Osteopathy Blog

Mechanical Neck Pain Manual Therapy and Prescriptive Exercise by Osteopaths

Mechanical Neck Pain

Mechanical Neck Pain is the general term that refers to any type of pain caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, mechanical pain results from bad habits, such as poor posture, poorly-designed seating, and incorrect bending and lifting motions.

 

What Manual Therapy Techniques do Osteopaths use to Treat Mechanical Neck Pain?

Osteopaths use spinal manipulation, spinal mobilisation / mobilization, spinal distraction, massage, myofascial, muscle energy techniques and strain /counterstrain techniques to treat mechanical neck pain.

Spinal Manipulation

There are different variations of manipulative techniques that can applied to neck and mid back to treat mechanical neck pain. Where a single cervical manipulation is capable of producing both immediate and short-term benefits for mechanical neck pain (Gorrell et al. 2016).

Also not all manipulative techniques have the same effect as the spinal manipulative tecnhiques have dfferent biomechanical characteristics that may be responsible for varying clinical effects (Gorrell et al. 2016).

So essentially the reduction in neck pain is dependent how the technique was applied, the biomechanics of the patients neck and which technique was applied.

Distraction

Manual cervical distraction (MCD) is a traction-based therapy performed with a manual contact over the cervical region (neck) producing repeating cycles while the person lies on their back. The traction force of the technique reduces neck pain intensity and neck-related disability (Gudavalli et al. 2015).

Massage

Regular massage over a 4 week period can significantly reduce (chronic) neck pain and dysfunction (Cook et al. 2015).

Myofascial Release

Myofascial release is a technique used to the connective tissues over the musculature, usually by pinching the skin and moving the tissue in a rolling motion. The technique has been shown to reduce neck pain disability in the short and long terms (De Meulemeester et al. 2017).

Which Manual Therapy Techniques are the Most Effective for Mechanical Neck Pain?

When you compare the effectiveness of manual therapy techniques applied as a treatment for mechanical neck pain.  It has been shown that the effect of manual therapy including spinal manipulation, mobilization, stretching and massage for patients seeking care for neck  pain in clinic is similar regardless if spinal manipulation or stretching is left out as a treatment option (Paanalahti et al. 2016).

So the osteopath will decide what is the most appropriate technique to apply on a case by case basis and no technique is superior to the other.

Are There Any Adverse Events following Manual Therapy?

Most reports of neck pain started after a manipulation and/or mobilisation, of which 53.4% lasted less than 24 hours, 38.1% more than 24 h but more than 3 months where 13.7% still experienced neck pain to date. Though mild to moderate adverse effects occur follwoing manual therapy are commonly reported and usually resolve within 24 hours (Thoomes-de Graaf et al. 2017).

Consequently, the benefits of reducing the severity of neck pain often outweigh the risks of treatment.  Furthermore, the Osteopath should be careful in their choice and application of manual therapy techniques for treating mechanical neck pain.

How Long Will It Take To Reduce The Severity of Mechanical Neck Pain Following Manual Therapy and Prescribed Exercise?

It can take anywhere between 48-96 hours. As one study showed that Improvements in neck disability and pain do not differ, for at least a 96-hour period, between patients performing general exercises and those performing an Augmented Exercise Programme following Manual Therapy (Petersen et al. 2015). Furthermore exercise  does have some preventive properties by reducing neck pain intensity and improved sensitivity (Murray et al. 2017).

Manual Therapy Treatment at Cam Osteopathy

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Reference List

Cook AJ, Wellman RD, Cherkin DC, Kahn JR, Sherman KJ. (2015). Randomized clinical trial assessing whether additional massage treatments for chronic neck painimprove 12- and 26-week outcomes. Spine J. Oct 1;15(10):2206-15

De Meulemeester KE, Castelein B, Coppieters I, Barbe T, Cools A, Cagnie B (2017). Comparing Trigger Point Dry Needling and Manual Pressure Technique for the Management of Myofascial Neck/Shoulder Pain: A Randomized Clinical Trial. Manipulative Physiol Ther. Jan;40(1):11-20

Gorrell LM, Beath K, Engel RM  (2016). Manual and Instrument Applied Cervical Manipulation for Mechanical Neck Pain: A Randomized Controlled Trial. Manipulative Physiol Ther. Jun;39(5):319-29.

Gudavalli MR, Salsbury SA, Vining RD, Long CR, Corber L, Patwardhan AG, Goertz CM (2015). Development of an attention-touch control for manual cervical distraction: a pilot randomized clinical trial for patients with neck painTrials. 2015 Jun 5;16:259

Murray M, Lange B, Nørnberg BR, Søgaard K, Sjøgaard G (2017). Self-administered physical exercise training as treatment of neck and shoulder pain among military helicopter pilots and crew: a randomized controlled trial. BMC Musculoskelet Disord. Apr 7;18(1):147

Paanalahti K, Holm LW, Nordin M, Höijer J, Lyander J, Asker M, Skillgate E (2016). Three combinations of manual therapy techniques within naprapathy in the treatment of neckand/or back pain: a randomized controlled trial. BMC Musculoskelet Disord. Apr 23;17:176.

Petersen SB, Cook C, Donaldson M, Hassen A, Ellis A, Learman K (2015). The effect of manual therapy with augmentative exercises for neck pain: a randomised clinical trial. J Man Manip Ther. Dec;23(5):264-75

Thoomes-de Graaf M, Thoomes E, Carlesso L, Kerry R, Rushton A (2017). Adverse effects as a consequence of being the subject of orthopaedic manual therapy training, a worldwide retrospective survey. Musculoskelet Sci Pract. Jun;29:20-27

Guide to HIV Associated Musculoskeletal Pain Treated with Massage by Osteopaths

What Musculoskeletal and Rheumatological Conditions Occur in HIV Patients?

The high prevalence of musculoskeletal involvement  of HIV cases occurs in the advanced stages. Though stage 2 patients predominantly suffer from arthralgia, spondyloarthropathy, and rheumatoid arthritis. Whereas patients with stage 3 disease had suffer predominantly from body ache and mechanical low back pain, but patients with stage 4 disease had suffered predominantly from septic arthritis, osteomyelitis, and pyomyositis (Kole et al. 2013).

However, musculoskeletal disorders are not always related to the HIV infection, these may be either the direct effect of the virus, opportunistic infections, noninfectious HIV complications (malignancy, drug toxicities), or unrelated rheumatologic disorders whose course have been altered (Kole et al. 2013).

