Chronic Pain – What Exactly Is It?

What is pain? It might not be something you’ve really thought about but it seems like a pretty easy answer – you stub your toe, it hurts. You touch a hot burner, or you roll your ankle and they hurt immediately. Pretty straight forward right? Pain is your body’s response to physical danger. Your brain receives a signal, whether it’s the crushing impact on your toe, or the heat from the burner on your skin and interprets those stimuli as a danger and creates a pain experience to alert you that something is wrong. In this way, pain is crucially important to our survival. People with decreased sensation can suffer serious consequences due to their inability to feel pain. Makes sense right, trauma = pain. Thank you Captain Obvious!

 Not so fast….

Pain is easily explained in acute situations like the ones above, but how do we explain pain that lasts for weeks, months or even years? Low back pain is a common example. Maybe you hurt your back picking something up, or you sleep in a weird position and wake up hardly able to move. For some lucky people this pain will last a matter of weeks and disappear, but unfortunately they’re the minority. For many others, the pain will continue to persist. We know how long various tissues take to heal, so how can this pain still remain long after those expected healing times have past? (Note: this cycle is often incorrectly attributed to continuously re-injuring the affected area but this isn’t always the case).

The answer lies in our brain, or more precisely, our entire central nervous system. We once believed that we had specific pain receptors all over our bodies but this isn’t entirely correct. What we actually have are called nocioceptors and can be thought of as your “danger sensors”. These receptors are simply sensors that monitor for a variety of potentially harmful stimuli and are responsible for alerting the brain. When we touch a hot stove our nocioceptors sense the increase in temperature but that’s all the information they know. They can send a “we’re touching something warm” signal to the brain but it becomes the brain’s job to interpret this signal. If your brain decides that it’s just warm, but not hot enough to damage your skin, it responds by inhibiting the original signal and you don’t feel any pain. However, if the brain decides that the temperature is enough to cause damage, your brain creates a pain signal and you will instinctively pull your hand away to protect the area.

So, if it’s the brain’s interpretation of these constant danger signals that can result in an experience of pain, why does your back still hurt 6 or 12 months after the initial injury? Longstanding pain is due to a process known as “sensitization”. This can happen in two places: First, at the original site of injury, the sensors around the injured area become more sensitive as they become accustomed to sending increased signals. Their increased input continues after the physical damage has resolved but the brain isn’t aware that the healing process is complete and continues to produce a protective pain response. This can occur to a stimulus as simple and harmless as light touch or movement. Secondly, changes can occur within the brain itself. The brain has designated areas for each and every body part and these areas are able to adapt and change over time. If the area for the low back is being constantly stimulated by danger messages, this area can grow and even start to overlap with surrounding areas. This can cause movement in other areas of your body to trigger danger messages that the brain interprets as originating from the back, and again you feel pain. This feeling of very real pain in the absence of true physical damage is what we know as chronic pain.

The good news….Both of these processes are completely reversible! The first step is understanding the complexity of the pain process are realizing that there may no longer be a physical injury. Then you can begin the process of re-training the brain and desensitizing the nervous system to restore a pain-free state!

It’s important to understand that this article only covers the physical mechanism behind pain. Pain can also be affected by non-physical elements such as emotional and social factors but that’s a subject for another blog! If you have longstanding aches and pains you may be suffering from chronic pain. Drop by and have a chat with your local physio to determine the appropriate treatment method to get you back on your feet!

This article originally appeared on Stoke Physio.

What is Femoroacetabular Impingement (FAI)?

Hip impingement, also known as femoroacetabular impingement (FAI), is a condition where there is abnormal contact between the femur bone (femoral head) and the socket of the hip joint (acetabulum) during certain movements of the hip.

The resulting impact can lead to damage of the cartilage inside the hip joint. This may in turn lead to premature arthritis.

FAI is traditionally described as due to either an abnormality of the shape of the ball of the femur (CAM deformity) or of the acetabular socket (PINCER deformity). Movement of the hip joint is complex, and more recent research has demonstrated that the overall 3-dimensional shape and orientation of the hip should be considered to properly evaluate and treat clinical impingement.

Symptoms:

Patients with FAI often experience pain in the groin with deep flexion (bending) or rotation of the hip during certain activities. There may also be inflammation of the tissues surrounding the hip such as on the outer side of the hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or inflammation of tendons in front of the hip, especially if the condition has been around for some time. Eventually, as the damage continues, the patient may begin to develop more arthritic symptoms such as a stiffness and a dull ache in the groin. Hip-related pain is not always felt directly over the groin. It may also be felt on the outer aspect of the thigh, the buttock or traveling down the leg.

