MCR

Musculoskeletal
Consumer Review
In Volume 2009:1
Neck-Related Headaches 1

The Buckling Knee 3

Posterior Pelvic Pain (Sacroiliac Joint Pain)

in Pregnant Women 6

Iliotibial Band Friction Syndrome 9

Lumbar Spinal Stenosis 10

What is Sciatica? 12

Herniated Disc or ‘Slipped’ Disc 14

Repetitive Strain Injuries - Are you a victim

of it? 16

Repetitive Strain Injuries - Prevention and

Management 20

Shin Splints from the Periosteum 23

9 Things To Take Pressure Off Your Back 2 6

Manual Therapy - Spinal Vertebra Mobili-

sation 28

Enabling Better Health Through Better Education


From the Editor
When we first started planning for what eventually be-
came Musculoskeletal Consumer Review or MCR as
we call it, we asked ourselves - “Does the world need
another collection of articles on health conditions?”. So
asked the people who knew best - our clients.
Surprisingly, the answer was yes. But with a few
caveats.
First, write to them as intelligent people but who happen
to have limited knowledge on matters of health.
Second, don’t barrage them with jargon. Most did not
appreciate being swamped with jargon.
Last but not least, they wanted interesting and different
topics. There are literally thousands of musculoskeletal
conditions but only a few common conditions get
written up on all the time.
So with these few conditions in hand, we wrote clear ly
and simply. We pitched the articles somewhere between
a lay-person and a medical professional. And we looked
at conditions less frequently covered by other sources
of information.
This journal collects a selection of articles from our main
site. We hope that you find them useful if not interesting
and that we kept faith the few caveats above.
Cindy Tan
Editor, Musculoskeletal Review
MCR
Published by
Musculoskeletal Consumer Review
A division of Core Concepts Pte Ltd
73 Tras Street, #02-01
Singapore 079012
Tel: 6226 3632
www.CoreConcepts.com.sg
Articles originally appeared in mcr.corecon-
cepts.com.sg
All rights reserved. No part of this
book shall be reproduced, stored in
a retrieval system, or transmitted by
any means, electronic, mechanical,
photocopying, recording, or other-
wise, without written permission
from the publisher. No patent liabil-
ity is assumed with respect to the use
of the information contained herein.
Although every precaution has been
taken in the preparation of this book,
the publisher and author assume no
responsibility for errors or omissions.
Nor is any liability assumed for dam-
ages resulting from the use of the in-
formation contained herein.
MUSCULOSKELETAL HEALTH GROUP
Copyright 2009 Core Concepts Pte Ltd
Artworks/Images: iStockPhoto
Neck-Related Headaches
H What are some of the activities
ave you ever had the feeling that
your headache is somehow related
to the pain in your neck? How that
it is such a coincidence that every time your
that aggravate this condition?
Typically, activities that require the neck to be
headache is preceded by the stiff neck that you in a sustained strained position for a prolonged
are experiencing? You are not imagining it! It is period of time will aggravate this problem. The
what the medical community calls cervicogenic neck posture is often faulty, the head is turned or
headaches, which means headaches originating
tilted to one side or sufferer is adopting the “poke
from the neck. chin” position.
Example of such activities include reading, using
What are the usual complaints the computer especially the laptop, putting on
from people who suffer from make up, looking up for too long or watching
cervicogenic
headaches?
Most sufferers complain of a
deep dull ache starting from the Nerves to the Head
base of the skull to the top of the
head, usually over just one side
of the head. It may be present
on both sides if the neck pain
and stiffness are on both sides
of the neck. Other complaints Nerves
include feeling pressure at the
back of the eye and discomfort
in the jaw.
Another symptom that confirms
the diagnosis is the presence
of tenderness when pressure is
applied over area of the cervical C1 vertebra
spine immediately under the
skull. In some cases, when C2 vertebra
pressure is applied for long
enough, sufferers feel some relief C3 vertebra
from the headache.
Spinal cord
source: visiblebody & core concepts
Musculoskeletal Consumer Review Volume 2009:1 
movies or theatre when seated
on the side of the hall. C1-2 Nerve Compression
The Buckling Knee
Why do these
activities aggravate
the headache? C1 vertebra

H
When we adopt the “poke chin”
posture, we apply compressive aving a sense of the knee ‘giving way’ or meniscus is better at the handling stress from an
Nerves exiting ‘locking’ is a fairly common complaint up and down motion. It doesn’t do as well under
stress to the upper part of the
between C1 and by athletes who have twisted their a twisting motion especially when compressed.
cervical spine, namely, C1 and
C2 vertebrae get knees in sports like basketball, netball, soccer This motion can cause a tear in the meniscus.
C2 levels (C1/C2 refers to the
first two cervical vertebrae in
irritated when or badminton. The sensation of ‘giving way’ The knee feels ‘locked’ when the torn part of the
the spine). Similarly, when we compressed is an indication that you might have torn your meniscus blocks the movement of the knee.
turn our head to one side, we Anterior Cruciate Ligament (ACL) while the
‘locking’ sensation is an indication of a possible Immediate swelling and severe pain in the knee
compress the C1-2 level on the C2 vertebra
meniscus tear. are common signs of this Triad injury. However,
same side. This happens as
there are occasions where there will be a delay
most of the movement of the
in the onset of swelling or even no swelling at
head occurs at these 2 spinal
levels. So if we sustained these
source: visiblebody & core concepts
ACL Injury all. Remember how you injured the knee. It helps
your Doctor or Physiotherapist in diagnosing
postures or repetitively perform
The ACL is a fairly strong ligament found this problem.
them, these 2 levels will start
to degenerate and the cartilage wears out over
What can we do? between the knee-joint. Its main role is to limit
the forward movement (anterior translation) of
time. This in turn results in stiffness of the upper We need to improve the cervical joint alignment
cervical spine.
the leg bone (tibia) on the thigh bone (femur). Solving the Problem
and mobility at the C1-2 levels and to remove
the compressive forces, which is to adopt good When athletes change direction quickly during Sadly, the ACL doesn’t heal on its own due to
posture. This will reduce the irritation to the their games, they twist their knee inwards. This the poor blood supply to the ligament. It would
What is relevance between the C1- nerves. increases the strain on the ACL and places the need to be reconstructed surgically by using
2 levels and headaches? ligament at risk of tearing. The ACL tears when either your hamstring tendon or patella tendon.
If the cervical facet joints are slightly rotated due the knee is force downwards and inwards beyond Rehabilitation after surgery normally takes about
The nerves that exit C1-2 and sometimes C3 to contractile forces of tight muscles surrounding the ligament’s ability to hold. Athletes who tear 6-9 months before the athlete is able to go back to
supply sensation to the back of the skull to the the neck, the affected joints are already in their ACL often report hearing a ‘pop’ on injury. full training.
top of the head and in some people to the jaw some amount of compression and may not
area. The nerves that exit from the right side of allow full functional or physiological range. In Unfortunately, the ACL is very rarely the only Nevertheless, there are about 20% of people
the neck will supply only the right side of the this situation, physiotherapists can apply the ligament involved in this kind of injury. It is with ACL tears who are able to go about their
head, likewise for the left. “MUSCLE ENERGY TECHNIQUE” to realign the normally accompanied with a slight tear in the day-to-day activities without having their ACL
joint position. This technique uses the muscles Medial Collateral Ligament (MCL) and either a reconstructed. To cope without surgery, the
When these joints are stiff or mal-aligned, the to reposition the joint. medial or lateral meniscus (cartilage) tear. These following muscles need to have good strength
nerves at the affected levels will be irritated three tears are commonly known as the ‘Unhappy and control:
causing pain. So when one has a right-sided Once the joint is in a neutral position, the actual Triad’ or ‘Terrible Triad’.
upper neck pain or stiffness, the pain is always stiffness (hypomobility) can then be accurately • Hamstrings
referred to the right side of the head. assessed. Stiffness can be treated by various
techniques, such as passive mobilization through Meniscal Injury • Quadriceps (thigh)