How Might Musculoskeletal Pain Manifest In HIV Patients?

Myalgia (muscle pain) was the commonest symptom present and arthralgia(joint pain) involving knee, shoulder, and elbow are frequent complaints. The most distressing musculoskeletal disorders were mechanical low back pain and painful articular syndromes (Kole et al. 2013).

How Might Massage Help HIV Patients?

Musculoskeletal involvement in human immunodeficiency virus infected patients are important disease manifestations, responsible for increased morbidity and also decreased quality of life (Kole et al. 2013).
The effects of massage on HIV / AIDS musculoskeletal soft tissues include pain relief, decreased levelof depression, improved immune function, improved blood floand blood composition, reduced edema, and increased mobility of connective tissue, muscle and the nervous system . Massage is therefore potentially effective in improving the quality of life in patients suffering from chronic disorders (Hillier et al. 2010).
Furthermore, an increase in immune function following massage where the proposed mechanisms for this effect occurs via alterations in bio-chemistry, such as reduced levels of cortisol and increased levelof serotonin and dopamine. Though what mediates these biochemical effects is not known but presumed to occur through stress reduction (Hillier et al. 2010).

Effectiveness of Massage for HIV Musculoskeletal Pain

In a Cochrane review by Hillier et al. (2010),  they found that individuadomains of quality of life, there were findings in favour of massage therapy in combination with other modalities,such as meditation and stress reduction, being superior to massage therapy alone oto the other modalities alone.

The Suitability of Massage for Musculoskeletal Pain in HIV Patients?

Osteopaths have had success at managing  musculoskeletal complaints in HIV patients at the Blanchard Clinic (affiliated with the University College of Osteopathy, London). There is even research to suggest massage treatment might be effective for managing the musculoskeletal pain associated with HIV.
Though bear in mind, the osteopath will decide whether massage isa suitable and safe treatment option for managing musculoskeletal pain associated with HIV by completing an appropriate case history and examination or decide to refer you to the most appropriate medical practitioner.

The Challenge of Managing HIV Patients in Musculoskeletal Practice

The major challenges for the osteopath includes not only recognizing HIV infection associated rheumatic disorders but also distinguishing them from classic rheumatic diseases like rheumatoid arthritis, SLE, spondyloarthropathy, and vasculitis. So an aggressive multidisciplinary approach to early detection and timely intervention of these disorders, sometimes in consultation with a rheumatologist are all essential for effective management and to improve the quality of life (Kole et al. 2013). The other consideration is infection control during treatment.

HIV Infection Control During Treatment

As a blood-borne pathogen HIV is controllable in healthcare environments using the same guidelines and universal precautions which prevent all blood-borne infections including infectious hepatitis. The routine practice of osteopathy involves non-invasive manual contact only, therefore precautions are minimal. On the occasions that digital work within body cavities does take place (i.e. intraoral, peranal) the practitioners hand should be suitably gloved (Blanchard, 2009).

Massage Treatment at Cam Osteopathy

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Reference List

Blanchard PD (2009).  Masterclass: HIV-infection and osteopathy. International Journal of Osteopathic Medicine 12: 115–120
Hillier SLLouw QMorris LUwimana JStatham S (2010). Massage Therapy for People with HIV/AIDS.  Cochrane Database Syst Rev. Jan 20;(1):CD007502
Kole AK, Roy R, Kole DC (2013)Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis. 2013 Jul;34(2):107-12.

Manipulation: Should Osteopaths Perform it on The Intervertebral Discs?

What is Spinal Manipulation?

The definition of spinal manipulation is quite broad and does have many descriptive elements as shown a paper by Evans and Lucas (2010) which provides a reappraisal of what spinal manipulation is.

 A force is applied to the recipient

Manipulation involves a force being applied to the recipient. Most commonly, this force is externally generated and is usually applied to the recipient by physical contact at the skin surface. The force may include reaction forces from furniture,such as a plinth or chair and, in some circumstances, gravitational force may be utilised (Evans and Lucas, 2010).

The line of action of this force is perpendicular to the articular surface of the affected joint

Importantly the force has always been applied along a line of action perpendicular to the articular surfaces of the affected joint. Moreover, the motion produced by this force was joint surface separation, without any obvious ‘gliding’ motion. As synovial joint surfaces are designed to glide smoothly over one
another, the motion produced during this type of MCP joint manipulation is hence distinguished from that produced during typical ‘physiological’ motion. A complexity of this feature is that most synovial joints are curved rather than planar, and are not always congruent (Evans and Lucas, 2010).

Whereas the line of action of the applied force may be perpendicular to one point along the articular surface, this will not be the case with the
entire articular surface. Hence, the applied force may be more accurately described as acting perpendicular to a plane that is tangential to a point of contact between the articular surfaces of the joint (Evans and Lucas, 2010).

This joint motion always includes articular surface separation

The applied force induces motion between the articular surfaces of the affected joint, and when measured, articular surface separation (gapping) has always been observed (Evans and Lucas, 2010).

Cavitation occurs within the affected joint

Associated with joint surface separation is the elicitation of a high frequency vibration that manifests as an audible ‘click’ or ‘crack’ sound. .The most likely and widely accepted explanation for this audible sound during joint manipulation is a process known as cavitation, occurring within the synovial fluid of the affected joint. Cavitation is an engineering term used to describe the formation and activity of bubbles (or cavities) within fluid, which are formed when tension is applied to the fluid as a result of a local reduction in pressure (Evans and Lucas, 2010).

The UK Osteopath’s attitude towards Manipulation of Intervertebral Discs

You will find that Osteopaths in the UK have  quite varied opinions either in favour or against manipulation of the Intervertebral Joints. Though as a student Osteopath in the Osteopathic Colleges of the United Kingdom, it is kind of frowned upon to manipulate the intervertebral joints, Particularly when they are a final year osteopathic student are sitting their final clinical competency exam to register with the General Osteopathic Council. If the student has case during the exam where there is an opportunity to manipulate, the examiner would ask, “so would you manipulate a disc injury /Disc herniation?” The answer expected of the student should be “No!”

However with the research emerging at the moment, it makes it quite hard to justify whether this sort of treatment is appropriate for disc injuries /disc herniations.

