What can we do about pain?
– sometimes tissues repair but associated protective patterns may not, and that may be creating the persisting pain. Have you developed protective, but harmful, movement patterns? Are there areas of tension, tightness, weakness, compensation, that are not allowing your body to function normally as it once did?
– some tissues don’t repair as well as we would want, so have you learned how to stabilize, support, mobilize, or strengthen the area to make it as healthy as possible?
Sciatica is the general term for symptoms-mostly numbness/tingling/burning- that occur in the low back and down the back of our leg. We mostly hear it being associated with terrifying diagnoses and terms such as bulging disc, degenerative disc disease, piriformis syndrome and the list goes on. I will touch more on this below.
Simplified, the sciatic nerve is a big nerve that starts in our lower back, goes down through the back of the leg then splits into 2 nerves that go into our foot. It is responsible for the movement and feeling in the back of our lower leg and foot. Again, simplified.
It is important to note that the issues mentioned above (e.g, disc bulge, degenerative disc) occur in the majority of the population and people have no sciatic symptoms or pain! So we can not say for certain that these imaging findings are causing your pain. What we do know, is that nerves require a lot of oxygen to function optimally (20% of our total oxygen intake goes toward our nervous system). So no matter how the symptoms are occurring, movement is key.
Movement = Bloodflow
Bloodflow = Oxygen
Oxygen = Happy Nerves
So where do you start if you are experiencing sciatica type symptoms?
Some tests that we perform are to determine how sensitive the sciatic nerve is to movements that restrict it of oxygen. If these are positive, then we typically give exercises that mobilize the sciatic nerve to get it more oxygen and get it used to moving again. This can look very different depending on how sensitive things are. However, if you look at our nervous system, you will realize that there are numerous ways to work into mobilizing the sciatic nerve- there is always a starting point. It is also very important to understand that just because you feel something abnormal along the sciatic nerve pathway, this doesn’t mean there is damage to the nerve or you. Hurt does not equal harm.
It is recommended to get a full detailed assessment of your experience. How sciatica is impacting you and the things you enjoy that you might be missing out on, what you are currently able to do, movements that you can do and movements that are challenging. Coming up with an appropriate progressional plan of movements/exercises that relate to your goals is a good starting point to help you return to the things that make you happy.
If you have any questions or are experiencing any sciatic symptoms please do not hesitate to reach out to our team.
-Tyler Dillman – Physiotherapist at One to One Wellness
October is here! That means we should be seeing the leaves changing color, maybe a bit more rain and a lot more pink ribbons. October is Breast Cancer Awareness Month and with the launch of our new Cancer Rehabilitation Program I thought it would be beneficial to help increase awareness of how movement, exercise, and education can significantly impact people’s breast cancer journey.
Ontario Cancer Care and the Clinical Oncology Society of Australia have both stated that exercise should be an integral part of a patient’s treatment plan and here are a few reasons why:
Pain is one of the main barriers to participating in an exercise program after treatments. So how can one overcome this barrier to start becoming more active?
Here are a couple of myths when thinking of exercise for Breast Cancer Survivors.:
No matter where you are at in your Breast Cancer journey, movement, education and exercise play a significant role in recovery and quality of life. If you want to move easier, have less pain, feel more energized or not feel sick, learning, moving and exercising can be the key to unlock those doors.
As an individual journey’s through their cancer diagnosis, the value of exercise cannot be overstated. It has benefits throughout all stages of treatment from pre-diagnosis for prevention, to all stages post diagnosis. It helps prepare your body and mind for treatments, recovery, pain management, coping skills and recurrence depending on what stage you are in (See Picture Below). 1,2
Another important health outcome post-cancer diagnosis is sedentary behaviour. This is concerning for the cancer population because 75% of their time is spent sedentary.1 Furthermore it has been shown that breast cancer survivors spend more time engaged in moderate to vigorous exercise, but spend more time sedentary than their healthy counterparts.,3 Additionally, engaging in this type of behaviour is being associated with cardiovascular risks, diabetes, and increased cancer risk. 4,5 So how do we reduce time spent not moving in a population that can struggle with pain, fatigue, and nausea just to name a few?7
First thing may be to start looking at activity as a continuum,1. When this is done, activity levels progress from doing nothing (.e.g., Watching TV) to activities such as sprinting. Both extremes are recommended occasionally, but not how we want to spend most of our day. In fact, the far right would be impossible to achieve. Now, depending on where an individual is at in their cancer recovery determines their starting point along the continuum. Some people may only be able to perform postural shifts to maintain comfort, and some may be able to do bouts of moderate exercise. Ideally, we want to spend most of our day in the middle of this continuum, with the goal of increasing the amount of time doing activities of daily living and light to moderate exercise.
