Osteopathy for Headaches and Migraines

Woman with headache

Chronic headache is the most common neurological complaint presenting to GPs in Australia. (1)

This means it’s likely to be even more widespread than statistics suggest, as many people simply don’t seek medical treatment for chronic pain conditions.

So it’s safe to say, headaches and migraines are kind of a big deal.

Most people experience headache at some point in their life. If it is simply a one off, or infrequent, then most of the time, the best management involves either putting up with it, taking simple over the counter analgaesics or getting treatment from an osteopath (or similar).

However, when headaches are persistent, more targeted management is needed, and the first step is identifying the type of headache you have, which will influence the type of treatment accordingly.

Types of Headache

When it comes to headaches and migraines, there are two broad categories:

  1. Primary headaches, which the headache is the problem itself. These include migraine, tension type headache, cluster headache and other (less common) primary headaches.
  2. Secondary headaches, where the headache is a symptom of an underlying condition, including meningitis, brain tumours, aneurysms and brain bleeds. (2)

Because of the serious nature of the underlying conditions that cause secondary headaches, new headaches, particularly very intense or persistent ones, and those with other neurological symptoms like nausea, dizziness, visual changes and loss of balance should be examined by a medical professional.

This post will look at primary headaches and migraines, to give an understanding of the physiology involved as well as treatment options and self-management strategies.

The Headache Continuum

Primary headaches account for 90% of headaches, and are a common cause of visits to health professionals, including osteopaths.

The two most common form of primary headache are migraines and the tension type headache.

Understanding the difference between the two will help identify appropriate management strategies, so an accurate diagnosis is imperative (this means seeking out someone who went to university and studied medicine, not someone who watched an episode of House and wrote in an online forum).

A helpful way to understand the differences between tension type headaches and migraines is by the use of a continuum (3).

Health professionals love a good continuum, and I’m no exception. In the case of headaches, we have migraines on the far left and tension type headaches on the far right.

Headache-Migraine Continuum

In terms of the continuum, we have neuro-vascular involvement (migraines) at one end, and psycho-neuro-muscular involvement at the other (tension type headaches).

Though not officially recognised by the International Headache Society (IHS), there tends to be an agreeance amongst many clinicians and academics of the existence of mixed type headaches as well, which would exist about halfway along the continuum.

Finally, for this post, we will consider cervicogenic headaches, as commonly diagnosed by osteopaths and physical therapists, as well as GPs, to be similar to tension type headaches, in that the clinical features and physiology underpinning them is quite similar.

Migraines

Migraines are typically intense headaches that can last up to 3 days, often accompanied by other neurological symptoms such as photophobia (sensitivity to light) and dizziness. There are two main types of migraine – those with an aura and those without.

Migraines involve the activation of, or the perception of, the activation of the pain-producing innvervation (nerve supply) of the cranial blood vessels. (4)

Diagnosing migraines comes down to a careful history.

As migraines involve a heightened sensitivity to change in stimulus, with a careful history, often triggers can be identified and managed.

Although this is a tedius process, for those sufferers who can identify specific triggers through a process of elimination, managing migraines with lifestyle changes becomes a whole lot more viable.

In addition to lifestyle changes, there are medications which are effective in both the management of acute migraine and in the prevention/reduction of chronic migraine.

For acute migraines, one of the most effective interventions is to take 900 mg of aspirin along with 1000 mg paracetamol. (5)

In some people, NSAIDs (Naproxen, Ibuprofen etc) will have a better effect.

In many cases, there are more specific medications that will work better than those listed, though the list is long-ish, so it might take some trial and error to find out the specific medication and dosage that works for you. Again, work with your doctor, not a blog, to figure out the best approach for you.

Please understand, all medications (in fact, all interventions) have potential side effects, so before you go taking any medications, get medical advice.

Tension Type Headaches

Tension type headaches are mostly diagnosed on an exclusion basis – that is, they don’t have particular features that would classify them as another type of headache. They are the most prevalent form of headache, but often go untreated, as people don’t seek out assistance for them.

The specific patho-physiology of tension-type headaches isn’t clearly understood, but the name implies some form of mental or physical tension involvement, which is agreed upon by headache researchers.

The reason they exist at the opposite end of the continuum to migraines is the absence of vascular involvement. (6)

It is most important to get an accurate diagnosis, as these headaches, are quite a clinical challenge to treat. So if you actually suffer from migraines, but get diagnosed as suffering from tension type headaches, you are potentially missing out on efficacious treatments.

Many people with tension type headaches experience exacerbation in times of psychological or physical stress.

If this is you, pro-actively managing your stress is one of the best preventative treatments available.

Additionally, tension type headaches often have a muscular component – that is, physical tension produced by overactive muscles, usually across the face, head and neck.

Osteopathy For Headaches and Migraines

What is interesting about headaches, is that, in terms of nerve supply, facial and cranial areas are all supplied by the trigeminal nucleus.

So although the cause may differ between a migraine and a tension type headache, the origin, may be the same.

This is clinically significant, because the trigeminal nucleus blends with the nerves from C1, C2 and C3 (the upper part of the neck).

This means that treatment to influence these nerves, can, theoretically, influence all kinds of headache.