In Favour of Manipulation of Intervertebral Discs

Reduction of radicular pain

The majority of patients in this study had either extruded or sequestered disc herniations. Patients with sequestered herniations treated with Spinal Manipulative Treatment to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points compared to patients with extruded disc herniations but this did not reach statistical significance. Further investigation is needed to determine mechanisms for this finding. This also calls into question the seriousness of disc sequestration in determining appropriate treatment (Ehrler et al. 2016).

Clinical Improvement with no serious adverse events

A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-amplitude side posture SMT reported clinically relevant “improvement” with no serious adverse events (Leemann et al. 2014).

Against Manipulation of Intervertebral Discs

Surgical Treatment maybe required when Manipulation of Intervertebral Joints causes Dics

Patients with Lumbar Disc Hernation, who underwent surgical treatment due to exacerbation of presentation caused by SMT. Five risk factors have been identified regarding the treatment of LDH by SMT. The present data attempt to offer guidance to chiropractors for the appropriate management of patients. Chiropractors should assess patients with back pain before performing SMT and practice the manipulation particularly carefully if any of the risk factors exists. To the best of our knowledge, this is the first study to address the risk factors of SMT in the treatment of LDH (Huang et al. 2015).

Potential Paralysis

We presented an extremely rare case of cervical intervertebral disc hernation causing progressive quadriparesis after excessive spinal manipulation therapy (Yang et al. 2016).

Conclusion

Osteopaths should think careful about whether is it safe and appropriate to manipulate the intervertebral joints. As their are arguements in favour of manipulation as treatment to reduce the symptomology associated with a discal injury /disc hernations. But their arguements against performing manipulative techniques on the intervertebral joints from a safety aspect and possible associated adverse events that can occur. In which it is completely understandable for the osteopathic colleges in the UK to teach osteopathic students not to manipulate the intervertebral joints of the spine in the teaching clinics.

 

Reference List

Ehrler M, Peterson C, Leemann S, Schmid C, Anklin B, Humphreys BK.  Symptomatic (2016). MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated With High-Velocity, Low-Amplitude Spinal ManipulationManipulative Physiol Ther. Mar-Apr;39(3):192-9

Evans DW, Lucas N (2010).  What is ‘manipulation‘? A reappraisal. Man Ther. Jun;15(3):286-91

Huang SL, Liu YX, Yuan GL, Zhang J, Yan HW (2015). Characteristics of lumbar disc herniation with exacerbation of presentation due to spinal manipulative therapy. Medicine (Baltimore). Mar;94(12):e661.

Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulativetherapy: a prospective observational cohort study with one-year follow-up. Manipulative Physiol Ther.  Mar-Apr;37(3):155-63.

Yang HS, Oh YM, Eun JP (2016). Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal ManipulationTherapy: A Case Report and Literature Review. Medicine (Baltimore).  Feb;95(6):e2797.

Cerebral Palsy: An Osteopathic Approach to Muscle Spascity

Cerebral Palsy

What Causes Cerebral Palsy?

Cerebral palsy (CP) is caused by an injury to an infants brain that interrupts normal development. People with CP have reduced muscle strength and aerobic fitness, which may impact their ability to perform activities such as standing, walking, running and to participate in everyday life. Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness. Aerobic exercise aims to improve aerobic fitness, while strength training aims to improve muscle strength. Health professionals often prescribe exercise to people with CP, primarily to improve function, but there has been no comprehensive evaluation of the evidence for th e effe ctiveness of these interventions in people with CP (Ryan et al, 2017).

Types of Cerebral Palsy

Exercise Prescription

aerobic exercise

resistance training

Mixed training

Passive muscle stretching

6 weeks of combined passive muscle stretching and whole body vibration could decrease the spasticity and increase the muscle strength and balance of children and adolescents with CP. Whole body vibration could be an alternative additional treatment to passive muscle stretching for both clinical and home therapy programs for children and adolescents with CP (Tupimai et al. 2016).

Effect of Massage Treatment on Microcirculation and musculoskeletal soft tissues

Massage is one of the oldest and most widely used treatments in complementary and alternative medicine, with more than 75 forms of it practised today.
Deepfriction massage (DFM), which was introduced by James Cyriax for treating tendon disorders, involves application of forces perpendicular to the fibres as to separate each fibre and align the newly formed collagen. It helps to promote analgesia, local hyperaemia, and reduce adherence of scar tissue to muscles, tendons and ligaments. Moreover, it helps to break subcutaneous adhesion and prevent fibrosis, leading to improved sensory feedback and decreased pain  (Rasool et al. 2017).

Massage has been used to improve blood and lymphatic circulation, enhance inelastic and elastic properties of muscles and connective tissue, alleviate muscle pain and promote relaxation. 9 It has been reported that mechanical properties and stretch reflex of spastic muscle differ from normal muscles. Stretch reflex is responsible for regulation of muscle stiffness and exaggerated response as this is responsible for hypertonia (Rasool et al. 2017).

Consequently, treatment is directed towards reducing stretch reflex which has been demonstrated by O’Dwyer et al. in young people with CP through the use of visual feedback.Deep cross-friction massage is used to stretch spasticmuscles and bring the sacromere length to an optimal level. Physical contact in this technique aids in decreasing the pain and benefiting the patient through psychological effects and by acting on the gate control theory.  M Hernandez Reif et al. found that children receiving massage therapy showed fewer cerebral palsy symptoms, including overall less rigid muscle tone reduced spasticity, and improvement in gross and fine motor functioning  (Rasool et al. 2017).

Effectiveness of Deep Friction Massage on Spascity associated with Cerebral Palsy

Deep Friction Massage was found to be a better and efficacious treatment option for management of spasticity in children with cerebral palsy than the traditional physical therapy alone. However, its role in improving function could not be established but it is speculated that reducing the spasticity
may help benefit in functional level and performance (Rasool et al. 2017).

Massage Treatment At Cam Osteopathy

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Reference List

Rasool F, Memon AR, Kiyani MM, Sajjad AG (2017). The effect of deep cross friction massage on spasticity of children with cerebral palsy: A double-blind randomised controlled trial. J Pak Med Assoc. Jan;67(1):87-91.

Ryan JM, Cassidy EE, Noorduyn SG, O’Connell NE (2017). Exercise interventions for cerebral palsyCochrane Database Syst Rev. Jun 11;6:CD011660

Tupimai T, Peungsuwan P, Prasertnoo J, Yamauchi J (2016). Effect of combining passive muscle stretching and whole body vibration on spasticity and physical performance of children and adolescents with cerebral palsyJ Phys Ther Sci. Jan;28(1):7-13.

