All you people who are now working from home since the last few months reaching out to me with neck and low back issues, I got you covered. I know you miss your ergonomic desks but until we all get back to it, here are some strategies to decrease the chances to have that dreaded neck and back pain your collogues keep complaining about. Here’s part one.
Since most of us are working from home on our makeshift workstations/couches etc there are too many sore necks and backs going around. Here’s a new video to hopefully keep you away from those statistic. Hope it helps.
Following up on my blog post last week (which you could find Here), in this blog post I put forth some Median nerve Neurodynamics home exercises. The general principle remains the same for me. Start slow, try to keep the exercises pain free/threat free if possible or at least to a minimum with head bend to the same side slowing progressing to head neutral and eventually away from the side that is being stretched. I start with sliders and then progress to tensioners.
If any of the exercises increase pain levels, I instruct my patients to either go gentler and if that does not help, I ask them to stop.
Enough said, here are some videos-
1. Unilateral exercises with nerve mobilization @ the wrist level-
2. Unilateral exercises with nerve mobilization @ the shoulder and the fingers-
3. Unilateral exercises with nerve mobilization @ the elbow with head neutral and slowly progressing to sliders.
(Starting position is shoulder abduction not flexion as mentioned in the video, sorry for the error but you knew that).
4. Unilateral exercises with nerve mobilization @ the elbow level with sliders and tensioners –
5. Bilateral exercises like the prayer stretch, butler’s busy bee-
I would love to know some of your favorite exercises, tweaks and variations. That’s all I got for this post. Keep fighting the good fight. Until next time.
This blog post will be a quick one. I often utilize the upper limb tension tests (ULTT) to assess patients with pain and other radicular symptoms going down the arm. I check first the unaffected side and then the affected side to compare asymmetries and also use it for mobilization of nerve roots. However, as a reoccuring theme I have been aggressive with my tension tests in the past just like so many other techniques and have had less than favourable results. So in accordance with my ‘less is more’ thought process (in terms of pressure/force/aggressivness) I have made some tweaks in how I perform my nerve mobilizations. This is especially true for ULTT and LLTT tests and mobs because these are provocative manuvers and ‘I like lightning bolts running down my arms and legs’ said NO ONE EVER. Today we will discuss Median Nerve Neurodynamics.
Components of Median nerve neurodynamics involve-
Shoulder abducted to about 60 degree. (Initially, I’d abduct to around 90-110. However, Butler and his colleagues at the NOI group have suggested that shoulder abduction at 60 degrees puts the most tension on the Median nerve root and my patients also seem to tolerate this a little better so I now do it at around 60).
Shoulder depression (I have stopped pushing down on it too much as it can be very aggressive and threatening to some patients. I just try to avoid shoulder hiking).
Full external rotation of shoulder.
Full elbow extension.
Full forearm supination. (In the past, I would often leave some slack here due to focusing on shoulder depression. Try to get end range supination).
Full wrist extension.
Full finger extension. (Important to make sure that the PIP and DIP do not flex).
Here is a video demonstration of the test with some variations.
Please note that in one of the mob variation with elbow movements, I do not press the wrist down into complete extension. That is because prior testing of this variation of nerve mobilization was very threat inducing and provocative and I didn’t want to be very aggressive.
What are your thoughts? Do you have some tweaks on hand placement, body positioning, force applied or different variations? I’d love to hear it.
In the next blog post we will discuss some home exercise programs (HEP) for self mobilization. Happy flossing (but go a little easy maybe). Until next time.
The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc. However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.
Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.
Furthermore, if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.
So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-
Bench/chair thoracic spine extension with stick-
T-Spine extension on foam roller
T-Spine windmill rotation
Four point T-Spine rotation
Threading the needle
Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.
Part deux of this blog is not really a course review but my thought on taking the Certified Mulligan Practitioner exam. To begin, I’ll say this, you don’t need to be a Certified Mulligan Practitioner (CMP) to be a good therapist. I know many physios who are great clinicians but haven’t taken the CMP exam. The Certified Mulligan Practitioner exam is a test to check your competency in Mulligan concept principles and application of techniques passing which you get the title CMP. Like I mentioned in the last blog, the Mulligan concept does not cover a whole lot on assessment/diagnosis. So the testing skips that part too.
What to expect in the test-
I gave the test back in 2010 and back then the test had two components. I have heard that the format has not changed a whole lot but don’t quote me on this.
Written Component- consisted of 50 MCQ’s. The Multiple choice questions which seemed tricky and often felt like they had more than one correct answer (they did not) was the easier part of the exam in my opinion.
