus forwards this incoming message to 2 main areas of the brain; the 1^st is to the part that registers sensory information (sensory cortex) and the 2^nd is to a deeper more primitive part of the brain which deals with our emotions (limbic system). This is the area of the brain in which we are aware of the unpleasantness of pain.

This is how we become aware of pain. However that which comes up must go down: this is another part of the sensory nervous system which sends information down the spinal cord (descending tracts). These are inhibitory nerves which in effect turn off the ascending (excitatory) tracts which are sending information up to the brain telling us that we hurt.

In the normal nervous system there exists a balance between the ascending (excitatory) and descending (inhibitory) tracts. In chronic pain conditions this balance is disrupted. It appears that FM patient’s central nervous system has become hyper sensitive to painful stimuli and in some cases non painful stimuli are recorded subjectively as painful.

An fMRI study in the USA showed that when the same pressure stimulus was applied to FM patients they demonstrated increased activity in all areas of the brain concerned with pain processing as compared to healthy (non FM) subjects (Williams & Gracely, 2006). This condition, where the nerves in the central nervous system (The brain and spinal cord) respond inappropriately to noxious (unpleasant) stimuli, is termed Central sensitisation.

Another fMRI study showed that when FM patients were given a cognitive task, which required a rapid physical response (e.g. rapidly touching finger to nose), they recruited many more areas of the brain to respond and complete the task than the control group of healthy subjects. (Cook & Lange 2004). This leads to the conclusion that FM patients have to work harder to complete the same tasks as non FM people. This could be the basis for what is commonly called Brain Fog.

There is a mechanism which may help to explain the illness syndrome associated with FM. It may explain why we have the co-morbid conditions such as fatigue, morning stiffness and cognitive impairment. This has been discovered through recent research into cells called Glial cells: these are supporting and immune response cells that are spread throughout the central nervous system. They are normally in a resting state, but when the CNS is damaged or becomes infected these cells migrate to the damaged area and release various chemicals, this increases pain sensitivity and ultimately leads to the illness syndrome. This in turn makes us want to go and lie down, rest, recuperate and be cared for. (This could explain the recent phenomena of Manflu!!). There is evidence to suggest that in FMS these Glial cells do not get switched off so we always feel ill!

There is a great deal of research being done at present which is finally validating FMS as a distinct disease. It is my belief that a multidisciplinary approach to treating this disease is the most effective way forward. I am currently looking at exercise, breathwork and meditation as possible ways in which we can help to combat the effects FMS has on us.

References:

Cook, D.B., Lange, G., Ciccone, D.S., Lui, W.C., Steffener, J., Natelson, B.H., 2004. Functional imaging of pain in patients with primary fibromyalgia. Journal Rheumatol, 31 (2): p364-78.

Williams, D.A., Gracely, R.H., (2006). Biology and therapy of fibromyalgia. Functional magnetic resonance imaging findings in fibromyalgia. Arthritis Research and Therapy, 8 (6): p224

Blog 2 from Lower Earley Osteopaths: Half Marathons

Emma, from Lower Earley Osteopaths, talks about her experience training and running the Reading half marathon and treating patients who were injured during their training.

Half marathon season is upon us! Having just run my first Half Marathon last weekend in Reading, alongside over 12,000 people, I could not believe the number of supporters who turned out to cheer us on and the incredible atmosphere and sense of community! Whether it was your first time (like me), a yearly tradition, one of the many half marathons or training for upcoming full marathons, they are hard work and include plenty of ups and downs.

If you, like me, ran the Reading Half Marathon then you may have undergone the teasing from love ones as you hobbled down the stairs Monday morning! Personally my hip is a little sore following the run and my knees a little stiff.......luckily I work in the right job (with a great boss) and had a little TLC treatment to get me back up and running, not before a few patients laughed at me hobbling around the treatment room!

The last few months have been hard work, I personally over came some injuries and had a number of patients come in desperate for me to answer the question..... “Can you fix this before the race?!” One patient in particular I managed to get back into training and he beat me across the line by 3 minutes!