Unfortunately, theory doesn’t always translate to practice, but many osteopathic techniques to treat this area relatively safe and risk free, with the big exception being techniques that involve end range rotation of the neck, thus it may be worth exploring.

Additionally, for most people, osteopathic treatment can help relieve some of the systemic effects of headache, including an increased stress response and muscular tension.

Some of these systemic effects include:

            • Sympathetic inhibition via rib raising. The sympathetic nervous system is involved in the stress response, including blood vessel dilation/constriction, which can potentially affect migraines. (7)
            • Parasympathetic stimulation via manual therapy and breathing exercises (see the image below). The parasympathetic nervous system counteracts the sympathetic nervous system, and stimulation is involved relaxation and recovery from many stress mediated conditions. (8,9)

Take a deep breath.Chances are you’re not aware how breathing can improve your health and wellbeing (beyond keeping…

Posted by Integrative Osteopathy on Monday, 8 February 2016

These manual techniques can be quite effective, however, as previously mentioned, it is important to “treat the person, not the headache” and consider psycho-social variables as well.

An osteopath can help you recognise and deal with particular triggers of migraines or your response to stressors that might be contributing to your tension type headache and if there is further management required, an osteopath will work alongside your “health team” which may include your GP, neurologist and possibly a psychologist to optimise your management.

What Can You Do For A Headache?

Best practice for the treatment of painful conditions involves what is term an “active approach“, that is, an approach where you are engaged in you care and actively participating to achieve a result.

i.e. “doing something”, as opposed to merely showing up and receiving treatment passively, or having something “done to you”.

This means, if you are suffering from headaches you can definitely do a few things that may help relieve or reduce the incidence:

                          • Educate yourself. Understanding a problem can help you deal with it better. Understanding alone doesn’t seem to improve pain outcomes, but when combined with other active therapies (as listed below) and incorporated into your medical management, it makes a big difference.
                          • Increase your physical activity. If you don’t meet the guidelines (>30 mins daily of moderate activity), then increasing your activity by walking more will have general health benefits that may improve your headaches.
                          • Practice mindfulness. Mindfulness helps you deal with stressful situations better. It also “strengthens” your brain, building neural links that are often negatively impacted with pain.
                          • Sleep better. Improve your sleep hygiene – take electronic devices out of your room, use black out curtains and keep the room slightly cooler than the rest of the house. Additionally, build a bed time routine so that you fall asleep more easily. Fatigue can increase neural sensitivity, and the only way to combat fatigue is with adequate high quality sleep.
                          • Talk to people. Chronic pain, including headaches, can be quite debilitating, as well as isolating. Talking to others who suffer from headaches/migraines in support groups, or a professional counsellor can help with some of the negative thoughts and feelings that develop around pain and often times make it worse.

The best thing about all of these things, are that they are either free, easy to do or both.

Conclusions

Headaches are debilitating, yet with a proper diagnosis, treatment and management is possible.

This treatment must incorporate biological (physical) as well as psycho-social factors.

Looking at the research on osteopathy/manual therapy and headaches, it can seem that often times “nothing much can be done about them”.

However, when you look at physiological plausible mechanisms of treatment, and apply these to both the causes and origins of headaches, the picture seems more promising.

As always, there is no holy grail, and getting on top of things takes a team effort between yourself and your practitioner(s).

Additionally, there is much you can do for yourself, which, while it may not be “headache specific” can greatly improve your health, wellbeing and potentially your headaches.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

(1,2, 3) RACGP – Management of Chronic Headache

(4,5,6) Wall and Melzack’s Textbook of Pain

(7) Rib raising and autonomic activity – http://www.ncbi.nlm.nih.gov/pubmed/20606239

(8) Osteopathic Manipulative Therapy and HRV – unpublished research from London School of Osteopathy

(9) Deep breathing, pain and autonomic activity – http://www.ncbi.nlm.nih.gov/pubmed/21939499

(10) Relationship between rcpm and dura – http://www.ncbi.nlm.nih.gov/pubmed/8610241

 

How Your Mindset Impacts Your Pain

Mind

Most people think pain is a physical problem, because we feel it in our body.

Whilst this is not wrong, it is not completely right either.

This is because all pain has 3 components:

  1. “Bio” (biological – aka what is going on in the body)
  2. “Psycho” (psychological – what’s going on in the mind)
  3. “Social” (what’s going on in our environment)

You might be thinking, that doesn’t apply to me, “I strained my back shifting the couch, there’s nothing going on in my head or around me”.

That might be so, but, even if we strain out back moving furniture (an obvious physical cause to pain), by the time we experience pain, our brains have done a magnificent job of filtering the sensory information from our body via all our existing biases and preconceptions (“psycho” and “social”).

This simply means, if you’ve heard your grandfather complain about how getting old sucks because his back hurts, and if you’ve heard people talk about “wear and tear” or anything else about back pain, you brain, cool as it is, will consider this when deciding whether to produce pain that you feel “in your back”.

The fancy name to describe this, is a neurotag.

I like to think of it as a filing system in our brains.

When you see, hear, or read something about low back pain for instance, it goes in your “file” titled “low back pain”.

It doesn’t stop there. Neurotags, I mean, the filing cabinet in our brain, also cross reference.