The practical component- I believe was demonstration of 10-15 techniques (approx). Successfully passing the exam requires the test taker to be competent in each and every technique of the book and one would be asked to demonstrate any random 10-15 techniques covering all bases. This included everything- NAG’S, SNAG’S, MWM’S, SMWAM, SMWLM, headache SNAG’S, belt techniques, BLR, taping techniques etc. The practical component was conducted by two Mulligan Concept Teachers Association (MCTA) members; in our case one local from India and one from Australia.
Passing requires around 80% scores (approx) and attention to detail is important making sure one applies all the 7 principles of the concept when performing the techniques.
Is it worth it?
I can see why this question would cross someone’s mind. After all, one doesn’t need the title to practice in the profession or even to apply these techniques. You could just do the workshop/seminar course and still apply the concepts in your clinical practice. However, in my opinion it is worth it. Going through the extra grind has its advantages. I’ll give you not one but…. two!!
Early on in my career as a new grad, I always used my CMP credentials to bag better than average job opportunities and a little higher than average salary that a new physio would expect. To the new graduates starting their career in physiotherapy I’d say this, physio school will teach you the basics and how not to harm a patient but some of the curriculum is not up to date with the latest in the field and taking certifications will improve your overall clinical skills. It will also make you a more desirable candidate in the job market. Good physiotherapy offices value continuing education certifications and titles. CMP is a good title to have.
On becoming a CMP, you become part of the network of Certified Mulligan Practitioners. The database for a full list of CMP’s across the world can be found on the Mulligan website here.. This directory can sometimes be a good source of referrals for new patients/clients. I have had other mulligan practitioners refer patients who were around my practice and I have also had patients use this directory to find me directly. It can be quite a useful tool.
Hope this information helps. More course reviews to follow in some upcoming blogs. Lets keep the dialogue going. Until next time.
Got a long drive ahead of you that you are dreading? Feel stiff and achy sitting all day. Below I present to you some simple exercises, stretches and strategies that you should try and incorporate if you know you would be behind the wheel for a few hours. Make them a non negotiable part of your drive (safety permitting) and more likely than not, your body will thank you for it.
Here you go-
1. While driving
(Disclaimer- do not take your hands of the wheel for more then 2-3 seconds and never both together, driving safety comes first. Do not let these exercises distract you from the primary activity of driving, I do these often and they are like second nature to me. Only perform them if you feel comfortable to do so safely depending upon your traffic conditions. Practice them at home or work first and then incorporate them carefully while driving. If you still feel unforgettable, avoid this and try the strategies in step two).
2. Take breaks often and move
Try holding the stretches in the above videos for about 30 seconds and repeat 2-3 times. For neck, wrist, back exercises that are not stretches, try about 10 repetitions. Although you ‘might’ feel some discomfort due to staying in one place for some a few hours, none of these exercises should cause pain. If they progressively increase pain and/or discomfort every time you do it, STOP. DO WHAT YOU CAN.
Always remember, the body is not meant to sit in one position all day and ‘motion is lotion’ for your body. Consult your physio if you have pre existing conditions as some of these exercises might not be right for you.
This one resonates close to me. It was the winter of 2013, excited for having cleared my board exam to practice as a physical therapist in the US, I had just landed my first job overseas. However, apart from being my first job this was not just anywhere in the US, I was to begin working in ‘New York City’ (Oh the dream, I recall). Not just anywhere in NYC, this office was in Manhattan, and if you know anything about that awesome city, it was not just anywhere in Manhattan, it was right in the heart of it all in midtown Manhattan. It came with its pressures, servicing a relatively high end clientele in a very busy office. And if there is one thing I could tell you about New Yorkers it is this, they are extremely driven, outcome oriented and unapologetically blatant. There was no ‘see me for 3x/week for 4 weeks to see results’ or ‘physical therapy effects take time to show’. They would have none of that spiel. No pressure right (haha)? Dead wrong.
Within the first week I crumbled under the pressure like a house of cards(though I didn’t show it to anyone). But that’s New York, if you have lived there, you’d know what I mean. Lest I digress more, part of the problem along with me just being a new kid on the block was that doing countless patient charts looking down for hours apart from the non stop physical work that comes with working as a physio, I started developing neck pain with a burning sensation down my left shoulder blade. With the passing weeks, it only got worse. The problem was that a lot of my patients were seeing me for more or less a similar problem spending hours on their workstations. If I couldn’t fix myself, how could I help them? I did what I could for myself and them but it was no walk in the park. A few years and grey hair have imparted some wisdom and learning. Having seen hundreds of patients since then, I am now at a better position to tackle this issue. Below are some of the most common advice I give to patients/people who are at a risk of neck pain. A general advice though, these exercises and strategies are to prevent this unpleasant occurrence. If you are already in pain, You must seek professional help and not rely on the videos presented below. There could be many reasons why you could have neck pain and everything is not covered here.