So how can Lower Earley Osteopaths help you? Let me tell you a little about my training and injury, and one of the patients I treated.

I have always wanted to run a half (and a full) marathon, whilst away travelling I thought it was time for a new challenge so I signed up as something to work towards when I returned. My training started in December, road and treadmill running, not long after Christmas I had my first knockback......medial tibial stress syndrome aka shin splints. The inside part of  my left shin started to hurt, every time I ran or walked long distances it would become painful. I decided it was time to talk to Marcus (The Boss) about treatment and to look into why it was happening. We decided to work together to resolve my injury with treatment and exercises. The more we looked into the problem the more it related to a patient I was treating for the same injury!

Firstly Marcus and I discussed my history, I had broken my left ankle 5 years previously and 4 years ago underwent reconstructive ligament surgery, I rehabilitated the ankle but this was the first time I had done such intensive road running.

Marcus carried out a physical examination; my left foot arch had dropped, potentially as a result of altered foot mechanics following my ankle surgery. That meant less shock absorption was occurring in the foot placing extra strain on my shin bone called the tibia. As I was walking my arches were flattening and my foot was rolling inwards or ‘overpronating’. Each time the arch flattened with walking or running it was over-stretching my posterior tibial tendon, which attaches the posterior tibial muscle to the bone. The muscle runs from the back and inside of the tibial bone, wraps around the inside of the ankle and attaches to the bottom of the foot. The over-stretching was causing a repeated tugging on the muscle’s attachment to the tibial bone. This leads to pain, inflammation and small areas of swelling along the inside of the tibia.                                                                                                                                                                                                          

However this pain can also be caused by stress fractures as they have similar symptoms. Stresses from continual running on hard surfaces and heavy strain from the tibialis muscles can weaken and fracture the tibia; if you continue to train through shin splints you can develop stress fractures.

We agreed I was suffering from medial tibial stress syndrome, in particular posterior shin splints. Shin splints is the name given to pain over the front of the tibial bone, it is often worse after weight bearing exercise and periods of being stationary such as sleeping. This is because the muscle shortens and therefore is sore when you first place pressure on it, until the muscle has stretched. Often other muscles tighten in response, frequently, and in my cause, this includes the calf muscles which exuberates the problem and prevents it resolving itself.

Shin splints are caused by overuse and sudden increase in duration or intensity of weight bearing activities such as running. The pain can be due to an imbalance in muscles, foot mechanics or the attachment of the muscle to the bone, most commonly caused by foot overpronation. There are a few types of shin splints; I suffered from posterior shin splints however there is also anterior shin splints.

Anterior shin splints is caused by over straining the anterior tibialis tendon and muscle. This is often brought on from start/stop sprinting, running downhill or people who run on the balls of their feet. When you run on the balls of you feet less absorption is dissipated by the foot arch, this forces the excess stress to be taken up by the anterior tibialis muscle leading to inflammation and pain on the outer part of the tibia, where it attaches.

Treatment of shin splints:

Firstly ice over the inside tibia to reduce the inflammatory pain. Secondly I brought a pair of trainers that corrected my overpronation by providing more arch support when I ran or walked. This reduced the irritation of the posterior tibialis muscle and the trainers provided extra shock absorption.

I created a stretching regime to stretch the tight calf muscles and exercises to change my gait mechanics, learning to run heel to toe, and heel raises to strengthen the weakened muscles.

I then did the hardest thing: rest. I took 3 weeks off running and replaced it with non weight bearing activities such as yoga, tai chi, pilates, swimming and aqua aerobics. This meant I was still maintaining my aerobic levels, strengthening my core and stretching any tight muscles but allowing the tendon and bone to repair and preventing the risk of a stress fracture. After those weeks I continued to do more non-weight bearing activities to create a healthy balance.

Treatment in the clinic involved acupuncture, low dose lazer treatment to encourage healing and soft tissue techniques to stretch tight muscles.

As a result I ran my first half marathon in 2 hours 10 minutes......I can’t wait to try to beat it next year!