So when your grandfather complains about being old and having low back pain, your brain files “low back pain” into the “old” file, and “old” into the “low back pain file”.

So, when you strain your back, causing the sensory nerves to start firing rapidly and bombard the spinal cord with messages of danger, your brain is pulling up all these files:

  • Danger is coming from the body
  • The danger seems to be around the low back
  • Low back pain
  • Old
  • Wear and tear
  • Can’t move
  • Never be the same

Or whatever else is stored in there. As you can imagine, over time, this could get pretty full.

All this means that even a “simple” low back strain is not so simple.

Some people are at a high risk of developing chronic pain, even from a relatively benign back strain. All because of the psycho-social factors involved. This is why it is important to always address all factors involved in your pain. After all, all chronic pain was acute at some stage. 

When it comes to treating pain, your mindset matters.

In general, there are two types mindsets that we can possess.  One can lead to a better recovery, while the other can actually impair your recovery.

The Two Types of Mindset

When it comes to our mindset, we either have a fixed mindset, or a growth mindset.

This concept was first described by a psychologist, Carol Dweck, who once had a teacher who arranged the seating order of the class by IQ. Whilst Dweck was actually in the number one position, she felt enormous pressure to maintain that position, whilst those lower in the order became resigned to their fate.

This teacher inspired Carol to conduct her own research, which lead her to conclude:

People with fixed mindsets believe that they were born with all the intelligence and talent they will ever have, and that this cannot change.

People with growth mindsets, as you might guess, believe that their abilities can expand and improve over time.

The vast majority of people who have had success in life, especially those who have had to overcome adversity, display characteristics of a growth mindset.

How Your Mindset Affects Pain

If you search for articles on “fixed vs growth mindset”, most of the results will be about personal development and business, but this concept can also apply to pain.

The easiest way to demonstrate this is with an example.

Let’s imagine two completely fictitious people, Danny and Danielle.

Danny

Danny, 30, is a rising star in the corporate world. He works his ass off every day to improve at his job – networking, learning persuasion and sales techniques, studying his field so he is on top of his game. He goes to the gym 5 times per week and ensures he eats well most of the time so he looks and feels good. On top of this, Danny has a daily ritual of visualising his success.

One day Danny starts to experience neck and shoulder pain. The onset wasn’t caused by anything in particular, but he did recall training extra hard that month.

Not wanting the pain to interrupt his life more than necessary, Danny seeks the help of an osteopath named Nick.

His osteopath formulates a treatment plan designed to get him back to full training in 4 weeks. In the mean time, Danny reads some articles Nick sent him and does some extra research on the topic from some trusted health sites he frequents.

At 4 weeks, Danny is not only pain free, but he has learnt about injury management and knows how to improve his gym workouts so that the issue doesn’t recur. In essence, he has come back stronger than ever.

Danielle

Now, let’s have a look at Danielle, 35, who is a public servant. Danielle enjoys her life – she works from Monday to Friday and enjoys exploring galleries and cafes on the weekends with her partner. At work she does what she has to do, but no more, thinking “if I’m not paid to do it, it’s not my responsibility”. Danielle feels like her life is pretty good, but she has one eye on retirement.

One day at work, Danielle starts experiencing neck and shoulder pain, and she recalls her mother having something similar due to her work as a seamstress and thinks to herself that it “must be genetic”. After talking to a colleague whose partner, Danny, had a similar problem and was able to resolve it after consulting an osteopath, she books an appointment with the same osteopath.

When she arrives for her consult, they discuss a treatment plan and get started. After a few days, there has been no change and Danielle loses motivation to do her home based exercises. She continues treatment for a few more weeks, as she enjoys the way manual therapy feels, but she is disengaged. After 6 weeks there is no change, and she is convinced her original thoughts were correct, and that her pain is “genetic” and “there is nothing she can do”.

Your Mindset Affects Your Behaviour

It should be obvious who has the growth mindset, and who has the fixed mindset, and as you can see, your mindset permeates every aspect of your life, including pain.

Having a growth mindset meant that Danny saw his pain as something that could be changed, if he changed what he was doing and improved (his knowledge, his body etc).

Having a fixed mindset limited Danielle’s recovery, as she saw her pain as her destiny (genetic), and thus was not inclined to try and change or help herself.

While pain is never simple, there are so many unseen factors, we can control much of our reaction to pain and what we do in the future. If you have the belief that you can grow and improve throughout your life, that it is likely this will extend to your beliefs around pain.

Can You Change Your Mindset?

This is the trickiest question to answer. People with a growth mindset will believe so, but people with a fixed mindset may not.

The science is unequivocal – our brains are plastic and can continue to change as long as we are alive.

As we change our thoughts and behaviours, our brain structure changes too.

If you want to change your mindset (wanting to change is key), then the best way is via actions.

You see, our brains are funny.

When we sit idle and think, especially about the future, our brains can get very creative. This can be a positive if you start thinking about where you want to be in 5 years and what you have to do to get there, but not so much if all this thinking does is keep you idling in place for another 1/2/5/oh-shit-where-did-my-life-go years.

It’s even worse if you start getting into negative thought spirals.