Pelvic Joint Dysfunction Diagnosis + Treatment: An Osteopathic Approach

The posterior pelvic joint (s) are also known as the sacroiliac joints.

The Sacroiliac Joint ( Posterior Pelvic Joint) and Low Back Pain

The Sacroiliac Joint has been identified as the source of low back and buttock pain for approximately 15% to 30% of the population. Pain resulting from mechanical disorders, including innominate (ilium) positional and movement abnormalities appears to be the most commonly reported causes for non-specific LBP of SIJ origin.  As it has been shown that movement of innominate bones of pelvis can indicate relationships between innominate kinematic anomalies and LBP of SIJ origin., This indicates that SIJ (pelvic joint) pain reproduction is closely linked in people with clinically diagnosed LBP (Adhia et al. 2016).

How do Osteopaths Diagnose a Sacroiliac Joint Dysfunction (Posterior Pelvic Joint)

Gillet Test

The Gillet test assesses SIJ mobility with sensitivity 8% and specificity 93% . To perform this test, the subjects stands while the examiner sits behind the patient and palpates each of the patient’s PSIS, one at a time, with one thumb on the inferior aspect of the PSIS while simultaneously palpating the sacrum with the other thumb staying parallel to the first thumb. The subject is then instructed to stand on one leg while pulling the opposite leg up toward the chest with hip and knee flexion. The test is then repeated on the other side and compared bilaterally. The test is negative when either PSIS moves posterior inferiorly in relation to the sacrum. If the PSIS on the ipsilateral side of the knee flexion does not move or moves posterior-inferiorly only minimally or even paradoxically moves superiorly, it indicates a positive test (Soleimanifar et al. 2017).

Standing in Flexion Test (SIFT)

The standing flexion test assesses SIJ (pelvic joint) mobility with sensitivity 17% and specificity 79% . To perform this test, the subject stands while the examiner sits behind the patient and palpates both of the patient’s posterior superior iliac spines on their inferior margins. The examiner maintains his/her eyes level with the palpating thumbs while the subject bends forward slowly as if to touch his/ her toes as far as comfortable while keeping both legs straight (knees extended). The examiner assesses the symmetry of movement of both PSIS landmarks. The test is negative if both PSIS landmarks appear to move equally and symmetrically; the test is positive on the side in which the PSIS moves superiorly more than the other side. A positive result in a standing flexion test indicates limited movement of the ilium on the sacrum, and therefore limited SIJ (pelvic joint) motion on the side of the superior PSIS (Soleimanifar et al. 2017).

The Sitting in Flexion Test

The sitting flexion test assesses SIJ mobility with sensitivity 9% and specificity 93% (Levangie, 1999). The procedure is similar to standing flexion test except that it is performed with the patient sitting on a level surface. A positive result in this test indicates limited movement of the sacrum on the ilium, and limited SIJ (Pelvic Joint) motion on the side of the superior PSIS (Soleimanifar et al. 2017).

How Osteopaths Treat a Sacroiliac Joint Dysfunction

Osteopaths can manual therapy interventions such as joint manipulation, joint mobilisation and soft tissues techniques as treatment for a sacroiliac joint dysfunction.

SIJ ( Posterior Pelvic Joint) manipulation

The patient was supine and the therapist stood contralateral to the side which was to be manipulated (e.g. right) (Fig. 2). The patient was passively moved into side bending toward the side to be manipulated. The patient interlocked the fingers behind his or her head. The therapist passively rotated the patient, and then delivered a quick thrust to the Anterior Superior Iliac Spine (ASIS) in a posterior and inferior direction (Cleland et al. 2006).

Lumbar rotational manipulation

The patient lay on a treatment table in lateral recumbent position with the more painful side uppermost (e.g. right) (Fig. 3). The therapist stood opposite the patient. The therapist then flexed the top leg until the lumbar spine was flexed and placed the patient’s foot in the popliteal fossa of the lower leg. Next, the therapist grasped the patient’s lower shoulder and arm, and introduced left trunk side bending and right rotation, until motion was felt at the desired segment of the lumbar spine. The patient’s arms were positioned around the therapist’s right arm. The set up was maintained while the patient was rolled toward the therapist. Finally, the therapist’s left arm was used to apply a high-velocity low-amplitude thrust of the pelvis in an anterior direction (Cleland et al. 2006).

Conclusion

It is concluded that both treatment techniques, e.g. SIJ (Pelvic Joint) manipulation and lumbar & SIJ manipulation, significantly improve pain and functional disability in patients diagnosed with SIJ syndrome (Kamil and Esmaeil, 2012).

Cam Osteopathy

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Reference List

Adhia DB, Milosavljevic S, Tumilty S, Bussey MD (2016). Innominate movement patterns, rotation trends and range of motion in individuals with low back pain of sacroiliac joint origin.  Manual Therapy, Volume 21, February, Pages 100-108

Cleland, J.A., Fritz, J.M., et al., (2006). Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: study protocol of a randomized clinical trial [NCT00257998]. BMC Musculoskelet. Disord. 7, 11

Kamali F, Esmaeil Shokri E (2012). COMPARATIVE STUDY The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome. Journal of Bodywork & Movement Therapies 16, 29e35.

Soleimanifar M, Karimi N, Arab AM (2017). Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders. Journal of Bodywork and Movement Therapies, Volume 21, Issue 2, April, Pages 240-245

Guide to Adhesive Encapsulitis (Frozen Shoulder) Osteopathy & Prescriptive Exercise

Adhesive encapsulitis (Frozen Shoulder)

The frozen shoulder is a multifactorial disease characterized by inflammatory adhesion and stiffness of the glenohumeral capsule, pain in the shoulder, and limitation of movements in all directions (especially abduction, external rotation, and posterior extension). The age of onset falls between 30 and 70 years, with an average of fifty. More females are affected than males, with the left shoulder more often involved than the right (Cui et al. 2017).