The meniscus, which is a crescent shaped cartilage • Gluteus Medius

. . . c o n t i n u e o n p a g e 18 between the knee, acts as a cushion to absorb
• Gastrocneumius (calf)
the impact between the leg and thigh bone. The

 Musculoskeletal Consumer Review Volume 2009:1 Musculoskeletal Consumer Review Volume 2009:1 
Besides doing strengthening exercises, slowly
getting back into sports specific training is
essential. This is so that your muscles can
develop an anticipatory reaction (feed-forward
mechanism) to prevent injury.
Choosing the R ig ht K nee
Suppor t
There are more than 10 different types of knee
supports on the market at this current time.
This gives us a headache deciding which one
should you get. How one makes a choice for the
appropriate knee support should depend on 2
major ‘type’ factors - type of injury and type of
sport that knee support is required for
A knee support SHOULD NOT be for long
term daily wear as it will weaken the muscles
of the knee, making one very dependent on
the support. Knee support should be used as
a TEMPORARY measure to manage your knee
discomfort until professional advice is sought.
Lateral View of the Knee
source: US GSA & core concepts
 Musculoskeletal Consumer Review Volume 2009:1
Sports taping of the knee to support the ACL and
MCL can also be done as a temporary measure
for the athlete to cope with the injury until the
BACK PAIN SPECIALISTS
end of the season.
The best way to manage your knee discomfort
is to see your physiotherapist for prescribed
exercises that would be beneficial for you and
to strengthen your knee.
Here is a simple guide to 5 of the more common
types of knee supports.
Closed Patellar Knee Support
This knee support is generally used to help
control slight swelling of the knee and can
also be used for jogging or brisk walking.
Commonly used with knee pain that is difficult
to isolate the area of pain. However, due to
the “closed” nature of this knee support, it is
not recommended for daily use if you’ve got
to climb stairs or squatting. This is because it
would compress your knee cap (Patellar bone)
against your thigh bone when your knee is
bent more than 45o thus increasing the risk of
degeneration of the knee cap and increasing
your pain.
Open Patellar Knee Support
Similar indication to the closed patellar knee
support but this can be used for daily use as it
doesn’t compress your knee cap. Recommended
for people who have pain behind their knee cap
with difficulty climbing stairs or squatting.
Hinged Knee Support
Generally prescribe by orthopedic surgeons
or sports physicians for athletes with ligament P H Y S I O T H E R A P Y C E N T R E
Appointment: 6353 5713 • 6226 3632 • 6887 4246
. . . c o n t i n u e o n p a g e 13
SHENTON WAY • PARKWAY PARADE • NOVENA S Q UA R E
 What are the
symptoms? SACROILLIAC JOINT (SIJ)
Posterior Pelvic Pain (Sacroiliac Of all the back pains
experienced during
Joint Pain) in Pregnant Women pregnancy, posterior pelvic
pain is the most common
Sacrum

- you are four times more SIJ is the joint

P
osterior pelvic pain (PPP) is pain felt at or
near the sacroiliac joints of your pelvis as
a result of sacroiliac joint dysfunction.
These are joints located at the 2 dimples of the
lower back. The pain often feels deep within your
lower back and can occur on one or both sides of
your back. In some cases, pain radiates down to
the buttock and the back of the thigh.
While pain may begin at any time during
pregnancy, PPP on average begins in the 18th
week of pregnancy and becomes more intense
as the pregnancy progresses. The pain usually
spontaneously resolves within 3 months post
delivery. But in some cases it can become chronic
and disabling.
What are the Sacroiliac joints?
The sacroiliac joints (SIJ) are formed between the
sacrum, a triangular-shaped bone in the lower
portion of the spine, and the right and left ilium
of the pelvis. The SIJ is a strong and stable weight-
bearing joint that permits very little movement
due to its natural structure. The main role of the
SIJ is to allow forces to be transmitted effectively
through the body, absorbing impact from the legs
to the spine during activities such as walking,
running and jumping.
The SIJ is kept stable through two mechanisms:
1. Firstly, the rough, groove-like connecting
surfaces of the sacrum and ilium interlock
and help stabilise the joint, like two pieces
of Lego together.
2. Secondly, the SIJ is further strengthened by
a complex mesh of ligaments and muscles
such as the core stabilizers. These core
muscles, such as the transversus abdominis
and multifidus which surround the SIJ, act
as active stabilizers by actively contracting
to create a compressive force over the SIJ,
gripping the joint firmly together. They
act as a natural corset by providing that
compression around the lower back and
pelvic region -much like wrapping your
fingers around the two Lego pieces, keeping
them firm and tight.
Posterior pelvic pain arises from sacroiliac joint
dysfunction, in other words, when the stability
of SIJ is compromised.
Why does it happen?
During pregnancy, mechanisms stabilising the
SIJ is affected. This instability allows for increased
motion, stressing the SIJ.
1. Hormones released during pregnancy relax
the ligaments of the body to allow the pelvis
to enlarge, in preparation for childbirth
2. Due to the growing uterus, some of the core
muscles around the pelvis get ‘stretched’
and weakened.
Moreover, the additional weight and altered
walking pattern associated with pregnancy
can cause significant mechanical strain on
the sacroiliac joints, which may result in SIJ
inflammation, giving a deep ache in the posterior
pelvis.
likely to experience PPP where the sacrum
than lumbar pain. meets the illium
You may have posterior
pelvic pain / sacroiliac
joint dysfunction if you
have:
• Deep, boring pain
in the back of the
Left Illium
pelvis (around the
sacroiliac joints)
• Pain may
occasionally radiate
to the groin and
thighs.
source: visiblebody & core concepts
• The pain is typically
worse with standing, X-ray may also help in the diagnosis. Another
walking, climbing stairs, resting on one leg, reliable diagnostic method involves injecting an
getting in and out of a low chair, rolling anesthetic agent into the SI joint, guided by an X-
over and twisting in bed, and lifting. The ray machine, numbing the irritated area, thereby
pain improved when lying down. identifying the pain source. However, due to the
concerns of fetal exposure to radiation, diagnostic
• If there is inflammation and arthritis in the procedures involving radiation is generally
SI joint, you may experience stiffness and a avoided.
burning sensation in the pelvis.
Treatment and Management
Diagnosing Sacroiliac Joint
The first-line treatment of pregnancy-related
Dysfunction in pregnancy
sacroiliac joint dysfunction is physiotherapy
Your doctor and/or physiotherapist will conduct and exercises that focuses on core stability of
the trunk and pelvic girdle. Sometimes, a sacro-
a thorough history and physical examination
iliac belt is prescribed to complement the core
to determine the underlying disorders for
stability exercises and to give quick pain relief.
your pain. That includes your description of
Exercises will form a large part of the treatment
symptoms, a series of tests designed to look at
and in some cases, mobilisation (a gentler form
the stability, movement, and pain in the sacroiliac
of manipulation) of your hip, back or pelvis may
joints and surrounding structures. Imaging,
such as computed tomography (CT) scan and be used to correct any underlying movement

 Musculoskeletal Consumer Review Volume 2009:1 Musculoskeletal Consumer Review Volume 2009:1 
dysfunction. Other manual techniques include
muscle energy technique (MET) and myofascial
release. It is vital to engage a physiotherapist who
is skilled in treating pregnancy-related pain as
she is aware of the studies that support the use of
specific stabilizing exercises and other treatment
techniques, thereby preventing the dysfunction
from escalating into a chronic condition.
Other alternative treatments include anesthetic
and steroidal injections into the SIJ that can
help in pain relief, which lasts from one day or
much more long-term. Oral anti-inflammatory
medications are often effective in pain relief as
well. However, these two treatments may be
contra-indicated during pregnancy.
Posterior Pelvic Pain Home
Advice
Here are some tips for expectant women with
posterior pelvic pain..
Lying down
• Avoid lying on your back for long periods
of time, particularly after the 19th week of
your pregnancy.
• Try lying on your side (preferably your left)
with a pillow placed between your knees
and another under your tummy.
• If your waist sags down into the bed, try
placing a small rolled up towel under your
waist.
Turning over in bed
• To turn to your right while lying on your
back, arch your lower back, tighten your
pelvic floor muscles and lower abdominal
muscles and bend both knees one by one.
• Turn your head to the right and take your
left arm over to the right of your body. Hold
onto the side of your bed if you can.
 Musculoskeletal Consumer Review Volume 2009:1
• To turn, pull with your left hand and take
both knees over to the right so that you roll
to the right. As soon as possible, bend your
knees up as high as they will go - this helps
to lock out your pelvis and lessen pain.
• Reverse this to turn to the left.
Getting out of bed
• Roll onto your side with your knees bent
up, move your feet over the edge of the bed
and push yourself up sideways with your
arms.
• Reverse the process when you lie down.
Standing from a sitting position.
• Sit on the edge of the chair.
• Keeping your knees apart slightly and lean
forwards till your head is directly over your
knees, keeping your back straight.
• Stand up by pushing up with your arms,
with your back straight and tummy tucked
in. This helps to hold your pelvic joints in
their most stable position and may reduce
your pain significantly.
Reference:
1. Fitzgerald CM and Le J. Back pain in
pregnancy requires practitioner creativity.
Biomechanics. 2007 November
2. Ostgaard HC, Andersson GB, Karlsson
K. Prevalence of back pain in pregnancy.
Spine. 1991; 16:549-552.
3. Ostgaard HC, Zetherstrom G, Roos-
Hansson E, Svanberg B. Reduction of back
and posterior pelvic pain in pregnancy.
Spine. 1994; 19:894-900.
. http://www.sidysfunction.com/articles/
lumbarbackandposteriorpelvicpain.html
Iliotibial Band Friction Syndrome
T
ell any long-distance runner or cyclist Bio-mechanical Gait
about your stinging pain at the side of the
knee or hip, and you will get a knowing Problems with foot structures such as high or low
arches and uneven leg length typically tighten
sympathetic look. ITB (Iliotibial band) friction
the ITB on one side. A complete biomechanical
syndrome is one of the commonest complaints
assessment helps determine the faults. Where
amongst runners, cyclists and intense court
appropriate, foot orthotics can correct these
sports.
problems.
ITB friction syndrome gets its name from the
Iliotibial Band rubbing against a bony protrusion
just at the side your knee. The ITB is a continuation Weak outer hip muscles
of one the largest hip muscles and spans as a
thick band of tissue on the outside of the thigh. Weak outer hip muscles forces the ITB to work
Starting from the pelvis, it runs over side of the harder to compensate and becomes tight as
hip and ending just below the knee. Just before a result. Exercise to strengthen the outer hip
it crosses the knee, it runs over a protrusion in muscles helps to lighten the load on the ITB.
the thigh bone (lateral femoral epicondyle). The
frequent rubbing of the band over this bony Despite avoiding all the three issues mentioned,
athletes with a high training volume often still
protrusion from bending and straightening of the
experience painful ITBs. In such cases, deep
knee irritates the band, causing an inflammation.
tissue massage will help release the tight band.
The tighter the ITB, the harder it rubs over the
protrusion.
Don’t forget to stretch the ITB. Ignoring ITB
tightness can lead to groin pain and low back
pains.
What tightens the ITB?
Three basic things tighten the ITB.
1. Training methods ITB: Bony Protrusion
ITB
2. Bio-mechanical gait issues snaps over
protrustion
3. Weak outer thigh muscles
lateral
femoral Irritated
epicondyle ITB
Training Methods (protrusion)
Running on banked surfaces, inadequate warm
up or cool down, increases in distance too fast or Knee-cap
excessive downhill running are faults associated
with running which strains the ITB. In cycling
having the feet toed inwards commonly causes
the band to get tight.
source: visiblebody & core concepts
Musculoskeletal Consumer Review Volume 2009:1 

Lumbar Spinal Stenosis
L
umbar spine stenosis is a condition
where the space in the lower spinal canal
narrows. The spinal canal houses the
spinal cord along the back. Narrowing of this
space causes pain, numbness to weakness in
the legs in more serious cases. In extreme cases,
loss of bladder and bowel control. This condition
typically affects adults over the age of 50.
Compression of the spinal cord
The pain symptoms result from the spinal cord
being compressed by the narrowing spinal
canal. Depending on the amount of pressure on
the spinal cord, the symptoms varies. Beginning
from mild pain when there is some compression
to weakness in the leg when there is so much
pressure that signals sent to the leg muscles
are cut off. In some cases, compression of the
nerves of the lumbar spinal cord can cause loss
of bladder, bowel and sexual functions.
People with lumbar stenosis find a bent forward
position while walking, sitting down or squatting
helps relieve the pain. This position relieves
some of the pressure by decompressing the
compressed area. Bending backwards on the
other hand increases the pain.
Why does the spinal canal
narrows?
In most case, the spinal canal narrows as a
result of degenerative changes in the lower back
vertebrae as we age. The degenerative process
causes excessive bone growth (osteophytes),
ligament enlargement (ligamenteous
hypertrophy), or loss of spinal disc height.
This is the main reason why lumbar stenosis
10 Musculoskeletal Consumer Review Volume 2009:1
THERAPY AT HOME
FOR STROKE AND
NEUROLOGICAL CONDITIONS
most commonly seen in adults over the age of
50.
What are the treatment options?
In severe cases where there is weakness in
the lower limbs or loss of bladder and bowel
functions, surgery is an option to immediately
relieve the pressure off the nerves.
In milder cases or immediately post-surgery,
rehabilitative treatment is recommended to
improve posture and strength of the muscles
around the lower back and abdominal region.
This helps reduce the amount of compression on
the spinal cord in the lower back area.
N
ote that even after surgery, treatment and
continued self-management through
exercises is important as degeneration,
the primary cause, continues. As we continue
to age, we continue to get more excessive bone
growth, our ligaments enlarge and our spinal
disc continues to lose their height.
Spinal Stenosis
Spinal Stenosis occurs when the spinal canal spaces
narrows, and the spinal cord gets compressed.
Spinal cord
Spinal canal space
(blue areas)
(dark brown region)
Narrowed space Cerebral Care
pressing on the (an associate company of Core Concepts)
spinal cord
Tel: 6226 3632
Fax: 6226 3571
source: debivort and core concepts
www.CerebralCare.com.sg
enquiry@cerebralcare.com.sg

What is Sciatica?
T
he sciatic nerve is the largest and longest
nerve in the body with a diameter of
almost 2cm. It starts from the sacral
plexus, a network of nerves in the pelvis region,
branching out down into each of the legs.
The sciatic nerve carries out two basic functions,
namely motor (movement) functions and
sensory (feeling) functions. When the nerve is
compressed, the symptoms are called sciatica.
Aside from sharp shooting pain, symptoms such
as loss of reflexes, weakness and numbness are
often present when both its motor and sensory
functions are imparied.
What Causes Sciatica?
One common cause of sciatica is a herniated disc
or “slipped disc”. The herniated disc protrudes
and places pressure on the nerve root which
connects to the sciatic nerve.
As the longest nerve in the body, there are ample
opportunities for the nerve to be compressed.
They include:
1. Piriformis Syndrome is pain caused by the
piriformis muscle that may be in inflamed,
or irritated. This muscle is in your buttock
and lies right on top of the sciatic nerve as
it exits the spine and goes down your leg.
When inflamed or irritated, this muscle
swells and applies pressure on the nerve
giving you the sciatica like symptoms.
2. Spinal Stenosis, which is the narrowing
of the spinal canal can cause sciatica-like
symptoms. The narrowing can be caused
by disc problems as well as arthritis of the
spine.
12 Musculoskeletal Consumer Review Volume 2009:1
Sciatica-like symptoms may also be caused by
other than compression on the sciatic nerve such
as.
1. Sacroiliitis is an inflammation of your
sacroiliac joint, where your hip meets the
spine. Inflammation caused by trauma
or arthritis can give you sciatica-like
symptoms.
2. Lumbar Facet Joint Syndrome is pain that
comes from the joints of your back causing
not only back discomfort, but also it can
give you sciatica-like symptoms. The facet
joint, like any other joint of your body, such
as the knee or elbow, can get inflamed and
cause pain.
3. Iliolumbar Syndrome is simply inflamma-
tion or a tear of the Iliolumbar ligament.
This ligament extends from the spine to the
iliac crest, which is the back of your pelvis.
Your doctor or physiotherapists can perform one
or more movement tests to determine the exact
cause of your symptoms.
What Are The Symptoms?
One or more of the following sensations may
occur as a result of sciatica:
1. Pain in the rear or leg that is worse when
sitting.
2. Burning or tingling down the leg
3. Weakness, numbness or difficulty moving
the leg or foot
. A constant pain on one side of the rear
5. A shooting pain that makes it difficult to both the
stand up pressure and
inflammation
If severe pain symptoms occur along with may be
bowel or bladder control problems, consider warranted
this as an emergency and is to be evaluated as if the sciatic Sciatic
soon as possible by a neurologist or orthopaedic nerve pain is Nerve
specialist. severe and
has not been
relieved with
Treatment
appropr iate
manual or
As nerve pain is caused by a combination of m e d i c a l
pressure and inflammation on the nerve root,
treatments.
and treatment is centered on relieving both of
these factors: When sciatica has
resolved, the patient
1. Manual treatments for sciatica including
should maintain
physiotherapy treatments such as
optimum conditions
mobilisation and manipulation to help
for their spine. The
relieve the pressure and inflammation with
fact that the spine
electrophysical agents. has had a prolapse,
and is not normal,
2. Medical treatments for sciatica (such
does not preclude a relatively normal lifestyle.
as NSAID’s, oral steroids, or epidural
Specific exercises such as core stability exercises
steroid injections) to help relieve the
to maintain flexibility and strengthen the
inflammation.
abdominal and spinal muscles are important.
3. Surgery for sciatica (such as microdiscectomy
or lumbar laminectomy) to help relieve
Choosing the Right Knee Support
. . . continued from page 4
recommended for athletes who have recovered
from ligament injuries and are just starting to go
damage that has been repaired to increase back to sports but still have a slight fear. Gives
stability and to protect the ligament. This is the athletes a fair amount of support.
ONLY type of support that should be worn every
waking hour until advised to remove either by
your surgeon or physiotherapist. This support Patellar tendon support
however is not allowed for most sports due to the
metal parts of the support. Commonly for people who complain of pain
over the patellar tendon on running or jumping.
Purpose of this support is to compress the patellar
Adjustable Stabilizing Knee Support
tendon to dissipate the strain to across the whole
tendon and thus decreases pain.
This type of knee support would be suitable for
sports if there is no metal support. Normally
Musculoskeletal Consumer Review Volume 2009:1 13
 Prolapsed Disc
Stretched Spinal Disc
Herniated Disc or ‘Slipped’ Disc At this stage, the bulge is
very prominent and the
soft jelly centre has spilled When a disc is stretched in one direction for a prolonged period, the tough
out to the inner edge of the fibres of the disc become overstretched and the disc does not return fully
outer fibres, barely held to its previous shape. Imagine the disc between two vertebras is like a
in by the remaining disc balloon sandwich.
Even Pressure
fibres. Balloon
No Pressure bulges
evenly all
round

A
herniated disc is known by many names, instead of air. Now, instead of squeezing the
Herniated Disc or
bulging disc, compressed disc, herniated balloon down evenly on both side, squeeze down Extrusion
intervertebral disc, herniated nucleus the sandwich at just one end. The balloon should
Herniation is a term to mean
pulposus, prolapsed disc, ruptured disc and, expand out at the other end of the sandwich. If
protrusion. In the case of a
perhaps the most inaccurate of all, slipped disc. It this position is held for long time, the balloon
herniated spinal disc, the Prolonged
is one of the better known spinal conditions and will becoming permanently stretched at one end. Uneven Pressure
soft jelly has completely
yet few know what it truly means. Let us that a When you let go of the sandwich, the balloon Balloon
spilled out of the disc and bulges
look at the structure of the disc and understand end will not shrink back fully but will remainly After pressure is
now protruding out of the at one side
what happens when a disc is said to herniate. slightly loose. The more often you stretch it and removed, the
disc fibres. balloon shrinks
the longer you hold the stretch, the looser is gets back to its smaller
over time. The jelly center bounces back but shape. But the

Structure of a disc
A spinal or inter-vertabral disc sits between two
spinal vertebrae. It acts mainly as a cushion to
take up the pressure off the spine. Most people
imagine the disc as a rubber disc with a soft-
jelly centre, much like a jelly donut. It is perhaps
more accurate to imagine a ball of jelly wrapped
around with a string over and over again until
the jelly ball is completely covered. So instead of
a solid rubber material, the soft center is actually
covered by a ring of tough string or fibres. This
ring of fibre is known as the outer annulus
fibrosus, which surrounds the inner ball of jelly,
nucleus pulposus.
How the disc works
Imagine that you have blown up a small red
balloon and ’sandwiched’ it between two slices
of bread. When you squeeze the slices of bread
together, the balloon resists the squeeze and
expands out of the side of the sandwich. Your
disc works in exactly the same way, only that the
disc’s wall is much thicker and has a jelly center
the tougher surrouding fibres won’t. If they are
over-stretched, they either break or remaining
stretched.
Stages of disc herniation
Like the balloon sandwich, the disc doesn’t burst
immediately unless squeezed extremely hard.
Instead it will get stretched gradually over time.
More accurately, each disc fibre gets stretched
over time. So it is a gradual process happening
over each fibre at a time. It is rarely a sudden
process. You don’t wake up one morning to find
a bulging disc when the disc was perfectly fine
the day before.
Bulging Disc
At this early stage, the disc is stretched and
doesn’t completely return to its normal shape
when pressure is relieved. It retains a slight bulge
at one side of the disc. Some of the inner disc
fibres could be torn and the soft jelly (nucleus
pulposus) is spiling outwards into the disc fibres
but not out of the disc.
Sequestered Disc
Here some of the jelly
material is breaking off
away from the disc into the surrounding area.
Can discs heal?
Unfortunately, a damaged disc cannot heal itself.
It has little blood supply (only at the flat top and
bottom of the disc) and the disc tissues cannot
regenerate themselves. Once the disc fibres are
stretched, it is currently not possible to un-stretch
back to their original state.
Is there pain?
There are few nerve endings in the spinal discs,
mainly in the edge of the disc facing out from
your back. So there is often little or no direct pain
felt from a degenerating, bulging or herniated
disc.
earlier over-
stretched bulging
side is a little
wrinkled
Pain felt from a herniated disc is more often
caused by the disc or its soft jelly core pressing
on its surrouding tissues which have more nerve
endings. So it is possible to have a herniated disc
and yet experience no pain if the herniated disc
does not pressed against any nerves
Another source of pain is when the disc first
herniates, the nucleous pulposus reacts with the
blood supply surrounding the disc to produce
chemicals that can also irritate to the surrouding
tissue causing inflammation.
Reference:
1. P. Prithvi Raj MD, FIPP, ABIPP (2008)
Intervertebral Disc: Anatomy-Physiology-
Pathophysiology-Treatment , Pain Practice 8
(1) , 18–44 doi:10.1111/j.1533-2500.2007.00171.
x
2. Medline Plus, http://www.nlm.nih.gov/

14 Musculoskeletal Consumer Review Volume 2009:1 Musculoskeletal Consumer Review Volume 2009:1 15
Repetitive Strain Injuries - Are you
a victim of it?
R
epetitive Strain Injuries is really a blanket
name for health problems that result
from over-use or misuse of muscles,
tendons, and nerves. Unlike strains and sprains,
which occurs from a single incident, RSIs develop
over time. Therefore, repetitive strain injuries are
also called Cumulative Trauma Disorders (CTD).
Other names include repetitive stress syndrome,
occupational overuse syndrome and repetitive
motion disorders.
RSIs are the most common form of occupational
(workplace) illness; some so crippling that
sufferers may require surgery or face permanent
disability. Though RSI is not localized to any one
type of job, the odds are higher for occupations
that involve repetitive work, such as, working
at the assembly line, food processing jobs, or
at visual display terminals. It can take years to
develop and therefore tend to strike when the
worker is in his prime of career usually around
the age of 40.
Occupation-related RSIs are caused by any
combination of the following factors (see
“Occupation-related RSIs Risk Factors”).
What are the signs & symptoms
of RSI?
RSIs can affect almost any part of the body,
but they often occur in upper body. The most
commonly affected body parts are the fingers,
hands, wrists, elbows, arms, shoulders, back, and
neck. One or more of the symptoms below may
be present in the injured area:
16 Musculoskeletal Consumer Review Volume 2009:1
• Meat packer • Hand-arm vibration syndrome, also known
as Raynaud’s Phenomenon
RSI symptoms can be mild, but they can also
become so severe till activities of daily living Disorder of blood vessels, usually in fingers
become difficult to perform, including turning or hands, which causes the affected area to
taps, opening a jar or getting dressed. lose color and feel cold or painful.
• Thoracic outlet syndrome, a neurovascular
• Tenderness What are the most common RSIs? disorder
Compression of the nerves and blood vessels
• Swelling There are many repetitive strain injuries,
in the shoulder, causing numbness in the
because many different parts of the body can be
fingers and weakening of the pulse. It can
• Aching affected. However, most job-related repetitive
cause pain anywhere between the shoulder
strain injuries affect the upper part of the body-
and the tips of the fingers. It results from the
• Electricity-like tingling and/or numbness the spinal column, neck, shoulders, arms and
compression of blood vessels from activities
Loss of joint movement hands.
that pull the shoulder back and down, such
• Weakness and decreased coordination of • De Quervain’s syndrome also known as as carrying heavy bag packs and constant
the injured body part washerwoman’s sprain, radial styloid overhead motions such as stacking dishes
tenosynovitis or supplies.
• Crackling
Inflammation of the tendons in the wrist
• Muscle spasms that control the thumb.
Resources
Symptoms may occur at any time i.e. during work, • Subacromial bursitis, also known as
immediately after work, or even many hours (or shoulder impingement syndrome 1. International Labour Organization.
days) after work. Typically, one first experience Listening to our pain. Preventing workplace
symptoms when he is not working. For example, Occurs as a result of the subacromial injuries and illnesses through ergonomics.
an injured worker may have no pain at work bursa ( a fluid-filled sac) being squashed World of Work. No. 21, September/October
and wake up in the night with a painful neck or or ‘impinged’ between the rotator cuff 1997
arm. muscles (Supraspinatus, Subscapularis,
Infraspinatus and Teres Minor) and the 2. National Education Association. Repetitive
Jobs that pose a particularly high risk of RSI are: collarbone, during repeated overhead Stress Injuries Handbook –Education
shoulder movements. Support Professionals. Website: http://www.
• Assembly line worker nea.org/esphome/nearesources/repstress-
• Carpal tunnel syndrome (CTS) part3.html
• Checkout scanner
Results when the median nerve in the wrist 3. New York Committee for Occupational
• Computer keyboard operator is compressed between tendon and the bone, Safety and Health. Repetitive Stress Injuries
leading to inflammation. Sufferers usually Website:
• Food handler
experience numbness, tingling and pain
in the thumb, index finger, middle finger . ht t p:// w w w. nyc o s h .or g / work pl ac e _
• Garment worker
and inner side of ring finger. CTS typically hazards/ PhysicalHazards/rsi.html
• Hand tool operator affects people who overuse their hands on
piano or computer keyboards, giving rise to
• Machine operator injuries to hand and wrist.
• Materials handler
Musculoskeletal Consumer Review Volume 2009:1 17
 Occupation-related RSIs Risk Factors

Risk Factor Explanation

EToNI
1. Repetition Doing the same motion over & over without allowing
your body to rest & recover from the stress and strain.

2. Awkward or fixed Working in awkward positions i.e. repeated overhead

posture motions; reaching down and behind your body; lifting &
twisting; or stay in a fixed/ sustained position for a long
time.

3. Fast pace Having to work quickly.

. Forceful movements
Using a lot of effort & strength to do the job i.e. lifting,
pulling, pushing and even small movements like
For Pregnant
Women with
pounding fingers on keyboard.

5. Frequent & difficult In a badly designed job, lifting even 10kg can cause
lifting injuries. Loads over 30kg are always dangerous for one

6. Excessive Vibration
person to lift.

Usually caused by power tools i.e. drills.

Musculoskeletal
7. Insufficient recovery
time
Inadequate rest breaks.
Pains
www.Etonia.com.sg
Neck-Related Headaches
. . . continued from page 2

the MAITLAND technique or with the clients’
active movement with the MULLIGAN SNAG
technique. If the joints remain stiff even after a
few sessions of mobilization, MANIPULATION
can be applied. Once the ideal mobility has been
achieved, the client will be expected to maintain
it by self mobilization with a strap.
Once the mobility is improved, the headache will
be resolved. The client can remain pain free for
a long time provided the original cause of poor
posture is solved. Good ergonomics here is
paramount..

18 Musculoskeletal Consumer Review Volume 2009:1 Musculoskeletal Consumer Review Volume 2009:1 19

Repetitive Strain Injuries -
Prevention and Management
I
n the previous article, Repetitive Strain
Injuries - Are you a victim of it?, we
highlighted that repetitive strain injuries
(RSIs) are mostly occupation related, but such
oversue injuries can be caused by activities
outside of work, such as sports and hobbies,
including badminton, tennis, golf or playing a
musical instrument.
Furthermore, older workers are more prone
to RSIs because the body’s ability to repair the
effects of wear and tear decreases with age.
RSIs are mostly caused by job demands and
workplace conditions. If the conditions and
demands of a job causes RSIs, they can be corrected
by using ‘Ergonomics’, the science of matching
jobs, systems, product and environments to the
physical and mental abilities and the limitations
of workers, instead of making the worker fit
the job. Prevention of RSIs is possible if either
ergonomical changes can be made to accomodate
the worker, by changing the physical set-up of
the workstation or he position or way one does
his tasks, or both.
The following are ergonomically friendly
suggestions to avoid RSIs.
1. Avoid Repetitive Work
Muscles work by contracting and relaxing,
stretching your tendons in the process.
Repeated stretching and pulling can cause
the tendon to swell and get sore. If the
muscles and tendons do not get enough
time for rest and recovery, the risk of injury
is increased. This is because as muscles
get tired from doing the same motion
20 Musculoskeletal Consumer Review Volume 2009:1
repeatedly, more effort is exerted to do the
job.
Remedy
Rest the muscles doing most of the work to
prevent tiredness. Take frequent “micro”
breaks, in which you use different muscles
to do the task or pause for a few seconds.
This relieves your muscles more effectively
than uninterrupted periods of work with
only one or two long rest breaks.
2. Avoid Awkward and Static Postures
A “neutral” body position is the most
comfortable working posture, in which the
shoulders are downswards and relaxed,
with the arms close by your sides, elbows
bent with your wrists and hands straight.
Deviating from the neutral posture will
increase the stress on joints, muscles,
tendons, nerves, and blood vessels. For
instance, if you work bent over and leaning
forward, with your arms above shoulder
level in a “fixed” or “static” posture, you are
likely to stress the lower back and shoulders.
Such static activities are very tiring and
stressful, and can potenially speed up the
wear and tear of your back and shoulders.
Remedy
Move around and change your posture
often. Take “micro” breaks. If you have been
bending or kneeling, switch to other tasks
to rest your back and knees. Also, using
the right tool for your tasks can reduce
Musculoskeletal Consumer Review Volume 2009:1 21
awkward postures. For example, using
an Allen key instead of a screwdriver can
reduce twisting and bending of your wrist
at awkward angles.
In addition, minimize static postures that
are “out of neutral” as these put further
stresses on your body. For example:
» Work tables, chairs and countertops
should be designed to eliminate frequent
bending and extended bending and
leaning
» Organize work tables so that materials
are within easy reach
» Keep arms and elbows low and close
to your body while working and reach
without stretching and straining
» Keep reaches below shoulder level
» Avoid stacking materials above shoulder
height
» Keep your elbows at the height of the
work counter
» Support your forearms with armrests or
other padded surfaces
» Have enough room in work area to use
your arms while keeping your wrists
straight
3. Avoid Prolonged Standing
Standing in one position for a long period
of time can put stress on your spine, back
muscles and legs.
Remedy
The stress caused by prolonged standing
can be reduced by:
» Using foot rests, to alternate the weight
bearing foot by shifting your weight
often
» Stand with knees slightly bent to prevent
locking, and thus relieving stress in the
knees
» Take “micro” breaks; general rule is a
5-minute break for every 45-60 minutes
of standing. Take this opportunity to
change positions or move around
4. Reduce the Amount of Force You Use
Using a lot of effort & strength to do the
job, even small movements like pounding
fingers on keyboard will increase the stress
your body takes. Forceful movements such
as pushing, pulling, tugging, and sliding
objects put strain on your lower back. They
also stress the muscles, tendons, and joints
of your shoulders, arms, upper back, and
legs. The more force you use, the more you
risk fatigue and injury.
Remedy
» When moving a heavy object, use trolley,
carts or equipment designed for pushing
instead of pulling. Pulling stresses
your shoulders and arms compared to
pushing. This is because when you push,
your body weight is being used to an
advantage.
» Avoid pushing or pulling in an awkward
posture as more force is required to
move the object. Similarly, avoid pushing
or pulling an object above shoulder
height or below waist height. Modify
your position to optimize your working
position and strength.
» Look out for large amounts of friction
between the surface and the object as this
increases the force used. Put a medium
 between the two to reduce the friction
i.e. wheels or sliding board.
5. Be Careful How you Lift
Faulty lifting techniques stress the back
muscles, tendons, ligaments and spine.
Even if the load is mildly heavy (less than
10kg), improper lifting can cause serious
back injuries.
Remedy
The key to proper lifting is to keep the back
in its natural position. Squat lifts put less
stress on your back, but only if you can fit
the object between your knees. Otherwise,
attempt to fit the object as close to your
body as you can. The best solution is to
reduce the size and weight of the load and
make repeated trips. Here are some tips for
a safer lifting procedure:
» Stand close to load with feet apart
» Tighten stomach muscles and tuck in
bottom
» Arch your lower back inward by pulling
shoulders back and sticking out your
chest, keeping spine in neutral position
» Keeping spine upright, bend knees or
squat down
» Face load directly. Do not twist your
shoulders to reach the load. Bring object
close to the body. The closer the load
to the body, the less pressure it puts on
your back
» Use stronger thigh muscles rather than
smaller muscles of the back for the lift
» Never pick up a load unless both feet are
firmly on the ground, and the load is no
higher than your shoulders. Minimize
22 Musculoskeletal Consumer Review Volume 2009:1
long reaches and avoid fast, jerky
movements
6. Design Computer Workstations to Fit You
Workstations must consider a worker’s
ability to comfortably see and handle the
work. Chairs with adjustable features
and proper back support are essential to
prevent injury and improve overall comfort
and work performance. For example, the
differences in chair height can affect the
whole body.
If the chair is too high, it can:
» Press thighs against the table
» Press seat against back of thigh
» Reduce blood flow to the feet
» Make wrists bend up
» Force the head to lean forward and look
down
» If the chair is too low, it can:
» Raise knees higher than hips and
encourage slouching
» Raise shoulders and arms causing stress
and fatigue especially if the table is at
chest level.
Remedy
A good chair should have:
» Adjustable seat heights and depth
» Backrest that is adjustable for the height
(up/down) and angle (forward/backward)
to help support the lower back
Shin Splints from the Periosteum
H
ave you had pain in your shin that splints actually come from the bone in most cases;
does not go away with rest? Runners or more accurately, from the periosteum, a thin
most often complain of shin splints sheath that covers all bones whose function is to
especially those that run often on hard surfaces, be provide nourishment to the bones. This sheath
a common enough situation here in Singapore. is rich in nerve endings, so it feels pain. When the
Unlike other injuries where you feel pain at the periosteum is over-strained and irritated, it gets
muscle, ligaments or joints, the pain from shin
Occupation-related RSIs Risk Factors
Causes Of Shin Splints Because
1. Pronation of your foot When the foot over-pronates (over rotate), the foot
arch pushes almost entirely off the big toe, straining the big
toe and the outside of the shin. When under-pronating,
too much weight is borne by the outside edge of the foot,
again straining the shin
2. Tightness of your calf A tight muscle cannot help absorb shock well. When taut, it
muscles transmits forces directly through to the connecting bone.
3. Running with shoes The leg has to absorb whatever leftover forces the shoe fails
with a lack of support absorb from each footfall. These leftover forces strain the
or cushioning muscles and connective tissues such as the periosteum.
. Running on hard When the running surface does not give, more shock is
surfaces ‘reflected’ back to the runner.
5. Poor running The human body absorbs and dissipates forces through
biomechanics its skeletal and muscular systems. When this system
does not function well through irregular running gait
or a mal- functioning component such as a tight calf
muscle, other parts of the system has to compensate and
becomes over loaded over time.
Table 1: Common Causes of Shins Splints
Musculoskeletal Consumer Review Volume 2009:1 23

inflamed causing pain. In the case of shin splints,
it is the sheath covering the tibia.
What pulls at the periosteum?
Most of the muscles in thecalf, ankle and foot
attach directly to the shinbone. When these
Occupation-related RSIs Risk Factors
muscles do not work well or work too forcefully,
it strains the periosteum covering the shinbone. Cause Treatment Solution
See table 1 for causes of shin splints.
1. Pronation of your foot An arch support or shock-absorbing insole is highly
Repeated strain onto the periosteum will lead to arch recommended.
the inflammation, causing the pain.
2. Tightness of your calf Sports massage to release the tight muscle.
muscles

3. Running with shoes Get properly fitted with the right shoes. If unsure, a

Bone Cross-Section
with a lack of support podiatrist, kinesiologist or sports physiotherapist can help
or cushioning you choose.

. Running on hard Run on softer surface

surfaces
Periosteum, a thin sheath of dense fibrous connective
tissue. It contains osteoprogenitor cells that grows and 5. Poor running A rehabilitation program which includes stretching
Dense Bone Matter Bone Marrow heals bone.
biomechanics your tight muscles, strengthening of muscles to correct
muscle imbalance and correction of biomechanical
abnormality in your running gait

Table 2: Shin Splint Treatment Options

Treating Shin Splints
The best way to treat shin splint is to remember
RICER (Rest, Ice, Compression, Elevation, and
Referral). Completely rest and ice the painful
region immediately when pain is first felt.
Compress and elevate your leg above your heart
if there is swelling and get a medical professional
to review your condition.
See Table 2 for treatment options.
your ankle or shin to reduce the pulling force off
the periosteum.
A final word of warning, chronic compartment
syndrome can also cause shin splints, where
pressure builds up within the muscle and
restricts blood flow. This requires immediate
medical attention as restricted blood flow can
lead to nerve and muscle death. Whenever any
type of pain persist, it is always prudent to seek
proper medical advice

A course of anti-inflammatory can help decrease

your pain. A sports physiotherapist may also tape

source: stained image: flickr/akay & core concepts

24 Musculoskeletal Consumer Review Volume 2009:1 Musculoskeletal Consumer Review Volume 2009:1 25
9 Things To Take Pressure Off Your
Back
O
ur spine bear a tremendous amount of load day-in, day-out. Here are 9 simply quick things
that you can do to lighten the load and why they work.
Occupation-related RSIs Risk Factors
Pressure Relievers
1. While standing to perform ordinary
tasks like ironing or folding laundry,
keep one foot on a small stepstool,
shifting between feet occasionally
2. Don’t sit or stand in the same position
for too long. Stretch, move about or take
a short walk when you can.
3. When bending from the waist, always
use your hands to support yourself.
. Because vacuuming can take a toll on
your back, tackle rooms in chunks,
spending no more than 5 to 10 minutes
at a time doing this task.
26 Musculoskeletal Consumer Review Volume 2009:1
Why They Work
To reduce the excessive lordorsis
(inward curvature of a portion of the
spine) that some people may have
especially in standing. Particularly
those with weak abdominals. The
foot on stool will take the pelvis into
posterior pelvic tilt, hence reducing the
lordosis
Allows the different postural muscles to
have a little rest.
The spine is made of many vertebrae
stacked on top of each other, allowing
each segment to move. Therefore, our
spine is built for movement and not to be
in one position for a prolonged period of
time
Reduces torque on the lower back.
Offers the back a chance to rest after a
period of sustained bending. Muscles
can get strained and fatigue, thus
compromising the support to the
lumbar spine
Musculoskeletal Consumer Review Volume 2009:1 27
Pressure Relievers
5. Choose an office chair that offers
good back support (preferably with an
adjustable backrest, lumbar support,
armrests, and wheels) and set up your
workspace so you don’t have to do a lot
of twisting.
6. Try not to overload briefcases or
backpacks (see “Lighten your load”).
7. Make frequent stops when driving long
distances.
8. While driving, sit back in your seat,
and if your seat does not provide
sufficient support, place a rolled blanket
or some towels behind your lower back.
Try to shift your weight occasionally.
If you have cruise control, use it when
you can. Also consider using a foam
seat cushion to absorb some of the
vibration.
9. Sleep on your side if you can, and curl
your body up a bit, and if possible,
with one knee bent and the other
straightened. Also, choose a pillow that
keeps your head level with your spine;
your pillow shouldn’t prop your head
up too high or let it droop. Choose a
mattress that’s firm enough to support
your spine (so that it doesn’t sag into
the bed) and that follows your body’s
contours.
Why They Work
Allows the spine to stay in an optimal
position as you work, without having
the back muscles constantly supporting
you.
It also facilitates the neck to be aligned
properly
Reduces loading of the back muscles
and disc pressure. As the muscles
fatigue, our bodies will adopt a
rounded upper back posture to
compensate, resulting in poor posture
and associated injuries
Prevents fatigue mentally and
physically to allow some mobility in the
spine and stretch out muscles that are
placed in the shortened position as we
drive
Allows the back to be in a proper
posture.
Weight shifting offers pressure
reliefand cruise control allows the foot
to rest and not sustained effort on the
accelerator
Vibrations can cause injury to the back
The spine will be well supported when
it is in the neutral position
Manual Therapy - Spinal Vertebra
Mobilisation
O
ne physiotherapy modality is fast
becoming de rigeur in the treatment
of referred pain cause by stiff joints is
manual therapy. Today, manual therapy is the
main stay of modern physiotherapy moving away
from the dependency on Electro Therapy Agents
such as Ultrasound, Short Wave and TENS as the
primary treatment modalities.
Referred pain is a very unpleasant sensation
localised to an area separate from the site of the
causative injury or other painful stimulation.
Often, referred pain arises when a nerve is
compressed or damaged at or near its origin.
In this circumstance, the sensation of pain will
generally be felt in the territory that the nerve
serves, even though the damage originates
elsewhere.
28 Musculoskeletal Consumer Review Volume 2009:1
Manual therapy consists of a range of
interventions, including hands-on techniques
such joint mobilisation. Joint mobilisation is
thought to help maintain or improve extensibility
and tensile strength of the articular tissues,
reduce the effects of mechanical limitations,
elongate hypomobile capsular, ligamentous and
connective tissue. It also stimulates mechano-
receptors and therefore may be responsible for
inhibiting the transmission of nociceptive stimuli
and in doing so, reduce pain perception. (Kisner
and Colby 2002).
In Singapore, there are two common concepts of
manual techniques used for spinal mobilisation–
the Maitland Concept and the Mulligan
Concept.
Maitland Concepts
Maitland’s Concepts (often also referred to as
the Maitland Technique) involve the application
of passive and accessory oscillatory movements
to spinal and vertebral joints to treat pain and
stiffness of a mechanical nature. The techniques
aim to restore motions of spin, glide and roll
between joint surfaces and are graded according
to their amplitude.
• Grade I is a small amplitude movement
performed below the range of resistance
and is suitable for treating highly irritable
conditions. Use of Grade I enables the slack
in collagen to be taken up when connective
tissue is not under load and can relieve
pain by working on neural structures
(Threlkeld).
• A Grade II mobilisation is wider in amplitude
but still below resistance. Use of Grade I and
II are appropriate when palpation elicits
pain before restriction of movement.
• Grade III and IV are used when resistance
to movement is encountered before pain.
A Grade III is a large amplitude movement
performed within resistance and generally
used to improve range of motion.
• Grade IV is a small amplitude movement
performed within resistance used for
chronic aches of low irritability.
• Grade V is a high velocity thrust used in
manipulation.
Application of Maitland techniques to the
vertebrae is along an anterior-posterior axis or
transverse irrespective of the angle of the joint.
Peripheral joints are similarly treated with
Maitland techniques on planes appropriate to
the condition, usually on the plane where there
is pain or restriction. These may be anterior-
posterior, transverse or longitudinal.
Mulligan’s Concept
Maitland argues that the comparable pain
response “is nearly always found with the
unphysiological movement rather than the
physiological movement”. Conversely, Brian
Mulligan applies movement in sympathy with
physiological movement. Mulligan is guided
towards restoration of correct physiological
tracking by the absence of pain. His techniques
are designed to deal with problems of restricted
or painful movement but are not highly irritable.
These techniques are therefore used for conditions
that are not acute when the biomechanics of
the joint may be altered without inducing pain.
The appropriateness of the technique is judged
against Maitland’s criteria of severity, irritation
and nature of the condition.
Mulligan does not prescribe grades of movement
or oscillatory movements. He prescribes taking
the joint through its full range of movement
and this entails taking it into resistance. The
physiotherapist superimposes an accessory
movement onto the patient’s active physiological
Musculoskeletal Consumer Review Volume 2009:1 29
movement with the aim of over-riding the
obstruction and re-establishing correct
alignment. The accessory movement takes
the joint through what would be the normal
physiological movement of the joint. The pre-
injury joint tracking is re-established reasserting
the ‘joint memory’ or prior conditioning of the
healthy joint.
Mulligan’s principle techniques are NAGS,
SNAGS and MWMs. NAGS are Natural
Apophyseal accessory Glides applied to the
cervical spine with the patient passive. SNAGS are
Sustained Natural Apophyseal accessory Glides
whereby the patient attempts to actively move a
painful or stiff joint through its range of motion
whilst the therapist overlays an accessory glide
parallel with the treatment plane. MWMs are
Mobilisations With Movement and are applied to
the peripheral joints. The underlying principle
to MWMs is derived from Kaltenborn (1989 in
Exelby 1995) who argued that joint surfaces are
not fully congruent, physiological movements
are a combination of rotation and glide, and glide
is essential to pain free movement. Glide occurs
in the direction of bone lever movement where
its articulating surface is concave and in the
opposite direction when convex. The treatment
plane lies at a ninety-degree angle to the concave
articulating surface of the bone and treatment
is applied parallel to the treatment plane.
The anterior-posterior and posterior-anterior
movements used in Maitland’s techniques follow
the same planes in peripheral joints.
However, in treating the spine Maitland will
follow the planes of the intervertebral body joints
whilst Mulligan techniques follow the plane of
the zygapophyseal joints.
Exelby argues that the zygapopheseal joints
guide the spine and so improving their glide by
applying NAGs and SNAGs will improve the
range of spinal movement. Applying treatment
on the plane of the intervertebral body joints
results in compression on the zygapopheseal
joints and will not promote glide.
 Shoulder and Knee
Rehabilitation Specialists
www.Back2Sportsr.com.sg