However, if we take action, any action, then our brains can’t get carried away. And, if we are smart, and start small, then we achieve a little success, we build confidence and momentum. Repeat this process long enough and you become a different person.

This, in essence, is mindfulness, but let’s call it something else – let’s call it momentum. Create momentum by starting small and before you know it, you have changed.

Really, My Back Hurts, How Does This Help Me?

In essence, it all boils down to this: are you resigned to having pain or looking for someone else to solve your problem (fixed mindset), or, are you willing to adapt, change and do what it takes to help yourself?

Some conditions are very easy to recover from, others very hard. What doesn’t change though, is that if you have no doubt in your mind you will improve, no matter what it takes, then you probably will*.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

 

 

References

(1) Wikipedia – Carol Dweck: https://en.wikipedia.org/wiki/Carol_Dweck

(2) Stanford News Service – Fixed versus growth intelligencehttp://news.stanford.edu/pr/2007/pr-dweck-020707.html

(3) NY Times – If You’re Open To Growth, You Tend To Grow: http://www.nytimes.com/2008/07/06/business/06unbox.html

(4) Brain Plasticity and Behaviour – https://www.psychologicalscience.org/journals/cd/12_1/Kolb.cfm

 

*Please don’t take this the wrong way if you suffer from chronic pain. This isn’t meant to belittle your pain or say you are not trying. The recovery rate for chronic pain is quite low, but many people learn to live fulfilling lives and manage their pain quite well. In part this comes from re-shaping their thoughts, emotions and behaviours around pain. Cognitive Behavioural Therapy (CBT) is quite helpful in this regard.

Rethink Pain: Osteoarthritis

Knee X-ray

In the first post of the Rethink Pain series, Moving Beyond Muscles and Bones, we discussed shifting your view of pain away from body tissues like muscles and bones towards a more accurate one, of pain as a protective neurological process.

This post will take that concept and apply it to one of the most prevalent and debilitating chronic conditions in the world today, arthritis.

Nearly everyone has heard of arthritis. Arthritis is actually a group of conditions that affect the joints, encompassing a variety of conditions from autoimmune to inflammatory. This post is going to focus on the most common form, osteoarthritis (OA). 

There is a lot of misinformation surrounding arthritis, spread by cultural memes and well meaning family and friends. This leads to erroneous thinking that is likely causing a nocebo effect (the opposite of the placebo effect).

What is Osteoarthritis?

Described as “wear and tear”, osteoarthritis is, more correctly, a condition of joint cartilage degradation and reactive bone growth.

Cartilage covers the surface of most of our movable joints, creating a smooth and gliding surface, as well as providing shock absorption.

Tissues are constantly being “broken down” and then “rebuilt” in our bodies. This is a completely normal process which allows us to grow, heal and adapt.

When someone has osteoarthritis, this rate of degradation is accelerated and not matched by an increase in the rate of cartilage regeneration.

Here’s a simple analogy:

Imagine you are spending $1000 per week and making $25 per hour. To break even, you must work 40 hours.

Next, imagine after a few years your spending increased to $1250, yet you are still making $25 per hour – you now have to work 50 hours per week to cover your costs.

A few more years pass, and your spending increases yet again, lets say to $1500 per week. This time, however, your hourly wage drops to $20 per hour – you now have to work 75 hours to break even.

Eventually, if this process continues you will not be able to keep up. This is similar to what happens in OA – the rate of cartilage regeneration cannot keep up with the rate of degradation.

What Causes Arthritis?

There is no singular causal factor for arthritis. There is a large genetic component along with the combination of other factors (1).

Some of these factors include:

  • Tissue susceptibility/genetics. Cartilage is slow regenerating tissue at best, due to both is structure and its low blood supply. Some people have slower regenerative rates or are more susceptible to increased degradation.
  • Aging. Rates of regeneration decrease as we age, arthritis is more common in older people, and we have an aging population.
  • Chronic systemic stress. Stress hormones are catabolic – they increase tissue breakdown. Stress levels seem to be higher these days, as a result of both economic and cultural/lifestyle changes taking place across the globe.
  • Obesity. People are heavier, on average, and obesity has a correlation to arthritis via two mechanisms: increased mechanical stress on joints and increased inflammatory mediators in the bloodstream (secreted by fat cells).
  • Mechanical stress/”overuse”. We’ll discuss this further below, as “wear and tear” or “overuse” is one of the most common throwaway descriptions of arthritis.

One factor that’s often cited by medical/health practitioners is mechanical stress, commonly termed overuse or wear and tear.

There are a few problems with this language.

First, what is overuse, and how do we measure it?

Second, it doesn’t take into account that different ways of using your body have different effects.

In the case of arthritis, full range of motion through the joints stimulates cells called synovites, which secrete joint fluid to provide nutrition and have a protective effect on the joints.

Limited and repetitive range of motion activities tend to create uneven joint stresses, causing reactive bone growth, and an increased firing of the nerves, which affects joint mechanics and can increase sensitivity and pain.

So yes, certain activities can increase the likelihood of arthritis in susceptible people, but simply using your body does not cause arthritis. This has been demonstrated in runners (2), for example, who have no more arthritis than non runners, despite the myth that “running is bad for your knees”.