From a rehabilitation standpoint, it would not be expected for someone to jump from sedentary to moderate exercise if they are physically and mentally unable to tolerate it. Understanding that discomfort and fatigue are two barriers to reducing sedentary behaviour in cancer populations6 is essential to this process. This makes us aware that we need to take more of a stepwise approach of building up tolerance by slowly pushing the limits of where your current level is to try and achieve the next activity goal (See Below). This is where professionals can help you gain a new perspective of why you are experiencing pain and fatigue, and give you strategies to better approach your activity transitions such as edgework and pacing. This may start with gentle postural shifts or mobility exercises to prep the musculature and nervous system to allow you to spend more time toward the middle of the continuum. It can also include multiple light walks or strengthening exercises, it all depends on your tolerance level.
Ultimately, the goal is to be as active as you possibly can throughout the day, and to understand that consistent movement within your limits has the potential to reduce various health risks. Although there is not a specific formula, what we know is that pain and cancer education, movement, exercise, and nutrition will put you in the best position to manage or overcome this cancer diagnosis, meanwhile reducing your future risk of side effects, recurrences, and other health issues.
“It is important to move and to move often, no matter how simple or limited the movement may be.1 ”1. Lucas AR, Klepin HD, Porges SW, Rejeski JW. Mindfulness-based movement: a polyvagal perspective. Int Can Ther. 2016. https://doi.org/10.1177/15347354166820872. Segal R, Zwaal C, Green E, Tomasone J, Loblaw A, Ptrella T, et al. Exercise for people with cancer. Toronto (ON): Cancer Care Ontario; 2015 Jun 30. Program in Evidence-based Care Guideline No.: 19-53. Phillips SM, Dodd KW, Steeves J, McClain J, Alfano CM, McAuley E. Physical activity and sedentary beavhiour in breast cancer survivors: new insight in to activity patterns and potential intervention targets. Gynecol Oncol.2015;138:398-4044. Wilmot EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ, Khunti K, Yates T, Biddle SJH. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis. Diabet. 2012;55(11);2895-29055. Lynch BM. Sedentary behaviour and cancer: a systematic review of the literature and proposed biological mechanisms. Can Epid Bio Prev.2010. doi: 10.1158/1055-9965.EPI-10-08156. Courneya KS, McKenzie DC, Reid RD, Mackey JR, Gelmon K, Friedenreich CM, et al. Barriers to supervised exercise training in randomized controlled trial of breast cancer patients receiving chemotherapy. Ann Behav Med. 2008: 35;116-122.
With regards to the brain: “All it has at its disposal is your past experience, the past experience it has wired into itself” A great quote from Lisa Feldman Barrett on how the brain works to make decisions throughout our day to day life (Interview here!)
But what does this mean for people where pain persists past normal healing time and is becoming chronic? How do your past experiences shape your current pain experience?
What Happened Before?
The brain is a phenomenal structure that drives everything we do. It receives an outstanding amount of information from your entire body in a fraction of a second, analyzes it at a ridiculous speed, tells us what action to do or not to do, and then briefly stores everything that just happened for possible future use. Beyond the fact that this happens without us even knowing, the fascinating thing is that if it keeps receiving the same information over and over, it becomes so fast and so great at analyzing the sequence, it typically has pinpoint accuracy in predicting what to do next. This is great when we are taking our next step while walking, or go to fall and are able to catch ourselves, but not so much when we are talking about pain sensitivity. So if you have been experiencing pain for a significant period of time, a major component can be that your brain is predicting things to be painful based on what’s happened previously (The Predictive Brain article here!).