Investigations:

Patients who have symptoms suggestive of hip impingement are usually investigated with x-rays of the hip first. Further investigations could include a CT scan and special MRI scan. The CT scan is performed to study the bony detail of the hip and the MRI is used to assess the cartilage, labrum and other soft tissue structures in and around the hip.

Treatment:

Non-surgical Treatment for FAI:

Treatment of femoroacetabular impingement symptoms often begins with conservative, non-surgical methods. Physiotherapy treatment may involve soft tissue work to relieve tight muscles around the hip, however the majority of treatment is rehabilitative based, to try strengthen the deep hip stabilizing muscles. The aim is to improve the stability and function of the hip. At Port Melbourne Physiotherapy & Pilates we commonly treat patients with hip/groin pain with a structured Pilates program aimed at strengthening the hip and pelvic muscles.
Rest, activity modifications and selective use of non-steroidal anti-inflammatory medication are often helpful in alleviating early symptoms. An injection of the hip joint with anaesthetic can provide some relief as well as diagnostic information in patients with symptoms which are unresponsive to treatment.

Surgical Treatment for FAI:

For patients not responding to conservative management, Femoroacetabular Impingement (FAI) can be addressed with surgery to improve the shape of the hip.
The aim is to correct the bony deformity before there is irreversible joint damage. In many cases this can be done by hip arthroscopy (keyhole surgery).

If you’d like further information on FAI or if you feel your symptoms match the description above, speak to your physio about what treatment options are available for you and whether further investigations are required.

This post was written by Sheree Freedman – Physiotherapist/ Director at Port Melbourne Physiotherapy & Pilates

Common Knee Injuries and How To Treat Them

In this post we will focus on knee injuries, and what treatment may be required to get back to living your barefoot lifestyle!

Common knee injuries can occur through daily movements and activities, whether it be a car ride, sport or landing differently on your knee. Three common knee injuries we will look at are ACL, PCL and Meniscus tear which cause discomfort and potential long term effects if not treated properly.

Common Injuries

Meniscus tear: Damage to the meniscus, can be caused by awkward pivoting on the knee, direct blow to the knee or in some cases repeated squatting with poor technique. Symptoms include pain in certain ranges of movement, a feeling of something ‘catching’ or ‘locking’ in the knee

Medial collateral or lateral collateral ligament tear: Damage to these ligaments typically occur from changing direction. This can be when the foot stays planted or a direct blow to the inside (LCL) or outside (MCL) of the knee. Symptoms include localised pain, swelling and feeling of instability.

ACL tear: Depending on the severity of the injury, the ACL could be strained, partially torn or completely ruptured. Damage to the ACL is often caused by pivoting/change of direction when the foot remains planted (most common). Damage can also be caused by hyperextension (eg knee being pushed past straight) which can occur when the foot remains planted, and the body pushed sideways (eg in a contact sport).

Symptoms include an audible popping noise at time of injury, significant pain and swelling immediately or a feeling of instability. Due to the mechanisms of injury, it is not uncommon for an ACL tear to occur with meniscus damage and medical collateral ligament damage (known as the “unhappy triad”).

PCL tear: PCL tears are much less common than ACL ruptures, as they are stronger and larger ligaments. A PCL tear can occur from direct force to the shin, while the knee is flexed (such as knee hitting the dashboard in a car accident). This is the most common cause of PCL injury. Another common PCL tear can occur from falling onto a bent a knee, with hyper extension causing damage to the PCL.

Symptoms are often similar but far  less severe than an ACL tear.

Treatment
If you have suffered an acute knee injury, or are feeling pain and discomfort in your knee/s then the following can help to reduce pain and inflamation,

Settle inflammation down:
Relative rest (don’t do anything painful, but don’t do nothing- aim to gently keep your knee moving); ice for 20 minutes every few hours; no alcohol; discuss anti-inflammatory medication options with your doctor or pharmacist

  • Consult your doctor or physio to determine if imaging is necessary. There are clinical tests that can help determine if any of these structures are damaged. Your physio or doctor should talk you through each test and your results. If there is any concern, an MRI (magnetic resonance image) will often be recommended for more certainty
  • If damage is detected on imaging, then your doctor will likely refer you to an orthopaedic surgeon (specialist doctor) to determine the best management for your injury (ie surgery or physio)
    Whether your injury requires surgery or not, we suggest popping in to see one of our physio’s to get you back to doing what you love, sooner!