We all have been in this position. It could be a busy day at work staring at your monitor for 8+ hours, staring down into your books pulling an all nighter before that big test, driving through endless traffic to get home ending up spending more time behind the wheel than you’d like to, maybe a car accident, a weight training injury at the gym or just sleeping wrong, very few have managed to escape this annoying and often debilitating condition. And just like if you hang around with the wrong company for too long, you’d find trouble, if the neck remains troubled and painful, chances are that the shoulders, upper back, arms and/or the head might feel some of that pain too. That’s right, often pain (or tingling/numbness) running down the arms, shoulder, upper back pain and/or headaches ‘might’ be because of that nagging neck pain. This is important so I’d like you to read that line again. However, like I mentioned before, neck pain is a complicated topic and beyond the scope of just one blog.
So today’s post and my first ever not for physios, but just people in general who might benefit from common advise we give to our patients is going to be preventative in nature. You probably won’t be surprised to know that a big chunk of neck pain clients that I have seen over the years come from just sitting wrong and too long, staring into a screen all day, snap chatting every few minutes etc than from car accidents (this might be different for the USA and Canada, there are a lot of MVA’s here).
So here are some exercises and strategies you could use if you are at a risk to experiencing neck pain or its related symptoms.
2. Chin tucks
3. Chin tucks and extension
(If you feel an increase in pain, tingling, numbness, dizziness etc with every repetetion, stop!!)
4. If you look on one side for extended periods of time, correction for that-
6. Neck stretches
7. Sitting posture and recommendations
(If you’re a image conscious New Yorker, I know your struggle. Don’t carry a sheet to work, shell out some $$ and get that lumbar roll, lol).
8. Setting timer/ reminder
9. Finally, don’t forget to MOVE!!
The key is to not think of them as exercises but as habits. Habits that are acquired and need to be incorporated into one’s routine on a daily note. Foremost remember, if you are in pain, go see a good physio and get it assessed. Some of the above advice might not be right for you depending upon what is going on. If some of the exercises seem to increase your pain, stop immediately. Comment below if you have questions.
Sometime last year, I wrote a blog post on how I managed cervical headaches which you can find Here. Having often been at the receiving end of this mostly bad and sometimes extremely painful condition, I have played around with the position I suggested in my last blog post and I have realized that there may be an even better way to manage a painful acute flair up.
Before I proceed to discuss this position, I want to give full credit to my father for this light bulb moment. Here’s how it happened. He was suffering from some dull 2-3/10 pain at his right shoulder for a few years now which of course was intermittent. He would often also complain of tingling and numbness along the median nerve root on his right hand but only around the fingers and palm. So after some assessment I put him on a textbook McKenzie chin retraction and side bending program which did provide him relief but not completely. I noticed that as he wore a turban, the extra weight on the head along with the way it was tied, prevented him from getting into a retracted neck position. Now this, along with sitting at work for 8+ hours for six days a week (ya, that’s right, 6 days, maybe we should stop complaining about our long work weeks, maybe. Lol) was putting him in the dreaded rounded shoulders, blah blah blah … upper crossed posture. So apart from the exercise and manual therapy, I put him in my headache posture in supine hoping for the positive results that I was getting for me and some of my patients.
Alas, to my great dismay, this was only minimally helping him. He still complained of shoulder pain and in fact didn’t like to lie in that position for too long (he didn’t want to tell me it wasn’t helping so instead he just asked for a little break. He’s a solid dad). Now, I often saw him place both his hands over/behind his head on numerous occasions and when I inquired about it, he said this was the only position that made him feel better. This got my neurons firing; how could this simple position make him feel better when other advanced physiotherapy techniques had fallen short? This warrantied some investigation and the answer wasn’t too hard to figure out.
So lets try and break it down- what are some of the conmon postural dysfunctions that we suspect causes headaches, neck pain, shoulder pain and symptoms down the arm?
Forward head and upper cervical extension
Protracted rounded shoulders
Rounded kyphotic upper and middle back region
Downward rotated scapula
Internally rotated shoulders.
On careful observation of his favorite ‘shoulder pain relieving position’ (For the sake of simplicity, I will use the term-Dad’s position) I realized that this position was putting his body in the exact opposite of some of the above mentioned shoulder dysfunction.
Minimum benefit in correcting forward head position.
Dad’s position forces the shoulders into retraction
Forces some extension at the thoracic spine.
Arm elevation causes scapular upward rotation.