My patient John*:

My patient came in with left calf pain. This first started after running the half marathon last year and reoccurred after a 10 mile run a few days previous. John was running 25 miles a week in preparation for the Wokingham half (in a week’s time) and the Reading half (5 weeks time).

Examination showed a left dropped foot arch causing a bowing in the calcaneal (Achilles) tendon. His left superior tibial/fibular joint was locked and his anterior tibialis muscle was tight. I diagnosed a calcaneal tendonitis due to an over-pronated arch. I recommended that John replaced his running shoes as they were a little over worn to provide more arch support. I gave him a couple of exercises such as calf raises and stretches and to relax into the running to shift his centre of gravity backwards slightly to prevent the overloading of the anterior tibialis muscle. Treatment included mobilising the locked joint, soft tissue techniques to the tight muscles, stretching the calcaneal ligament and freeing the compaction in the left foot. He appeared fit and ready for the Wokingham half, so I booked John in the Monday after the race to loosen any tight muscles and check any problems post race.

Monday came and John hobbled into the clinic, two days before the race he had lifted a tumble dryer and injured the lower right hand side of his back, therefore he was unable to run the Wokingham half. We diagnosed a right sided sacro-iliac joint lock with hypertonia of his buttock muscles, which were mildly compressing a nerve down the back of the leg. We manipulated the lock joint and used soft tissue and stretching techniques to release the spasmed muscles. I gave John some stretches to continue loosening the tight muscles and advised ice to reduce any inflammation around the joint.

I saw John a week later, he was much better and had returned to his usual training, I treated the residual tightness, told John to continue his stretches and advised no more tumble dryer lifting! The next time I saw John was at the Reading half as he beat me across the finishing line by 3 minutes!

*name changed to anonymise the patient.

Blog 1 from Lower Earley Osteopaths: Desk based workers.

A case study to demonstrate how we work, using a patient we saw called Mary:

Mary, a 53 year old office worker, had been suffering from chronic right sided neck pain with occasional severe headaches.

She had a history of vertigo (dizziness) and occasional light headedness and had been diagnosed as suffering from positional vertigo (dizziness when she went from sitting or lying to standing). She had been using a variety of pain killers for some time but didn’t really feel that they were helping.

On advice from a work colleague she made an appointment with us and came to see us the next day.  She was very nervous at first, but after reassurance that we wasn’t going to twist her head round sharply she became more relaxed.

A full examination of her posture revealed that her right shoulder was being pulled forward by a tight pectoral muscle hence there was a reduced range of movement in the right shoulder. The muscles in her neck and upper back were all very tight, more so on the right hand side. Her mildly curved spinal posture was adding to the tension in her neck muscles.

Following questioning about her work environment we discovered that she was sitting incorrectly. Mary’s work station was poorly setup and constant use of her mouse in this position was one of the causative and maintaining factors of her problem.

How were we able to help?

The initial session was aimed at identifying as many of the predisposing and maintaining factors causing her pain.

Treatment was aimed at decreasing the muscle tension in the right shoulder hence returning the muscular balance and improving Mary’s posture. This was achieved by stretching, soft tissue massage and postural advice. We did not manipulate the joints (the clicking sound often heard from increasing the joints movement) due to a medical condition that was discussed when her medical history was taken in the first treatment.

Together we formulated a plan to reduce the pain by altering the way she sat at her desk and improving the way her musculo-skeletal system worked. She had an ergonomic check of her work station which repositioned her computer and mouse, including a wrist guard, and a new lumbar supportive chair which all improved her sitting posture.

Mary was given exercises to begin to correct her poor posture including neck and chin repositioning exercises, stretches for the front of her chest and strengthening the muscles in the back, all of which she was able to do at home or work.

Within 2 treatments Mary was feeling much better. To combat Mary being sat all day at work she agreed to continue doing her stretches each day to keep her muscles looser and more balanced, Mary understood that by doing these exercises for a couple of minutes a day she could prevent the pain from returning and is now pain free.