This article was originally posted on barefootphysiotherapy.com.au. It has been re-published with the permission of the author.

Not All Hamstring Strains Are Equal

Hamstring Strains Are Most Frequently A Sprinting Injury

The winter sports season is upon us, meaning physiotherapists all around Melbourne will be dealing with athletes having suffered hamstring strains. AFL and soccer are sports with notoriously high numbers of hamstring strains the majority of which occur during high speed running.

70% of hamstring injuries in elite football players occur during high-speed running (sprinting) and the rest with stretching, sliding, twisting, turning, passing, jumping and overuse.

Predictors Of Poor Recovery With Hamstring Strains

Poor prognostic predictors regarding hamstring strains and athletes returning to play following hamstring injury (referring to hamstring injuries that are likely to take longer than average to recover) include:

  • Suffering a stretching type injury such as reaching for a ball with an outstretched leg or bending to pick up a ball whilst on the move are injuries that have on average 84% longer return to play times than contraction injuries (contraction injuries referring to hamstring strains occurring during regular sprinting motions).
  • The area where the peak point of pain is to touch on the back of the thigh. The closer to your sit bones (the ischial tuberosity) the peak pain point is felt the longer the recover times.
  • Location of swelling. Similar to the location of peak pain, the closer any swelling present is to the ischial tuberosity the poorer the prognosis.
  • Most weekend warriors will not require an MRI for an acute hamstring strain but another predictor of poor prognosis found was the length of swelling upon MRI. The longer the area of swelling visualized on imaging likely indicates a longer return to play time frame.
  • These findings although relating to the professional footballer (soccer player) can arguably be applied to the weekend warrior. Notably the professional athlete may have both more resources and motivation to aid their return to play but these can be considered useful guidelines for the armature sportsman to help with estimating a safe return to play.

Return To Play In 23 Days

45% of athletes return to play in 23 days following sustaining a hamstring strain. Individuals variations will always exist and many variables come in to play such as pre injury status, adherence to any physiotherapy guided protocols… But it is nice to have a bench mark to aim for and the realization that with the majority of hamstring strains the sportsperson is likely to miss 2-3 matches based on having weekly games.

It is easy to see improving recovery times by just a few days could be the difference between missing only two matches verses three or more. In a short season every game missed through injury is significant so adherence to physiotherapy advice and protocols can help you play more matches during the season which is what being a weekend warrior is all about, getting out there and having a run.

Loading Over Stretching With Hamstring Strains

With hamstring strains rehabilitation programs based on exercises primarily involving high loads at long muscle-tendon lengths were found by Askling CM, et al to be the most effective at reducing the time to return to play.

The idea is that rehabilitation in a controlled graduated fashion should attempt to mirror the particular situation that lead to the injury. Where rehabilitation of acute hamstring injuries should build on attaining eccentric loading at long muscle lengths (the phase of contraction that occurs as the muscle lengthens is considered an eccentric contraction).

Eccentric loading and loading muscles towards their end of range can put strain on healthy tissue let alone muscle tissue recovering from injury so guidance with such rehabilitation techniques is crucial for successful outcomes.

Professionally Guided Management Makes The Difference

If you have sustained a hamstring strain having a physiotherapist assess your injury to help gauge a working return to play time frame and set up a rehabilitation protocol. Can help you return to play quicker and reduce the likelihood of any recurrence.

Reference: 2013 Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Askling CM, et al Br J Sports Med 2013.

Written by Hayden Latimer. Hayden’s practice is based in Sydney, he is the owner of Sydney Physio Clinic. Prior to opening https://www.sydneyphysioclinic.com.au/ Hayden has worked as a physiotherapist around the world for over 15 years.

Sciatica: What You Need to Know

Sciatica is commonly described as pain experienced mostly on one side of the body and runs down the buttock, hamstring and sometimes extends to the lower leg. Sciatica pain is normally caused by compression of the nerve that originates from your lower back. It can be triggered by joint inflammation, tight buttock, arthritic growth or locked facet joints.

Symptoms that are generally experienced are:

  • Pain in the lower back, buttock and back of leg
  • Pins and needles down the leg
  • Weakness and numbness of the leg or foot
  • Sharp pain when standing up

However, just because you tick most of the boxes above, you still may not have sciatica. Leg pain can be from various causes and sciatica is often misdiagnosed. Therefore, you should always get yourself diagnosed by a therapist who will take into consideration the findings from the physical examination and the history of symptoms.

