Clearing the confusion around arthritis

As a physiotherapist, I am always explaining the differences between osteo and rheumatoid arthritis. There is a common misconception that they are the same disease, however, they are very different.

When reading through X-Ray or MRI reports together with my patients, this discussion about the differing arthritis conditions typically arises. These scan reports speak of ‘degenerative changes’, ‘bony spurring’, ‘osteophytes’, and ‘osteoarthrosis.’ These words all sound a little scary, don’t they? However, it is often said that if each person over 40 were scanned from head to toe, there would be these changes in every one of these people in at least one of their joints. It really is a natural part of aging and shouldn’t be viewed as a catastrophe!

Practitioners, doctors and those with these X-ray changes should really look to the associated symptoms felt at these affected joints (if there are even any?) before rushing to blaming these findings as the cause of pain and dysfunction. Often investigations such as scans like these can show the presence of ‘degenerative changes’ but without any associated pain or other symptom. Scans really should be read and used with caution for this very reason.

Let’s look in more depth at the main characteristics of osteoarthritis (OA) this month. In our next newsletter, we will explore rheumatoid arthritis (RA).

The 5 features of osteoarthritis.

• OA is the most prevalent type of arthritis with a report from the Australian government from December 2015 reporting that self-reported OA is as high as 1 in 13 Australians. Of these, every 2 in 3 are female. It is not at all common in children and comes with ages over 40.

• OA is also known as the ‘wear and tear’ arthritis or degenerative joint disease. It is mostly found in the fingers, thumb, big toe, lumbar spine, hips and knees. It is most painful and symptomatic in the hips and knees. When someone is off to have their knee and/or hip joint replaced, they are typically receiving new stainless steel or titanium joints to replace their old worn out ones from the degenerative process of OA. The before mentioned Australian government report states that there was a 32% rise in total knee replacements from 2004 to 2014.

• OA is caused by the slow breakdown or erosion of the cartilage which lines our joints. This cartilage acts as a cushioning between the 2 bones making up a joint. The cartilage allows for the smooth sliding of one joint surface over the other as we move and can absorb impact and pressures like a shock absorber. If a joint is used too much or has excessive loading such as with some repetitive movements of sport or from carrying too much weight, the watery composure of the cartilage breaks down almost to the point of bone rubbing on bone. This stimulates the body to respond, changing the affected joint’s muscle and bone. This is where thickening of the soft tissue or the growth of bone spurs will occur.

• Bone spurs- also called osteophytes- are the body’s clever response to the bone on bone abnormality of an affected arthritic joint. The exposed bone within the joint can become inflamed and this stimulates further bone to grow around the edges of the joint. It can be thought of as the body trying to increase the surface area of the joint to spread the pressures and stresses across a greater area. Unfortunately, some osteophytes can cause problems, but this is not a blanket norm. In some joints such as the small facet joints on the spine, bony spurring can restrict the space of a nerve canal, causing possible irritation of the nerve. Another problematic spurring of bone can be at the big toe. Generally bone spurs themselves are not problematic, but they are a signal of an underlying problem that often needs to be addressed. They can be documented to help assess the severity of a condition such as arthritis.

• OA is characterised by stiffness and limited movement in the affected joint. Initially, pain is felt after activity and settles with rest. There may be some stiffness in the morning, but this is mild and lasts less than 30 minutes. As the OA worsens, the joint may become enlarged and tender due to bony spurring. Tis can affect pain free movement and alter the mechanics of good movement across the region, making everyday activities such as walking difficult.

How can exercise like Pilates assist with pain associated with osteoarthritis?

As OA is a ‘wear and tear’ disease that is associated with aging, often is cannot be helped. However, its progression or severity can be altered with a few practices.

Exercise is a well documented management for those suffering from OA. This is a broad statement and to dissect it a little is time well spent. Here are some points to consider:

• OA needs the right balance between exercise and rest. Too much of the wrong exercise can load up the affected joints more and cause increases in pain and stiffness. Too much rest and no exercise makes the joints also stiffen and the muscles around to weaken.
• All joints in the human body require synovial fluid and lubrication to stay mobile. This fluid will be secreted by the cells in your joint with the response to movement. So, move it, or lose it ( as they say)!
• Too much heavy weight bearing exercise such as jogging, jumping, lifting can over load already painful eroded joints. Preventing repetitive joint loading tasks where possible, including kneeling, squatting or heavy lifting
• Muscular support and strength about the OA joints will make will offer support and shock absorption that would otherwise be transmitted into the painful joint. Good muscle condition is paramount.
• Exercise will assist in keeping weight controlled and down. There is nothing less a knee, hip or spine likes than carrying about too much weight. Ow!