Shoulders comfortably in an externally rotated position.
All of the above seem like thing we recommend to our patients all the time, no wonder his shoulders and arm were happy in this position. However, there were still a few things that had to be tweaked. I asked him to tuck his chin in and to avoid shrugging his shoulders so that the upper traps didn’t tense up. Even better, he reported after trying it a few times!!
Now if you have been following my blog posts from before, you’d know that I almost always consider a shoulder problem as a neck problem and vice-versa. They generally go hand in hand and are my ‘usual suspects’. So given this logic, I applied this on myself and some of my patients for neck related issues , headaches and got some extremely encouraging results. After all what better position to get the neck into retraction then in supine and gently force the thoracic spine into extension with a small pillow under it?? Adding heating packs could be the cherry on top if your a cherry person.
So with the explanation out of the way, I would like to present to you my modified position for cervicogenic headaches (also for neck and shoulder pain).
So after a through assessment, if your patients fit the bill, I recommend you try it out and please let me know your thought on this subject. As always,
I have had a long standing history of suffering from headaches. Since I was little, I have had these bouts of headaches at least once a month, where nothing seemed to help. Nothing except medication. I had been to numerous doctors and was diagnosed with migraine, tension and sinus headaches. No matter the diagnosis or the subsequent interventions (I have tried quite a few of them; from different manual therapy techniques working on my trigger points/taut bands at the neck ,to steam inhalation for stubborn sinuses, proper hydration, breathing techniques in a sensory deprived atmosphere, Kinesiology tapes to making dietary changes) the one thing that has provided me relief over the years is, medication. Some of the remedies have helped me a little but I’d be lying if I said that any of them took my pain away except medication.
As a therapist treating people with headaches I have often found a strong co-relationship between headaches and neck pain. Now for those of us in this profession, this is hardly a breaking news. There is tons of research out there that points out to the fact that a lot of headaches start from the neck and a lot of neck pain symptoms mimic migraine pain. Sure the neck muscles feel stiff and tight and you might find a few trigger points at the upper trapezius, levator scapula, the SCM’s and the other usual suspects. However, the challenge lies in the management of the condition when someone is experiencing an episode of headache. In my own experience working with patients, when someone walks in my office with a headache, any kind of hands on intervention around the head, neck, TMJ, especially the aggressive kind has yielded me less than favorable outcomes. I have done this before only to make matters worse and have also been at the receiving end of such treatment interventions. I didn’t like them.
Sticking to the mantra of ‘less is more’ principle as it relates to manual therapy, I have been using a lot of McKenzie treatment principles which has been a game changer for me in managing my own headaches and that of my patients. So now, when I see a patient with headaches, I prefer a more ‘hands off’ approach as I do not want to trigger an already sensitized neuro-muscular system. So instead I do a quick postural assessment and I try to correct what I think are the more common dysfunctional patterns that I have come across in people with cervicogenic headaches. The common pattern resembles our typical upper crossed syndrome pattern of –
Forward head position with increased cervical lordosis and resultant upper cervical spine extension causing compression of important cervical nerve roots and sub cranial dysfunction.
Increased kyphosis of the thoracic spine.
How do I correct them? If the headaches are sever and the patient is highly sensitized, I have them lay down in a supine position with a small pillow under the upper/middle back with no pillows under the head making sure that the chin is in a retracted (tucked in) position. Now, some of your patients might tolerate this position better than others. For the geriatric population or with people with highly kyphotic, stiff thoracic spine you might want to consider giving them a few pillows under the knees to reduce the tension on the lower back by causing an anterior pelvic tilt (remember, making a person as comfortable as possible helps). Ask them to lay in this position for about 5 minutes. If their symptoms of headache/neck pain seem to subside with this position, chances are that their migraine headaches might be arising due to faulty posture and neck pain. I could and often do classic chin tucks to see if the symptoms subside but again in my experience in the trenches, the less I do, the better. Hence, I regress the chin tucks in a non weight-bearing position and leave them be for a few minutes in a nice quite room. Having your patients do diaphragmatic breathing in this position may be the icing on the cake.
Needless to say, this is not the only method to manage headaches (not to forget there are different types of headaches). However, it is one of the easier ways to do it, very well tolerated by patients compared to the traditional ‘hands-on’ during an acute episode and also a good diagnostic tool to see if the patient will respond well to repeated loading strategies. As the symptoms subside, I’ll start doing some soft tissue work (always gentle, of course) on the hypertonic upper traps, levators and upper cervical muscles etc and follow with exercises. More on that on my subsequent blog on this topic.
I would love to hear your feedback and some of the strategies you use to treat this condition.