Treatment

Sciatica is firstly managed conservatively with a combination of pain relief medications and physical therapy. The majority of people who experience sciatica get better within a few weeks or months with the right Physiotherapy treatment. If the symptoms do not improve your therapist might suggest surgery (only as a last resort). However, research has shown that long term benefits from surgery appear to be equivalent to the conservative care.
Research conducted in 2011 showed that the best results are seen by restoring normal flexibility, posture and strength through a directional bias exercise plan. Here, at Fresh Start Physio we treat our patients using the concept of Clinical Pilates which is a rehabilitation modality developed by Craig Phillips, Director of DMA (Dance Medicine Australia). Clinical Pilates is used to restore dynamic postural stability deficits following the directional bias concept.

This article was originally published on Wisdom Physiotherapy. It has been modified and re-published with permission.

References

Valat, JP; Genevay, S; Marty, M; Rozenberg, S; Koes, B (April 2010). “Sciatica.”. Best practice & research. Clinical rheumatology. 24 (2): 241–52. 

Markova, Tsvetio (2007). “Treatment of Acute Sciatica”. Am Fam Physician. 75 (1): 99–100.

Angela Dunsford, Saravana Kumar and Sarah Clarke. (2011). “Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain”. J Multidiscip Healthc. 4: 393–402.

Arthritis And My Hands: Can A Hand Physiotherapist Help?

Hands are very important tools in our daily lives. We use them to dress, do housework, put food in our mouths, work to earn a crust, use them as part of our body language to express our emotions. However, when we have pain, stiffness, swelling and an altered appearance, our lives can become very challenging.

Arthritis is a term to describe over 100 forms of a condition where a person may experience symptoms including:

– Stiffness
– Inflammation
– Damage to the joint cartilage (tissue that covers the ends of bones)
– Swelling

These symptoms can result in deformity of the joints, joint weakness, joint instability and weakness of the surrounding tissues such as ligaments and tendons. So, enough of the doom and gloom.

Hand Physiotherapy Can Help You

A Hand Physiotherapist will be able to assess your hand function, including the range, stability and quality of your joint movement, the strength and length of all of the muscles in your hand and has the ability to order and view your x-ray when they are appropriate.

From here, your Hand Physiotherapist will be able to determine your key problems and discuss a tailored management plan with you.

Moderate Your Activities

Quite often, joints of the hand and wrist are overused with repetitive movement and become highly inflamed and very painful. Your Hand Physiotherapist can advise you of how to moderate your activities, so you can use your hands without experiencing these flare ups.

A Resting Splint

Sometimes, a joint may need a rest. A resting splint may be custom made to enable the joint to be protected from excessive movements if it is unstable, or rested if it is very inflamed and painful. Splints are a great way of managing your symptoms and protecting your joints.

Exercise

You may also require exercises for strengthening weak muscles of the hand and wrist, or you may require hands on treatment and exercises to optimise the movement of your joints. All of these factors will be thoroughly addressed by your Hand Physiotherapist during your consultation.

Finally, the word “management” is the key, when addressing arthritis. We can’t reverse the arthritic changes that have already occurred, but a Hand Physiotherapist is able to help you to slow down and further prevent joint destruction, reduce your pain, improve your strength and joint movement by providing you with a tailored hands on treatment program, home management program and information during your journey.

If you are experiencing pain or issues with your hands, it might be time to visit a Hand Physiotherapist who offers hand therapy.

Written by Sophie Halsall-McLennan, Fresh Start Physiotherapy

References:
www.arthritisaustralia.com.au

About The Author

Sophie Halsall-McLennan is the owner of Fresh Start Physiotherapy and has a special interest in Hand Therapy and Shoulder Rehabilitation.  She has a Bachelor of Physiotherapy from Charles Sturt University, over 13 years of clinical experience as a Physiotherapist and is registered with AHPRA. She is also a lecturer at Deakin University.

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Sophie Halsall-McLennan is a mother of two, has a passion for rowing, skiing, classical ballet and spending time with her family.

Staying continually up-to-date with the latest evidence-based practice, including treatments and rehabilitation programs keeps Sophie at the forefront of Physiotherapy. With these skills and knowledge, she can equip her clients with the best available information and treatment.

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