 Arthritis Pain

The biggest problem with arthritis is the associated pain. Most people don’t consult a doctor or allied health professional for anything else related to arthritis.

Pain doesn’t correlate well with imaging findings or the severity of joint degradation (my emphasis):

Patients largely present with pain and disability after significant loss of cartilage has occurred, but it is estimated that up to 40% of individuals with radiological damage have no pain. (3)

This kind of blows the “damage causes pain” thought process out the window, doesn’t it?

So how might this be?

Pain is a perception created by our brains in response to a variety of different sensory “inputs” including:

  • “Danger signals” from peripheral nerves in joints, muscles and other body tissues
  • Thoughts and expectations
  • Emotions
  • Brain and body chemistry – for example, hormonal status

We can divide these into central factors (brain and spinal cord related) and peripheral factors (everything else).

One of the most important central factors is called sensitisation. Basically, this means that the spinal cord and brain become more sensitive and produce pain in response to less and less stimuli.

This mechanism is proposed to be largely involved in arthritis related pain.

This then triggers a positive feedback loop whereby the pain causes negative emotions, reduction or avoidance of movement and an increase in stress hormones which then further aggravates the pain.

An example of a positive feedback loop between pain, cognition and emotions.

An example of a positive feedback loop between pain, cognition and emotions.

In addition to the central factors described above, there are peripheral factors that likely contribute to arthritis pain as well.

Some of these peripheral factors would include:

  • Impaired fluid dynamics of the joint
  • Inflammation
  • Mechanical strain

All these factors would likely increase the frequency and intensity of nociception, the transmission of “danger signals” from the nerves in the joints, causing the brain to produce a protective response of pain and stiffness.

If this cycle continues for long enough, then the peripheral nerves can also become sensitised, leading them to start firing at lower thresholds, much in the way central sensitisation works.

For a more in depth understanding of these processes, read Pain Science BasicsIt describes in easy to understand detail what is actually happening when we experience pain.

Osteopathy For Arthritis

The osteopath’s way of thinking is to look backwards from the presenting symptoms to try to work out why the body would “adapt” in such a way.

In the case of osteoarthritis, we would want to know the answer to the following questions:

  1. What has lead to the increased rate of cartilage degeneration in this person, in this joint?
  2. What has lead to a decrease in the rate of cartilage regeneration in this person?
  3. What potential factors may be contributing to this person’s pain?

As a result of these questions, two different people with knee osteoarthritis may end up with differing treatments, based on their primary causative factors.

Of course, the disease process is common, so there will be a lot of overlap, but treatment will always be tailored to your individual’s needs.

If you were suffering from OA and came for treatment, we would want you to feel a part of the process and be engaged in your care.

This means we’d place a large emphasis on educating you so that you fully understand what is happening, why it is happening and the implications for your life presently and in the future.

We would also present you with your treatment options, their risk, benefits, cost and the likely results of not doing anything.

We would then, use manual therapy to mobilise the entire body. Why the entire body? For starters, if your osteoarthritis is the result of, in part, altered biomechanics, treating the entire body is the only way to restore balance.

You see, whilst there may be altered loading of the affected joint(s), this may be the result of a protective response by the nervous system resulting from adverse tension elsewhere, in other words, your body is compensating for another issue.

Additionally, it is important to recognise that separation of the body exists only in our minds. Our knees are served by the same organs that serve our shoulders and everything is integrated by the one brain. This means it only makes sense to treat the entire body – we are, after all, not body parts, but people.

Our osteopathic treatment for osteoarthritis is gentle, slow and rhythmic, allowing for the body to self correct with movement/relaxation of muscle and joint tension, all the while helping with fluid dynamics throughout the body. It shouldn’t be painful, as we don’t want to increase any sensitisation that may be present.

Further, in addition to manual osteopathic techniques, we would show you how to manage or improve your condition with lifestyle changes, which we will discuss further below.

What Can You Do To Help Yourself?

Although genetic predisposition can play a large role in the development of OA, for most people, it is complex interaction between genetics and environment that leads to the onset of physical changes to the affected joint(s), and an even more complex interaction that leads to the onset of pain.

With this in mind, you can definitely take action to help prevent/delay/manage the onset of osteoarthritis in your life.

Things that you can do include:

Maintain an optimal body weight for your frame

Every body is different. Some people have a large skeletal frame, others are more compact. Some people are naturally lean, others tend to carry more body fat.

What is undeniable, however, is that from a medical point of view, there is an optimal weight range for your frame.

At this weight, you are not so big that there is increased stress on your joints and organs, but not so small you compromise your lean body mass and hormones.

In terms of osteoarthritis, increased weight, as mentioned earlier, is a risk factor both biomechanically and chemically as a result of increased systemic inflammation.

The BMI is a good general guide to maintaining a healthy weight, but it does not take into account body composition (muscle vs fat), only total body weight.

Waist measurements are another good guide to whether you are storing a lot of risky visceral fat (the fat that sits on your organs and leads to conditions like diabetes and heart disease).

If you are overweight, it’s a good idea to speak to your doctor as a starting point, to get blood work done and then any referrals you need to other health professionals who specialise in weight loss, because, aside from OA, there are many other health conditions made worse by being over weight.

Lead an active lifestyle

Some people love to exercise, others don’t. That is completely fine.