Confused?

So, for those of you with OA or any painful joint, you need to move, strengthen your muscles but without repetitive excessive loading on your sore joints.

There is still so much choice for you to keep up the exercise. Why not try:

• Pilates? Controlled, weighted exercise without the repetitive pounding on your joints. And on top of that, improving posture and mindfulness to keep your painful joints well aligned. Well aligned joints will be happy loaded joints.
• Swimming or aqua-aerobics? Resisted exercise in the pool without the effects of gravity stressing your joints. You’d be surprised with the workout you get with some of the props and equipment that gets used in the pool for these classes.
• Weights and cardio equipment? A targeted weights program can really build your muscle strength. Speak with a physio about guiding you through the best exercises for your OA. Your physio can work with a trainer to help your program become established without the flare-up of your pain.

Feel free to chat with our physio team if you need guidance and treatment for your painful joints.

Picture the cylinder that holds your spine and pelvis strong

We know that visualisation is an amazing learning tool. Picturing a concept or an idea can allow the brain to interpret or reinforce new ideas being learned. Seeing muscles and joints in the body can help you to understand the workings better. It may even have you feel the muscles working better if you can picture them activating. This can be very much so in the deep ‘core muscles’ of the lower trunk and pelvis.

This illustration above may assist you in getting your head around the muscles we are always talking about in your Fix Program classes. These muscles form a part of your body’s postural control system as you go about your day. The very same deep muscles that stop your bones from falling to bits and the cause of our many aches and pains!

In our Pilates classes, you will hear us repetitively saying:

“Breathe in deep and wide, and as you exhale, imagine gently lifting your pelvic floor ( feeling your’ pebble lift from the pond’) and become aware of the front hip bones drawing towards each other”

The ‘cylinder’ of lower trunk support

When looking at the picture above more carefully, and if using your imagination a little, you will see that the 4 sets of muscles make a cylinder-like shape. After looking at these muscles, try to picture a basic cylinder in your mind. Now place the diaphragm on top of your cylinder, the pelvic floor muscular sling on the bottom, and wrap the transverses abdominus ( deepest of the abs) around the rest. This cylinder fills the circumference of the lower half of your trunk, from the lower ribs to the base of the pelvis. Multifidis is another deep postural muscle that ‘laces up’ through the spinal vertebra and completes the picture.

Visualising this muscular cylinder can really help you to ‘find’ and activate your pelvic postural muscles better.

So, now that you can visualise your muscular cylinder, what comes next?

With the cylinder of muscles now pictured better in your brain, you may start to locate, contract and strengthen your ‘core’ even better than you thought. Why not try connecting your cylinder picture with the instructions you hear at class.

• “Breathe in deep and wide”

When looking at the diaphragm sitting at the top of cylinder under your lower rib cage, picture your diaphragm descending downward slightly into your cylinder as you breathe in ‘deep and wide.’ As you exhale the diaphragm moves upwards to its starting position.

• “As you exhale, lift you pelvic floor as you’d imagine a pebble lifting from a pond”

When picturing the diaphragm ascending as you exhale, you may see now that this creates a vacuum within the cylinder. This region of less pressure makes it easy now for your pelvic floor at the bottom of your cylinder to lift. Do you now understand why we lift the pelvic floor as we exhale? The pelvic floor and diaphragm have a direct relationship with each other. As the diaphragm ascends, so does the pelvic floor. Likewise, as the diaphragm descends as you inhale, so does the pelvic floor. This is the natural pelvic floor-diaphragm rhythm.

• “Imagine your hip bones drawing together as your deep abdominal activates”

The pelvic floor, transversus abdominus and diaphragm muscles are all interconnected through nerve and fascial (thin tissue between muscles and organs) networks. Muscles connected in this way will contract together and relax together. So, let’s now imagine the circular component of your cylinder.

While your diaphragm and pelvic floor ascend together on your exhale breath, the deep abdominal will slightly draw in, as if tightening a belt gently around the lower cylinder. This apparent tightening will be felt the full circumference of the cylinder in those very aware of their bodies, even around the sides of the waists and in towards the lower back. For others, the feeling will seem heightened at the front of the pelvis between the ‘hip bones’. The slight drawing in of the cylinder can almost have you believe these ‘hip bones’ are being gently pulled towards each other.