The prediction of danger is a genius protective mechanism during the initial stages of healing when things need to be protected, but not so much when things are healed and life needs to return to normal. So once the danger is no longer present (i.e.,muscle/ligament is healed, cast is off etc…), thank your brain for trying to protect you, but start letting it know that it’s no longer necessary. The major question is how do you go about that? Here are a few tips: 1) Know that movement is safe and needed for healing. 2 )Pain is not a direct measure of tissue damage. 3) Keep moving within your limits. Somatic exercises can be a great place to start (Youtube One to One Wellness). Finding your limits can be difficult so seeking professional help is strongly encouraged. 4) Start loading. Our brain needs to understand that this area is capable of going under stress, and that it is safe to do so. Star with low intensity and go slowly to build up tolerance and confidence. 5)Have recovery time and sleep. Your brain and body need time to adapt to these increases in demand and it can only do so if you are getting adequate breaks and a good night’s sleep. 6) Take a look at what you are eating. There is truth to the old saying “you are what you eat”.
The changes will not happen overnight but when you provide new, SAFE experiences to help re-wire the predictive nature from danger to safety, we can change for the better.
Lisa Feldman Barrett is a neuroscientist, psychologist and author who researches how the brain constructs emotion.
Many thanks to those who came to our seminar series “Understanding and Overcoming Persistent Pain” at the Halifax Library. It was great to help people gain more knowledge about treating and, more importantly, preventing pain. Based on our experience, we know there is a gap in people’s understanding of pain. We wanted to let people know that (1) that they are not alone, (2) that help is available and (3) that it’s possible to regain control over that aspect of life.
Our passion stems from helping people who are suffering with persistent pain live more fulfilled lives. Education, movement, and exercise are key to achieving this. We are firm believers that knowledge is power and it is the first step in gaining freedom from persistent pain.
We were very pleased with the turnout for the last series of workshops and recognize that people want help managing their pain or a loved one’s pain. Here are some upcoming opportunities to learn more:
April 27th at One to One Wellness:
“Health Empowerment: 4 Steps for Shifting From Pain to Performance”
June Seminar Series at the Halifax Library: “Strengthen Your Health”
We will explore different wellness principles and how putting all the pieces together helps to not only overcome pain, but to optimize performance as well. Please come along and bring a friend. If you have any questions in the meantime, feel free to ask!
My inspiration for this blog article comes from a recent visit I had this weekend at my sister in-law’s house. They are dealing with an issue that many North American families have to deal with….kids that spend way too much time using electronic devices. She was upset because on a sunny day, her son spent 6 straight hours playing X-box. In addition to that, he spent time on the computer on MSN, Youtube, Facebook, and numerous other websites. Don’t forget television as well. This trend is growing at a ridiculous rate, and as a physiotherapist I get to see the physical effects.
RSI, or Repetitive Strain Injury, is a collective term for syndromes characterized by discomfort, impairment and loss of muscle strength and function. RSI often affects the neck, the back and particularly the arms and hands. It is found primarily in adults who perform repeated movements such as those involved in typing or playing musical instruments. It is commonly named according to the part of the body affected, e.g. tennis elbow, carpal tunnel syndrome, golfer’s elbow. We are starting to see RSI turn up in younger and younger patients which is rather alarming.
In addition to computers and gaming devices, there has been a substantial increase in the amount of time teenagers spend on their cellular phones sending text messages, thereby potentially affecting the prevalence of RSI in this group (2). The increased frequency of texting is leading to a condition popularly termed “Blackberry Thumb”, or “teen texting tendonitis”. This occurs because these devices rely almost solely on the use of your thumbs (not all of your fingers) for typing. Any device that relies on the thumbs for typing can cause this type of injury because the thumbs simply weren’t designed for such use (1,3). Repetitive mechanical loading of the thumb, combined with inactivity, and prolonged slouched postures resulting in increased neural tension results in increased risk of developing RSI.