Leading an active lifestyle doesn’t mean you must spend hours every week in the gym or running the streets. If you don’t like exercising, and you otherwise have a sedentary lifestyle, it is in your interests to increase your activity levels.

This could be as simple as walking or cycling more as a means of transport.

Incorporating some form of work with resistance is also important for health, again, if you don’t like the gym, this could be doing physical work in the garden or around the house that involves lifting, pushing and pulling.

Now, if you are suffering from OA pain, this can be hard to do, so as always, prevention is better than cure. However, there are generally ways you can increase your activity, even with OA.

Live with purpose

As humans, we need meaning in our lives. This meaning, or purpose, gives us reason to get out of bed a do things each day. Without it, we waste away, mentally and physically.

Everyone will have different things that give them meaning, this doesn’t matter, it’s what makes us great. What does matter, is living with purpose.

Research is unequivocal – those who live with purpose have longer and healthier lives in almost every meaningful measure, including pain.

Maintain strong social networks

Whether you have a huge family or a strong network of good friends and acquaintances, maintaining social ties is not only linked to better health and wellbeing, but less pain.

Whilst living in pain can feel isolating, living without social contact is quite bad for us in both the long and short terms.

One study showed that adolescents in isolation demonstrated increased levels on inflammatory mediators in their blood, which affected their physiology for their entire lifespan! (6)

Open up to your existing friends and family more, reach out to those you’ve lost contact with and get engaged with like minded people to make more connections.

The internet has make connecting so much easier, but staring at a social network on a screen does not replace face to face interaction.

Increase Your “Physiological Buffer Zone”

The physiological buffer zone is a concept described by Patrick Ward, MS, an American sports scientist currently working with the Seattle Sounders FC.

In simple terms, it is basically the buffer you have between physiological stress and the onset of injuries and symptoms.

To increase this, an analysis of your physical status is required and then a prescription of exercise, lifestyle, nutritional and recovery advice is given, aiming to improve your resilience.

Whilst this concept was developed for athletes, it is certainly applicable to everyday people with everyday pain.

Medications

Medications to help manage arthritis pain do exist, but most are not very effective. Some relief can be expected, but it is very rare for medications to provide complete relief from osteoarthritis pain.

One medication that seems to be promising, is topical capsaicin. Capsaicin is the active ingredient in chillies. Extracts in topical creams stimulate particular nerves that have been shown to decrease pain. (8) The promise with capsaicin is that the side effects are quite minimal, unlike other many other common medications used to manage osteoarthritis pain.

You should consult your doctor for options about medications, asking about their effectiveness along with their side effects.

Conclusions

Osteoarthritis is a multi-factorial condition that affects a large number of people. By far the most common complaint is pain, which doesn’t seem to be directly caused by the extent of joint changes, but rather by increased sensitivity, both centrally and within the joints.

In general, the best way to treat/manage osteoarthritis long term is to strive to improve your health in all aspects whilst utilising specific treatments to reduce your pain and other symptoms.

Together with right environmental factors, you give yourself the best chance to lead a full life.

If you suffer from OA and would like to add anything, we’d love to hear your story in the comments below.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

References

(1) Kumar, et al, Robbins and Cotran Pathologic Basis of Disease,  Elsevier Saunders, 2005, PA

(2) Running and osteoarthritis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556152/

(3) What makes osteoarthritis painful?: http://rheumatology.oxfordjournals.org/content/50/12/2157.long?view=long&pmid=21954151

(4) Positive feedback loop in pain : http://www.nature.com/nrn/journal/v14/n7/fig_tab/nrn3516_F1.html

(5) Obesity and arthritis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406287/

(6) Obesity and arthritis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2573886/

(7) Social networks and long term health: http://www.pnas.org/content/early/2016/01/02/1511085112

(8) Social networks and pain: http://www.ncbi.nlm.nih.gov/pubmed/15561396

(9) Topical capsaicin for pain: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169333/

A Simple Mind Hack To Reduce Pain

Neurons

Neurons

Pain is the conscious correlate of perceived threat. – Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy, Uni SA

Pain is only pain if we are consciously aware of it, if you aren’t aware of pain, you don’t have pain!

Knowing this, if we can shift our awareness away from pain, we can reduce it.

In medical terminology, this is described as distraction therapy.

Distraction therapy is an effective pain management strategy, and it’s something you’re likely to be familiar with.

If you’ve ever spent any time with children, you’ll have seen them hurt themselves. Sometimes, after a minor fall/scratch/scrape children make a bigger fuss than warranted (tears and tantrums), mostly for attention. Many clever parents use simple distraction techniques to take a child’s mind off the pain they are experiencing. It usually works a treat.

This is distraction therapy.

How Does It Work

There are 2 inter-related but separate mechanisms that are at play.

The first, and probably the coolest, is that distraction therapy leads to the secretion of pain relieving opoids by the brain (1).

These opioids, termed endogenous, as opposed to exogenous opioids that you consume (codeine, oxycodone etc) act within the central nervous system to reduce pain.

The second involves competition for attention between an important sensation and consciously directed focus (2).

This is because the conscious mind can only focus on one thing at a time.

Sure, we can rapidly alternate our attention between two or more things, but at any given moment our attention can only be on one thing.