Putting it all together

This muscular cylinder is only the beginning of wonderful postural support for your pelvis, spine and body. These muscles work subtlely throughout your day, gently holding your spine and pelvis aligned. For maximum benefit, these muscles need to be trained ‘functionally.’ This means whilst doing other things such as moving, bending, lifting, twisting, walking, running, jumping and even sitting at your desk. There are other muscles all involved here too from upper back and shoulder muscles to spinal muscles, hip muscles and leg muscles, both deep and superficial layers.

So when involved in any of these activities above (which pretty much means all of the time when awake and conscious!), can you imagine your deep muscular cylinder at work? Sitting in there within your pelvis and lower trunk with the involved muscles on each surface all acting in a connected way?

Try it and you may be surprised at your postural alignment, endurance and movement freedom and efficiency.

March is the month to raise awareness on endometriosis

With Endometriosis Awareness Month in March coming up I thought it was timely to post to The Fix Program blog about how hands on therapy such as women’s health physiotherapy can go a long way in helping endometriosis sufferers recover. Endometriosis is characterised by pain - period pain, abdominal & pelvic pain, pain with urination and with bowel movements, and pain with sex.

When women and younger girls suffer from endometriosis, they often spend a lot of time curled up in bed during period times, and often outside of period time too. All of those cramps, spasms, inflammation and pain make the tissues in the abdominal, pelvic and back area really tight. There is also a build up of scar tissue from the endometriosis or from the surgeries to remove endometriosis. This tightness in the muscles and connective tissue (fascia) in the area can then cause further pain. The pain cycle begins, going round and round in a vicious circle of increasing pain, tightness and inflammation.

I didn’t realise that physios can help with endometriosis.

Physios are thought to only treat sports injuries or back pain. Little is known in the general arena of medicine and the general public about the wonderful role women’s health specialised physiotherapists can play in changing these women’s lives.

I’m a big fan of manual therapy and myofascial massage in this area to release scar tissue, adhesions, spasms, fascial and muscle tightness, and to restore the correct alignment of the bones, soft tissues and the pelvic and abdominal organs.

Sometimes the pelvic bones and joints are not in a neutral or appropriate alignment and this can further affect the muscles and fascia in the lower back, pelvic and hip regions. This can usually happen after surgery as often the endometriosis or scar tissue can be more one-sided within the pelvic organs. When surgery is done to remove this, one side of the pelvic tissues can scar and tighten up more and pull the joints out of alignment.

At The Fix Program we treat pelvic dysfunctions such as is seen with endometriosis with myofascial massage, muscle energy techniques and exercise to restore the pelvis, hip and spine joints back to a good neutral alignment. Often women with endometriosis have been told they have sacro-iliac joint dysfunctions in the pelvic joints, so an integrative approach of external and internal physiotherapy techniques is important for optimal results.

Endometriosis severely impacts the pelvic floor, and more often than not, women who suffer from endometriosis also suffer from a hypertonic, overactive or tight pelvic floor. If the pelvic floor muscles and fascia are tight, then they are often also very painful, leading to pain with sex. They can also make period pain worse because when the uterus contracts to expel blood, the pelvic floor muscle and fascia system will be contracting too (it’s like trying to walk with a sprained ankle). This is why a lot of women with period pain also experience vaginal pain during their periods.

What can I expect after seeing a women’s health physiotherapist for me endometriosis?

Almost every woman who walks into The Fix Program with endometriosis often has tightness or trigger points in her pelvic floor muscles, so a lot of the treatment she would have would involve internal vaginal muscle releases. Within 3 months of treatment internally and externally ( the outer muscles of the hip, buttocks, spine and abdomen), she will report less pelvic and sexual pain, better bladder and bowel control, regular bowel emptying, better digestion, and best of all, less period pain.

Periods can also become shorter, more regular, with less spotting before and after periods. Part of the reason for this is because the uterus is now aligned ‘neutrally’ from all the muscle and fascial release work around it, rather than tipping forwards or sideways. If the uterus isn’t positioned ‘neutral’ or well within the pelvis, blood can stay back in the curves rather than flowing straight down and stay there until the next period, when it comes out as dark spotting.

Next month, I will explore a nutritional approach for the management of endometriosis. In the meantime support endometriosis awareness by attending events held by Endometriosis Australia and Worldwide EndoMarch.

http://www.endometriosisaustralia.org/

http://www.marchintoyellow.org.au/

http://www.endomarchaustralia.com.au/

http://www.luminosity.org.au/