Symptoms of “Blackberry thumb” include pain and numbness in the thumbs and joints of the hand (1). But there are also other bodily symptoms:
It is estimated that teenagers sending and receiving an average of 80 text messages each day may be vulnerable to repetitive stress injuries of the thumb (4). If you think this is a high number and unlikely, consider these statistics:
If you think my sister in-law’s son is a minority, then guess again. Here is another interesting statistic: Americans between ages 8 and 18 spend an average of 7.5 hours a day using an electronic device, be it a computer, cellular phone, or television (4). If this sounds like your child, or one you know, then consider these tips to avoid developing these repetitive strain conditions:
Restricting time spent on electronic devices, and increasing physical activity will significantly reduce the risk of developing RSI conditions. If your child develops symptoms of RSI, please see an appropriate health practitioner to help deal with the issue. If left unchecked, these symptoms can progress and become quite severe and debilitating. If this issue is familiar to you, the staff at One To One Wellness would like to help you.
Without any thorough examination, you may have been given the diagnosis of osteoarthritis and be expected to just live with it. However, you may be experiencing Saphenous Nerve Entrapment.
Saphenous nerve entrapment is a frequently overlooked cause of persistent medial (inner) knee pain. I chose to write about it because I saw 2 cases of random knee pain and swelling recently.
Nerve entrapment is often the cause of pain when you cannot recall a mechanism of injury. This condition can result from low grade irritation over a long period of time from sustained postures or repetitive activities, or perhaps resulting from guarding mechanisms that never fully resolved from a previous injury. Symptoms can be episodic (come and go), may come on randomly, and may resolve randomly as well.
The saphenous nerve is the longest branch of the femoral nerve. It travels from the groin, down the front of the inner thigh, past the inner knee, and into the inner lower leg. Because of its long course, it can become entrapped in multiple locations from the thigh to the lower leg. The saphenous nerve is often entrapped by connective tissues where it pierces the muscles of the inner thigh, or where it takes a sharp turn at the inner knee. The nerve can also be injured as a result of an improperly protected knee during surgeries or activity that puts pressure on the nerve (kneeling).
It is a pure sensory nerve, meaning it is responsible for sensation and not muscle contraction. As this is a purely sensory nerve, weakness should not be noted with an isolated injury or entrapment of this nerve. Some mild weakness may be present because of guarding from pain, but no significant direct weakness will result from the nerve impingement.
Symptoms of entrapment: may include swelling of the knee, a deep aching sensation in the thigh, knee pain, tenderness along the nerve pathway, and altered sensation in the knee and lower leg such as numbness, tingling, pins and needles, reduced sensitivity to heat or cold, reduced vibration sense, and dullness to touch. The main diagnostic features of this condition are altered sensation (vibration sense is usually the first to be affected), and reproduction of symptoms during a femoral/saphenous nerve neurodynamic test.
Other diagnoses given for this condition may be arthritis, bursitis, patella femoral pain syndrome, or chondromalacia patella.
Treatment to resolve this issue may be as simple as learning to do some gentle nerve gliding exercises. Effective treatment may also involve soft tissue release (via massage or physio); and gentle manual mobilization techniques that reduce mechanical forces on the nerve, improve nerve mobility, reduce muscle guarding, and restore blood flow to the affected nerve.
It may not be arthritis, and you may not have to just live with it.
In industrialized countries, many people sit for most of the time that they are awake. They sit while having breakfast, while going to work in cars or buses, in school classrooms, in meetings, in offices, during dinner, and at home while watching television. Many people also sit at work operating machines which new technology has developed to replace manual work.
Although sitting requires less physical effort than standing or walking, it puts a lot of stress on lumbar area. Combined effects of a sedentary lifestyle, and a job that requires sitting can lead to many health problems. The selection of a suitable chair is a critical step in preventing health problems in people who work in a sitting position. However, you do not have to spend a lot of money to find a proper ergonomic chair.
A good ergonomic chair will have basic adjustability features. The features that should be considered include:
Seat height adjustability: Adjustability is a must – feet should rest comfortably on the floor without pressure on the back of the thighs. When seated, your hips should be slightly higher than your knees. To achieve proper height with respect to your desk or keyboard tray height, you may need a foot rest.
Seat depth adjustability: The depth of the seat is important in order to reduce pressure on the back of your thighs or calves. If the seat puts pressure on the back of the knee, or mid posterior thigh, this will reduce circulation and cause a pooling of blood in the extremities. This can lead to varicose veins, painful conditions, and also blood pressure issues over time. Proper seat depth will allow for a 2-3 finger width distance from the back of the knee to the edge of the chair.