And going back to the opening quote, “pain is the conscious correlate of perceived threat”, if our consciousness is focused elsewhere, then it cannot focus on pain.

How Do You Use It?

The great thing about this, just like with children, you can use this to help reduce your pain.

It’s important to understand that distraction therapy is not magical. It is simply a pain management technique that is free, easy to implement and accessible to all.

Distraction therapy can work with pain of all different causes, but you can’t ignore the underlying issue:

  • If your pain is caused by a medical condition, see a doctor!
  • If you are suffering pain due to injury, the injury must heal first before the pain goes away.
  • Likewise if you have pain related to movement issues, they must be resolved.
  • Finally, please understand, that persistent or chronic pain is considered a disease in its own right, it’s also not considered to be curable, instead, focus on finding effective management strategies.

 

So how do you do it? The beauty of distraction therapy is that there is no one way.

The most important thing is to use an activity that is interesting and meaningful to you. One that is comfortable and immersive.

You can’t think to yourself “I’m doing to distract myself from the pain by doing this” while you are doing it, because that means your attention is on your pain and not on the activity.

Doing this causes you to engage in a state of flow, and given that your brain will want to remain in this state, it will secrete opioids to modulate your pain.

That’s a win-win. You get to do something that is important to you and reduce your pain at the same time!

There is no limit to how long this will work for, it depends on how strong your concentration is.

Intention and Distraction: The Next Level?

Whilst the research on distraction therapy focuses on the immediacy of performing a task and the subsequent physiological response, here at Integrative Osteopathy we have used similar principles to help patients throughout their entire day.

This is not, strictly speaking, distraction therapy, but the principles are similar – namely that the conscious mind can only give attention to one thing at a time.

Not only does this technique help with pain management, but it can improve your mood and even your life.

The technique is called setting your intention.

It simply involves a short period of quiet contemplation in which you focus your attention on your intention.

What is your intention? It is another way of describing your focus.

If you look back through time, pretty much all cultures had periods of quiet contemplation built into their lives.

Whether it was prayer, meditation or spiritual rituals, these practices allowed people to process events that had happened and the associated thoughts and emotions, and find a place of comfort, if not clarity.

It is part of the reason mindfulness/meditation is gaining such traction in recent years – our attention is being attacked from every direction, distracting us – mindfulness helps with finding clarity again.

To add in quiet contemplation to your life, it need not be complex. In fact, it’s better if it’s not.

How To Set Your Intention

Setting your intention starts with quiet contemplation. A great time to implement it is in the morning, as it sets you up for the day ahead.

Pick something you habitually do, like taking a shower or brushing your teeth, and immediately before/after, close your eyes, slow your breathing and spend a few minutes alone with your thoughts and feelings.

Focus on the one thing, above all else, that you want for the day. This is your intention.

 

Your intention needs to be framed in a positive way. Your brain doesn’t recognise negative words. To illustrate, make sure you don’t think of dancing elephants while you’re reading this sentence.

Once you have the elephants out of your mind, get back to setting an intention.

This focus will govern all your actions for the day, both consciously and unconsciously.

After you have set your intention, you can create an intention card (3). Write your intention down on the front of small card, in one word. Then, on the back of that card, write out a prompt question.

Usually, you would frame it like this:

A. Statement of the intention
B. A question prompting the action which leads to the intention

Here’s an example:

Imagine someone who always feels stiff.

They might set their statement of intention as this: Fluid movement.

Then their question might read: what do I have to do to experience more fluid movement?

Instead of thinking about how stiff they feel, this question prompts somebody to get up and move, to stretch, to avoid prolonged positions and a whole heap of other things, all from a positive outlook. In essence, it’s distracting them from the problem whilst prompting a solution.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

References

(1) Attention Modulates Spinal Cord Response To Pain – http://www.sciencedirect.com/science/article/pii/S0960982212003934

(2) How Does Distraction Therapy Work – http://www.ncbi.nlm.nih.gov/pubmed/15745617

(3) Intention Cards – http://www.authenticeducation.com.au/intention-cards/

Exercise For Low Back Pain

Fit girl lift weights at fitness gym center. Deadlift workout.

Any article about exercise for pain needs to cover one important fact before it goes on:

The body will tend towards self-correction/health/resolution, if, and that’s a big if, the right conditions are present.

The biggest challenge facing an osteopath, or any other therapist, is finding, or more likely, stumbling upon, the right conditions for the individual seeking help.

Whilst there are general guidelines to abide by, every one of us has a unique set of experiences, thus different stories, explanations, treatment techniques and movements are required to facilitate a recovery; not to mention all the environmental factors that come into play.

This article intends to discuss the general principles that should underpin your actions when exercising for/with low back pain.

Where Most Back Pain Exercise Programs “Go Wrong”

Most back pain exercises or exercise programs are based on the notion that pain is the result of specific factors, and that these factors can be specifically identified and then specifically addressed.

There are a variety of factors that can contribute to low back pain, but aside from a history of previous episodes of low back pain, nothing drastically stands out as being identifiable. (1)

As an aside, this perhaps points the finger at us, therapists and rehab professionals, who are not doing a good enough job in the first place (on a population, not individual level).

It is also highly important for sufferers of low back pain to understand, as many people decide to cease treatment/rehab as soon as their pain is gone, rather than concluding the full course of treatment and restoring “lost” function.

Unfortunately, it is very difficult to specifically assess and as a result, address them with targeted exercises.

So knowing that specific factors may be hard to identify and treat, it seems more important to build resilience with a complete mobility, strength and conditioning program.

Take home point number 1: exercise programs for low back pain should not attempt to be specific, but rather improve all physical qualities.

There Are No ‘Good’ And ‘Bad’ Exercises

Another misconception surrounding exercise for low back pain is the concept of ‘good’ and ‘bad’ exercises.

Generally, if you are reading a fitness article, the concept of “neutral spine” is mentioned quite a lot. Lifting should always take place with a neutral spine, regardless.

If you are reading a rehab article, limits might be imposed on external loading, as in, any lifting above 10 kg is bad, and must be avoided.

Or you might read a medical article which mentions you should simply avoid things that hurt.

All of these comments have a place, and are neither right or wrong without any context to define them.

A ‘good’ exercise is one that you can do safely, is suitable for your current ability, is able to be gradually progressed and fits in with your needs and wants (aka your goals).

Take home point number 2: blanket statements and absolutes do more harm than good. There are times when a moderate approach doesn’t work and more extreme action needs to be taken, but it is rarely either or. Exercise selection is based on your needs and wants, not an arbitrary definition of good and bad.

Self-Limiting Movements

This is a concept that was popularised by American physical therapist Gray Cook, in his book Movement.

Self limiting movements/exercises are those that have an inbuilt “coaching mechanism”, meaning doing them forces you to increase your awareness with movement, and often times with these type of movements you can only perform them correctly, or not at all.

Utilising self limiting movements as part of an exercise program for low back pain allows you to safely challenge your body and brain, leading to improvements, without the risk of overdoing it.

There are many different examples of self-limiting exercises. The specifics are not as important as being able to move with increased awareness and a low risk. This is a big focus of our exercise programming for low back pain, especially in the early stages.

Take home point number 3: a good exercise program will provide both a challenge and the option to “fail safely” – thus reducing the fear associated with facing more demanding movement challenges.

Our Approach To Programming

There is no one way to program exercise for low back pain. As long as the programming is underpinned by sound principles, and not “technique based”, then it should be sufficient.

We strive for more than sufficient, we strive for optimal.

As such, over the years our approach to exercise programming for low back pain has been refined to what it currently is. Chances are, in another 5 years it will be further refined, but the vast majority will be consistent, as it is all principle based.

First, we consider the body as a whole. We don’t only do “low back” or “core” exercises, but rather we devise a total body program. This is the underpinning principle of osteopathy, and is also applicable to exercise programming.

Second, we ensure that of physical qualities are developed in the right sequence.

If we start with osteopathic manual treatment in the consultation room, we then progress to mobility and flexibility exercises.

These will usually start on the ground, as this provides the most stable environment, thus is the least threatening.

Considering pain occurs when there is a perception of threat by the brain (if you haven’t already, have a read of Pain Basics), this is one of the best ways to regain movement and avoid inefficient compensation patterns taking over.

From there you are looking to build “motor control” – this is simply the ability to control movement well.

We can call this stability, but that implies static positions and discounts the movement component. This is actually achieved simultaneously with improving movement/mobility/flexibility.

We can consider mobility as “end range strength”, and we are simply progressively challenging you so that both qualities improve.

Once you have achieved adequate movement and control (adequate is based on your individual needs), if you want and/or need, we would add load. This might be in the form of external resistance, increased leverage challenge or even changing the tempo.

Only when you are moving competently under load do we add a conditioning component – that is, more volume of work. This is the challenge of fatigue to your new found movement abilities, and if done correctly, is the difference between breaking down when the going gets tough and being able to withstand (almost) anything.

Take home point number 4: whole body, principle based programming that utilises appropriate methods of progression yield the best long term outcomes (based on clinical experience and research) (2) for sufferers of low back pain.

Conclusions

There is a well worn quote:

Methods are many, principles are few. Methods always change but principles never do.

This served as inspiration for this post – there is no point showing you how to do an exercise with no context as to whether it is appropriate for you or not.

Rather, it is important to have an understanding of why you are doing something – even if you only care about the “what”.

This understanding means you will not chop and change based on the latest article in your newsfeed.

It means you will take the time to get things right, knowing that making progress is all the matters, even if it is “slow”.

It also means that you have a better chance at a good outcome and are less likely to become a statistic of low back pain recurrence.

Reducing the article to four sentences, we would end up with something like this:

  1. Do something you enjoy doing, that has intrinsic reward – there are no “good” or “bad” exercises.
  2. Ensure you take a “whole body” approach to exercise. Don’t simply focus on “low back exercises”.
  3. Start slowly, progress gradually.
  4. Vary the stimulus over time, but not too much or too often (or you won’t elicit adaptations).

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

(1) Incidence and risk factors for low back pain: http://www.ncbi.nlm.nih.gov/pubmed/24462537

(2) Resistance training and low back pain in active males: http://www.ncbi.nlm.nih.gov/pubmed/20093971