The prevalence of frozen shoulder is about 2%–5%. Risk factors include diabetes, thyroid diseases, stroke, and autoimmune diseases. The prevalence of frozen shoulder in patients with diabetes is as high as 10%–20% and in patients with paralysis 16%–84% (Cui et al. 2017).

frozen shoulder adhesive encapsulitis

Imaging of Frozen Shoulder

Imaging studies of frozen shoulder (s) revealed reduced joint volume and a thickened and shortened glenohumeral capsule. Magnetic resonance imaging showed a significant thickening of the coracohumeral ligament and the rotator cuff interval as well as obliteration of the fat triangle between the coracoid process and the coracohumeral ligament (Cui et al. 2017).

frozen shoulder adhesive encapsulitis

Effectiveness of Osteopathic Treatment for Frozen Shoulder

Manual Mobilization with Exercise for Frozen Shoulder

Both manual mobilization therapy along with general exercises and exercises alone brought improvements in outcome measure scales for pain, glenohumeral ranges and shoulder pain and disability index but none of intervention is significantly effective over one another in 5 weeks of treatment (Ali and Khan, 2015).

There is a wide variety of manual therapy techniques that can be applied to treat frozen shoulder.

Angular Joint Mobilization for Frozen Shoulder

A case report suggests that Angular Joint Mobilization , which is rotational joint mobilization with joint axis shift, may be an effective intervention for improving shoulder pain, ROM, and disability in individuals with adhesive capsulitis (Kim and Lee , 2017).

Mobilization with Distension For Frozen Shoulder

Also hydraulic distension plus manual therapy decreased shoulder pain and improved shoulder function. Specifically, pain, satisfaction, and range of motion showed quick improvement from 6 weeks to 12 weeks after treatment. The treatment results of this study can be used for frozen shoulders (Kwak and Kim, 2016).

Mobilization with Distension combined with Steriod Injections for Frozen Shoulder

Whereas another study suggested that the most effective treatment for subacute Adhesive encapsulitis is a combination of intensive mobilization and steroid injection with capsular distension, and helped to control inflammation, extend joint space, and recover ROM. Therefore, intensive mobilization should be conducted by a skilled physical therapist after steroid injection with capsular distension to optimize the treatment effect for patients with Adhesive Encapsulitis (Park et al. 2014).

Spencer Technique for Frozen shoulder

Osteopaths use hydraulic distention when applying an articulatory technique to the shoulder known as the Spencer Technique  to help relieve restriction and pain at the shoulder. Although variations exist, normally 7 steps are included. Indications for the Spencer technique include adhesive capsulitis.

The following is a common sequence (of the 7 stages of the technique:

 

spencer technique frozen shoulder

Spencer Technique

A pilot study suggested that the Spencer technique is an effective treatment modality for improving the functional ability of the shoulder in the elderly (Knebl et al. 2002).

Niel Asher Technique

The Niel-Asher technique (NAT) involves a deliberate, specific algorithm of manipulations to the muscular and ligamentous apparatus of the glenohumeral
joint based around a five-step treatment protocol. Treatment sessions last between 25 and 40 (average of 30) minutes in duration; the technique was performed on all patients in sequential order on each visit. Within the five steps of the NAT protocol there are two main types of techniques employed which have been slightly modified; deep stroking massage (step one) and compression of trigger points (steps two, four and five) (Niel-Asher et al. 2014).

The notion of a “one-technique-fits-all” technique may initially seem an anathema to the “treat the individual” model that osteopathy currently promotes.
Whilst the idea may be challenging to some, the results of NAT are fast, effective and reproducible (Niel-Asher et al. 2014).

Compression technique

This technique involves locating the tender point that when compressed triggers a specific referred pain pattern (preferably reproducing the patient’s symptoms)and applying a direct pressure to this point:

Technique
1. Identify the tender/trigger point you wish to work on
2. Place the patient in a comfortable position,where the tissue which contains the tender/trigger point can undergo full excursion if required;
3. Apply gentle, gradually increasing pressure to the tender point until you feel resistance;
4. This should be experienced by the patient as therapeutic discomfort but in this technique it may sometimes border on pain;
5. Apply sustained pressure until you feel the tender point yield and soften. This can take from seconds to several minutes;
6. This can be repeated, gradually increasing the pressure on the tender/trigger point until it has fully yielded.
7. To achieve a better result, you can try to change the direction of pressure during these repetitions.

(Niel-Asher et al. 2014).

Deep stroking massage technique

This approach follows a technique advocated by Travell and Simons involves a deep slow stroking technique over a tender/trigger point rather than a compression as described above

Technique
1. Place the patient in a comfortable position, where the affected/host muscle can undergo full excursion;
2. Lubricate the skin if required (the lead author uses simple BLUE NIVEA);
3. Identify and locate the tender/trigger point or taut band;
4. Perform slow stroking massage using your thumb/applicator just beneath the taut band, and reinforce with your other hand if required;
5. This should be experienced by the patient as therapeutic discomfort but in this technique it may sometimes border on pain;
6. Sustained pressure is applied until the tender/ trigger point softens, followed by continued stroking in the same direction towards the attachment of the taut band;

(Niel-Asher et al. 2014).

Manual Therapy for Frozen Shoulder in Diabetics

Manual therapy approaches may be safely applied in diabetic patients with frozen shoulder (Düzgün et al. 2012).

Cochrane Review of Manual Therapy and exercise for Frozen Shoulder

The best available data show that a combination of manual therapy and exercise may not be as effective as glucocorticoid injection in the short-term. It is unclear whether a combination of manual therapy, exercise and electrotherapy is an effective adjunct to glucocorticoid injection or oral NSAID. Following arthrographic joint distension with glucocorticoid and saline, manual therapy and exercise may confer effects similar to those of sham ultrasound in terms of overall pain, function and quality of life, but may provide greater patient-reported treatment success and active range of motion (Page et al. 2014)

Treatment at Cam Osteopathy

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Reference List

Ali SA, Khan M (2015). Comparison for efficacy of general exercises with and without mobilization therapy for the management of adhesive capsulitis of shoulder – An interventional study. Pak J Med Sci.  Nov-Dec;31(6):1372-6

Cui J, Lu W, He Y, Jiang L, Li K, Zhu W, Wang D (2017). Molecular biology of frozen shoulder-induced limitation of shoulder joint movements. J Res Med Sci. May 30;22:61

Düzgün I, Baltaci G, Atay OA (2012). Manual therapy is an effective treatment for frozen shoulder in diabetics: an observational study.  23(2):94-9.

Kim Y, Lee G (2017). Immediate Effects of Angular Joint Mobilization (a New Concept of Joint Mobilization) on Pain, Range of Motion, and Disability in a Patient with Shoulder Adhesive Capsulitis: A Case Report. Am J Case Rep. Feb 10;18:148-156.

Knebl JA, Shores JH, Gamber RG, Gray WT, Herron KM (2002). Improving functional ability in the elderly via the Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trialJ Am Osteopath Assoc. Jul;102(7):387-96.

Kwak KI,  Kim EK (2016).  The clinical effect of hydraulic distension plus manual therapy on patients with frozen shoulderJ Phys Ther Sci. Aug;28(8):2393-6.

Niel-Asher S, Hibberd S, Bentley S, Reynolds J (2014).  RESEARCH REPORT Adhesive capsulitis: Prospective observational multi-center study on the Niel-Asher technique (NAT) International Journal of Osteopathic Medicine. 17, 232e242

Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R (2014). Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. Aug 26;(8)
Park SW, Lee HS, Kim JH (2014). The effectiveness of intensive mobilization techniques combined with capsular distension for adhesive capsulitis of the shoulder. J Phys Ther Sci. Nov;26(11):1767-70.

Osteopathic Management of Spondylosis (Intervertebral Disc Degeneration)

Spondylosis

Spondylosis is a broad term meaning degeneration of the spinal column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related wear and tear of the spinal column. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints (facet syndrome). If severe, it may cause pressure on nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, and muscle weakness in the limbs.

When the space between two adjacent vertebrae narrows, compression of a nerve root emerging from the spinal cord may result in radiculopathy (sensory and motor disturbances, such as severe pain in the neck, shoulder, arm, back, or leg, accompanied by muscle weakness). Less commonly, direct pressure on the spinal cord (typically in the cervical spine) may result in myelopathy, characterized by global weakness, gait dysfunction, loss of balance, and loss of bowel or bladder control. The patient may experience shocks (paresthesia) in hands and legs because of nerve compression and lack of blood flow.

Osteopathic Treatment

Osteopathic treatment cannot cure the condition, but can be an intervention to help manage the pain and mobility issues associated with spondylosis.

The aim of osteopathic treatment is to improve joint range of motion and reduce any pain associated with spondylosis. It has been shown that vertebral mobilization techniques in cervical spine (neck) can be effective for these objectives. Four mobilization techniques can be applied, these include Anterior-Posterior Unilateral Pressure (APUP), Posterior-Anterior Unilateral Pressure (PAUP),  Cervical Oscillatory Rotation (COR) and Transverse Oscillatory Pressure (TOP). Treatment with APUP and PAUP achieve faster pain relief results in unilateral cervical spondylosis than rotation or transverse process oscillatory techniques (Egwu, 2008). Though no studies are currently available for the application of these mobilization techniques for thoracic and lumbar regions of the spine in relation to spondylosis.

Please do bare in mind, there is very limited evidence to support the application of manual therapies for spondylosis.

Cam Osteopathy

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Reference List

Egwu MO (2008). Relative Therapeutic Efficacy of some Vertebral Mobilization Techniques in the Management of Unilateral Cervical Spondylosis; A Comparative Study. J Phys Ther Sci 20:103-108

Pubic Symphysis Dysfunction Manual Therapy by Osteopaths

Pubic Symphysis Dysfunction

Pubic symphysis dysfunction occurs at the front of the pelvis.

The joint comprises the medial surfaces of the pubic bones and an intervening fibrocartilaginous disc, which may contain a cleft. Functionally, it resists tension, shearing and compression and yet is able to widen during pregnancy. Pain in the region of the pubic symphysis, referred to as symphyseal pain, symphysitis or symphyseal dysfunction, can affect a diverse group of individuals including athletes, patients with traumatic pelvic injuries, and pregnant women (Becker et al. 2010).

During pregnancy, symphyseal pain typically causes difficulty with weight-bearing activities such as walking and climbing stairs, and turning over in bed  climbing stairs, and turning over in bed; symptoms do not necessarily resolve after childbirth and are very disabling for some women. The reported incidence and point prevalence of pregnancy-related pelvic girdle pain, which includes symphyseal pain, varies widely. This is in part related to differences in the definition of signs and symptoms, but a generally accepted figure for point prevalence is 20% (Becker et al. 2010).

Biomechanics

During everyday activities, the pubic symphysis is subjected to a variety of forces. These include traction on the inferior part of the joint and compression of the superior region when standing, compression when sitting, and shearing and compression during single-leg stance (Meissner et al. 1996). The healthy joint is highly resistant to separation although, on rare occasions, it may rupture during childbirth (Becker et al. 2010).

Pubic Symphysis dysfunction is very common and frequently overlooked condition where joint capsular pain occurs as result of the assymetrical imbalance between the innominate bones at anterior aspect (front) of the pelvis. It can occur as a result of a pelvic ring fracture or muscular imbalance between the abdominal muscles and adductor muscles (of the inner thigh) (DeStefano et al. 2012).

Screening can include functional pelvic / sacroiliac testing, Presence of tenderness around the inguinal ligament.

Pubic symphysis dysfunction can restrict the motion that occurs at the hip.

The pubic symphysis plays a role in dissipating energy and cushioning of impact forces during the human normal gait (walking) and those forces multiply during sport causing biomechanical strain on the pubic symphysis. Chronic Pain at the pubic symphysis results from joint instability. This injury typically occurs where high speed cutting activity is common and is often present with an adductor muscle strain. The disorder an also be seen in pregnancy with the widening of the pelvic joints occuring to allow the passage of a newborn infant through the pelvis during delivery (Seidenberg et al. 2016).

Treatment

There are two techniques that can be applied by Osteopaths to Treat Pubic Symphysis Dysfunction these include a muscle energy technique and a high velocity low amplitude manipulative technique known as a ‘shotgun’. As the technique can cause an audible click / pop.

Pubic Symphysis Superior or Inferior Shearing (Muscle Energy Technique). This procedure is employed to improve the motion between the pelvic bones at the pubic symphysis. Dysfunctional restriction of motion between the two pelvic bones such as one pubic bone is inferior position and the other in a superior position. Since the relationship between these two bones occurs at the pubic symphysis (Nelson et al. 2007)

Cam Osteopathy

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Reference List

Becker Ines, Woodley SJ and Stringer MD (2010). REVIEW The adult human pubic symphysis: a systematic review. J. Anat. 217, pp 475–487

Lisa A. DeStefano (2012). Greenman’s Principles of Manual Medicine. Lippincott Williams & Wilkins

Kenneth E. Nelson, ‎Thomas Glonek (2007). Somatic Dysfunction in Osteopathic Family Medicine. American College of Osteopathic Family Physicians

Peter H. Seidenberg, ‎Jimmy D. Bowen, ‎David J. King (2016). The Hip and Pelvis in Sports Medicine and Primary Care (2nd). Springer.

Heel Pain Osteopathy and Prescriptive Exercise by Osteopaths

Heel Pain

Heel pain usually builds up gradually and gets worse over time. The pain is often severe and occurs when you place weight on your heel.

In most cases, only one heel is affected, although estimates suggest that around a third of people have pain in both heels.

The pain is usually worse first thing in the morning, or when you first take a step after a period of inactivity. Walking usually improves the pain, but it often gets worse again after walking or standing for a long time.

Some people may limp or develop an abnormal walking style as they try to avoid placing weight on the affected heel.

Common causes of heel pain

Plantar Fasciitis

Plantar Fasciitis occurs when the plantar fascia ligament of the foot spanning the arch of the foot to induce the excessively inward rolling with either over-flexion or stretching. The ligament becomes irritated and inflamed and small tears may develop in the tissue (Agyekum and Ma,  2015).

Heel spur

Heel Spur also contributes to heel pain. When stress is put on the plantar fascia ligament, it does not cause only plantar fasciitis, but cause a heel spur to where the plantar fascia attaches to the heel bone. A heel spur is an abnormal growth of bone at the area where the plantar fascia attaches to the heel bone. It is caused by long-term stress on the plantar fascia and muscles of the foot, especially in fat and overweight people, active runners or joggers. Heel spurs may not be the cause of heel pain even when it shows on an X-ray. They may develop as a reaction to plantar fasciitis (Agyekum and Ma,  2015).

Sever’s Disease

Sever’s Disease, also known as calcaneal apophysitis, is an inflammation of the growth plate in the heel of growing children, typically adolescents. The condition refer to the pain in the heel and is caused by recurrent stress to the heel and thus is particularly common in active children. It usually resolves once the bone has completed growth or activities reduce. Sever’s disease is directly related to overuse of the bone and tendons in the heel. This can come from playing sports or anything that involves a lot of heel movement. Too much weight bearing on the heel can also cause it, as can excessive traction since the bones and tendons are still developing (Agyekum and Ma,  2015).

Haglund’s deformity (heel bump)

Heel bumps or exostoses occur just lateral to the Achilles tendon and cause particular worry to teenagers in whom they interfere with shoes wear. The soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis, which is an inflammation of the bursa that produces the redness and swelling associated with Haglund’s deformity (Agyekum and Ma,  2015).

Achilles Tendinopathy

The Achilles tendon constitutes the distal insertion of the gastrocnemius and soleus muscles into the calcaneus. It is the inflammatory process within the tendinous insertion of the Achilles. This condition also refers to Achilles tendonitis, tenosynovitis, peritendinitis, paratenonitis (acute disease), tendinosis (chronic disease), and achillodynia. The acute phase of Achilles tendinopathy is secondary to acute overexertion, blunt trauma, or chronic overuse and muscle (Agyekum and Ma,  2015).

Heel neuritis

Compression of a small nerve (a branch of the lateral plantar nerve) can cause pain, numbness or tingling in the heel area. In many cases, this nerve compression is related to a sprain, fracture or varicose (swollen) vein near the heel. (Agyekum and Ma,  2015).

Heel Bursitis

Heel bursitis It is an inflammation of the heel bursa. It causes includes; landing awkwardly or hard on the heels and pressure from footwear. Heel bursitis pain is typically felt either deep inside the heel or behind the heel. Occasionally the Achilles tendon may swell. As the day goes by, the pain usually gets worse (Agyekum and Ma,  2015).

When to see your GP

See your GP or a podiatrist (foot problems specialist) if you’ve had persistent heel pain for a number of weeks and it hasn’t cleared up.

It is advised that a patient should make an appointment to see a health care professional if he or she has significant heel pain that does not improve within a few days or if the patient is unsure of the cause of the symptoms, or does not know the specific treatment recommendations for the condition. A doctor should be consulted if a patient experience: severe pain accompanied by swelling near the heel, numbness or tingling sensation in the heel, as well as pain and fever; pain in the heel as well as fever; being unable to work normally; being unable to bend the foot downwards; being unable to stand with the backs of the feet raised (you cannot rise onto your toes) (Agyekum and Ma,  2015).

They should be able to diagnose the cause of your heel pain by asking about your symptoms and medical history and examining your heel and foot.

Further tests will only usually be needed if you have additional symptoms that suggest the cause of your heel pain isn’t inflammation, such as:

  • numbness or a tingling sensation in your foot, which could be a sign of nerve damage in your feet and legs (peripheral neuropathy)
  • your foot feels hot and you have a high temperature (fever) of 38°C (100.4°F) or above, which could be a sign of a bone infection
  • your heel is stiff and swollen, which could be a sign of arthritis

Possible further tests that may be recommended include blood tests, X-rays, a magnetic resonance imaging (MRI) scan or an ultrasound scan.

Who gets heel pain?

Heel pain is a common foot condition. An estimated one in 10 people will have at least one episode of heel pain at some point in their life.

People who run or jog regularly, and older adults who are 40-60 years of age, are the two main groups affected by heel pain.

Treating heel pain

There are a number of treatments that can help relieve heel pain and speed up your recovery. These include:

  • resting your heel – avoiding walking long distances and standing for long periods
  • regular stretching – stretching your calf muscles and plantar fascia
  • pain relief – using an ice pack on the affected heel and taking painkillers, such as non-steroidal anti-inflammatory drugs (NSAIDs)
  • wearing well fitted shoes that support and cushion your feetrunning shoes are particularly useful
  • using supportive devices – such as orthoses (rigid supports that are put inside the shoe) or strapping

Foot Orthoses /Orthotics

Osteopaths generally prescribe insoles or custom orthotics to treat a mechanical issue of the lower limb and / or lower back. In the event that heel pain is due to a health issue, you are likely be referred to a GP or Podiatrist.

A summer alternative to wearing shoe insoles and orthotics, should be contoured sandals. Contoured provides a similar beneficial effect to that of a contoured shoe insert and a superior effect to that of a flat flip-flop over a 3 month period. The contoured shoe can be a prefabricated shoe foot orthoses that have been shown to be of benefit over 3 months (Vicenzino et al. 2015).

Osteopathic Treatment

Massage

Massage therapy to posterior calf muscles and neural mobilization combined with stretching exercises had superior short-term FS outcomes compared to ultrasound treatment with stretching exercises (Saban et al. 2014).

Neuromuscular Inibition

Neuromuscular inhibition techniques can be applied to reduce sensitivity of the soft tissues of the lower limb that that causes heel pain.

This can then by combined with a self-stretching protocol prescribed by an osteopath.

In particular it has been shown that adding Trigger Point manual therapies to a self-stretching protocol, it gives superior results to the sole application of self stretching in the treatment of individuals with plantar heel pain at short-term. The stretching protocol should include the calf musculature and plantar fascia for the treatment of plantar heel pain. Though it is unclearly of the long term effects of this treatment (Renan-Ordine et al. 2011).

Effect of Stretching on Plantar Heel Pain

The main pain-relieving benefits of stretching appear to occur within the first two weeks to four months. There is no conclusive evidence regarding the most effective number of repetitions or frequency of stretching, or whether self or therapist applied stretches are most effective. Inclusion of stretches directly to the plantar fascia may provide better short-term pain relief than stretching the Achilles tendon alone (Sweeting et al. 2011).

Evidence Base

Recent evidence suggests that manual therapy is effective in the long term in the treatment of plantar heel pain using joint, soft tissue and neural mobilization techniques (Mischke et al. 2017).

Cam Osteopathy

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Reference List

Agyekum EK, Ma K (2015). Heel pain: A systematic review. Chin J Traumatol. 18(3):164-9.

Mischke JJ, Jayaseelan DJ, Sault JD, Emerson Kavchak AJ (2017). The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review. J Man Manip Ther. Feb;25(1):3-10.

Renan-Ordine R, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernández-de-Las-Peñas C.(2011). Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. Feb; 41(2):43-50.

Saban B, Deutscher D , Ziv T (2014).  Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Man Ther. Apr;19(2):102-8.

Sweeting D, Parish B, Hooper L and Chester R (2011). REVIEW The effectiveness of manual stretching in the treatment of plantar heel pain: a systematic review. Journal of Foot and Ankle Research 4:19

Vicenzino B, McPoil TG, Stephenson A, Paul SK (2015). Orthosis-Shaped Sandals Are as Efficacious as In-Shoe Orthoses and Better than Flat Sandals for Plantar Heel Pain: A Randomized Control Trial. PLoS One.  Dec 15;10(12):e0142789.

Breast size: How large breasts cause Musculoskeletal pain

Breast Size Varies throughout Life

Breast size and mass vary throughout life, influenced by hormonal changes, body fat composition, stage of reproductive cycle, and breast pathology. Bra size, when fitted according to defined industry standards, may be used as an estimate of breast size. Across the lifespan and across the population, bra size is not a consistent measure of breast mass which is most accurately estimated from radiographic measures of volumetric density, but among healthy women who have never been pregnant or experienced breast pathology, bra size is likely to be a consistent measure (Wood et al. 2008).

Large Breasts (Macromastia) and Musculoskeletal Pain

Back pain, including thoracic spinal pain, is a common, potentially disabling, routine presenting complaint to general practitioners [1]. Macromastia is the state of having disproportionately large breasts. Some macromastic women report breast pain and other symptoms, and the intuitively logical assumption is that breast size is the key influence on clinical presentation. Clinical symptoms attributed to macromastia include neck, thoracic spine and shoulder pain, breast pain, headaches, grooving and associated pain caused by bra straps, intertrigo (inflammation of skinfolds), and ulnar nerve paresthesia (Wood et al. 2008).

Pain is more likely to affect women with breast size D or bigger. As the large breast sizes were found to affect the mechanics of the spine, both the thoracic kyphosis and the lumbar lordosis angle were higher in women with bra size D than in women with bra size A, B, or C.This is because  women with macromastia adopt a corrective posture due to the effect of the breasts on their center of gravity and possibly in a subconscious effort to conceal their breasts (Lapid et al. 2013).

Breast Related Thoracic (Mid-Back) Pain

Breast-related thoracic spinal pain is thought to result from changes in centre of gravity as that static spinal posture differs significantly according to breast size. Large breasts can increase cervical lordosis and thoracic kyphosis, shift the centre of gravity away from the spine and increase muscular effort required to maintain balance. They also suggested that large or heavy breasts may also lead to continuous tension on the middle and lower fibres of the trapezius muscle and associated muscle groups (Wood et al. 2008).

Having large breast size may place addition weight through your spinal column predisposing you to mechanical back pain.  As Foreman et al. (2009) hypothesized that mammaplasty surgery would result in reductions in low-back compressive forces in women with macromastia.

Large Breasts can cause Headaches

Having large breasts can cause headaches. As it found that  patients with macromastia who have occipital neuralgia and/or chronic headaches/migraines can experience headache relief following reduction mammaplasty (Ivica and Matthew,  2010).

Osteopathic Treatment

Osteopathic treatment is a manual therapy approach to treating neck pain, shoulder and back pain. Treatment also focuses on addressing my postural complaints and lifestyle issues.

To make an appointment with an osteopath at Cam Osteopathy click on book an appointment

If osteopathic treatment is unable to reduce the pain associated with back, shoulder and neck, then a referral to a plastic surgeon maybe required for breast reduction surgery.

Breast Reduction Surgery

Some women with macromastia (large breasts) have to undergo a breast reduction due to back pain (92%), painful bra grooving (94%), neck pain (95%), and shoulder pain (94%). Bra grooving and back, neck, and shoulder pain significantly decrease or totally disappear after reduction mammaplasty.

Reference List

Ivica D and Matthew L (2010). Chronic Headaches/Migraines: Extending Indications for Breast Reduction. Plastic & Reconstructive Surgery: January 2010 – Volume 125 – Issue 1 – pp 44-49

Foreman KB1, Dibble LE, Droge J, Carson R, Rockwell WB (2009). The impact of breast reduction surgery on low-back compressive forces and function in individuals with macromastia. Plast Reconstr Surg. Nov;124(5):1393-9

Lapid O, de Groof EJ, Corion LU, Smeulders MJ, van der Horst CM (2013). The effect of breast hypertrophy on patient posture. Arch Plast Surg. Sep;40(5):559-63.

Wood K, Cameron M, Fitzgerald K (2008). Breast size, bra fit and thoracic pain in young women: a correlational studyChiropr Osteopat.  Mar 13;16:1