Armrests (height adjustable): To reduce strain on your neck and upper extremities, your armrest height should be as follows: with the arm relaxed and bent while seated, the arm rest should be a 2 finger width higher than the bottom of the bent elbow. Armrests set too high will cause compression of your thoracic outlet. Armrests set too low will cause traction on your neck. The length of the armrests may need to be considered as well so they do not prevent you from pulling in close to your desk or keyboard tray. Armrests set approximately 15cm back from the edge of the chair should be adequate.
Back rest height: A mid back or high back chair offers more support and will reduce lumbar strain. A low back chair is not recommended if you spend a fair amount of time sitting. Regarding shape of the back rest, do not get hung up on molded forms and fancy adjustable parts. The most important factor in reducing back discomfort while sitting is the ability to move around frequently. A chair should not lock you into a position and restrict your movement.
Many of the features described here allow a chair to adjust to a given posture or body size, but it is important to remember the importance of posture change. Adjustability features should allow, rather than inhibit, free posture change. Sitting increases the mechanical force applied on your body.
Stationary postures cause tonic muscle contraction which means they are constantly contracted. This does not allow for the muscles to rest, or allow blood flow. Therefore, by not altering postures or taking short frequent movement breaks, you are at risk of experiencing mechanical pain conditions and excessive muscle tension. Therefore, move around or fidget in your chair frequently, and get up and move around at least every half hour. Your movement breaks do not have to last long, but they do have to be frequent in order to minimize your chances of experiencing discomfort.
How to know when I need some help for my pain:
We trip, hurt our knee. Twist a little too far, your back spasms. That ache in your elbow that used to only be a problem when playing tennis is now bothering you at work and even just reading a book. Checking my blind spot is nearly impossible now without turning my whole body.
When is it ok to just let things heal in their own time and when do you need to get a professional opinion?
The best way to approach this questions is knowing what “acute” versus “chronic” means. Acute injury symptoms are what the body presents in the first 24-48 hours on the initial onset of pain (ranging from pain that can be dull or sharp, redness, swelling, bruising, difficulty moving the affected area, pain-related weakness, avoidance of activity through protective movement mechanisms). Chronic pain is when pain continues well after healing should be complete (3-6 weeks) with similar as well as very different symptoms (less swelling, more dull instead of sharp but perhaps increased pain even a rest, better movement range but perhaps still decreased, weakness in affected and perhaps increased locations, and protective movements can increase creating other areas that become sore). Chronic pain is much more complicated to resolve.
When we get injured, you should remember the rule of “FIDA”, for Frequency, Intensity, and Duration, Activity. If you tripped, twisted your ankle, and immediately have pain, or maybe not much pain until the next day (when your body has had some time to begin the inflammatory response). Pain could be very severe, even at rest, range of motion extremely decreased, and it could hurt just to have your foot on the floor. The normal healing process should see incremental improvements of frequency (how often it hurts as well as how large of an area affected), intensity (how much it hurts), duration (does it recovery quicker with a movement that normally bothers it) and activity (are you starting to go back more normal activity levels and actions required of daily living). My general rule is that if all of these FIDA areas are not incrementally improving within a week, I would get a professional to look at them to make sure that you are doing the right things, avoiding the wrong thing, and that things are not more serious that your originally thought.
With an injury, there are three stages to recovery.
1. Avoid further injury.. Action: avoid repeating the same thing again, cease current movement, make the “danger” stop.
Sometimes there was no specific “injury” and your symptoms just seemed to crop up out of the blue or slowly over time. Interestingly enough, even without the apparent “danger” signal to the brain, our bodies will still follow the same stages of recovery because of some action that we keep repeating (or lack of an important action) that leads to the brain reacting as if there were an injury.
A lot of non-serious injuries will start to heal and have noticeable improvement in pain levels, range of motion, and strength within 4-7 days with proper rest and avoidance of the “danger”, if known. But if things are not improving by that time, there may be more to the issue than you realize. And that is when you may really benefit from a professional to assess it to avoid the problem becoming chronic. Obviously, avoiding an acute injury from turning to chronic is extremely important to anyone. If you are wondering whether you should seek help, as yourself these questions: