Piriformis syndrome is a painful condition involving the compression of the sciatic nerve due to tightness of the piriformis muscle.

The sciatic nerve (responsible for supplying sensory and motor function to the back of the thigh, leg and part of the foot) runs beneath, or in 15% of individuals, runs through the piriformis muscle which is located in the buttock region. When the piriformis muscle becomes tight and contracts, it can compress the sciatic nerve triggering symptoms. Pain, numbness and tingling can be felt in the buttock, back of the thigh and at times, in the calf and foot. Pain can be felt especially with activities such as prolonged standing, sitting or rising from a seated position. Furthermore, the affected muscles innervated by the sciatic nerve may also become weak which can affect other areas, including triggering low back pain.

Piriformis syndrome is most prevalent during pregnancy and those who drive for prolonged periods of time.

Massage therapy can help with piriformis syndrome by significantly reducing muscle tightness and pain, accelerating recovery and return to function.

If you have any questions about piriformis syndrome and how registered massage therapy can help, please give us a call at 416-926-0084.

Linda is a Registered Massage Therapist practicing at the Rosedale Natural Health Clinic, located one block south of Yonge and St. Clair in downtown Toronto.

If you are one of those who think running barefoot is better than wearing running shoes, this article is not for you. However for most people who engage in running or walking for exercise, recreation or sports they will need a good pair of running shoes to provide support, cushioning and help prevent repetitive strain injuries. Compared to the equipment of other sports this is not as big an investment; however running shoes typically cost $100-200. What many people do not realize though is that their shoes will wear out sooner than they think. Many experts agree that running shoes generally last 600-800 kilometers, which for many is about 6-months to a year of use. In light of this I have written the article below to give suggestions to help you get the most from your running shoes.

Basic Parts of a Stable Running Shoe

Running Shoe – parts of the shoe
It is important to understand some basics about running shoe anatomy to understand how to get the most from your shoes. As almost all runners and walkers need a stability running shoe, as opposed to a cushioning shoe, I will focus on those (see picture). The very bottom of the shoes, the outsole, is a tough rubber material that provides traction and resists wear. There are also strategically placed groves in this tough rubber to allow flexibility and promote normal foot motion. Just above the outsole is a softer material (which is often white) called the midsole. The midsole is the part of the running shoe that will absorb the impact as well as provide much of the support for the foot. These two opposing functions (cushioning and support) are usually accomplished with a dual-density system. For example, the medial side of a stability shoe, where the instep side of the midsole is, will have a darker region (usually grey). This is a firm material which prevents the arch of your feet from collapsing too quickly during walking and running. It is slightly harder material than the white area of the midsole which is softer to absorb impact in high-pressure areas. The upper part of the shoe will have solid pieces but also has areas of mesh to let the foot “breathe” and let out perspiration. It also keeps the weight of the shoes lighter. If you firmly compress the back of the shoe, known as the heel counter, you will notice the “heel cup” which is a firm piece that hugs the heel of your foot. This helps to stabilize the heel when the foot first hits the ground with each step as most runners and walkers contact the ground with the heel first before the rest of the foot. The front part of the shoe is called the toe box. There is a lot more design and technology that goes into running shoes and their materials, but these are the basics for what you need to know for this article.

Getting the most from the materials
The midsole is the arguably the most important part of the running shoe, and if you compare brands you will see that different shoe companies have tried to develop proprietary patented materials to improve the performance of the midsoles in their shoes. Realize that the outsole is quite tough and it may still look as though it’s in good shape long before the midsole is permanently compressed from use. This compression of the midsole is why running shoes usually need to be replaced. Furthermore, the midsole breaks down not only with wear, but also with time. So even though a pair of shoes you bought a year ago that has been in the closet for a year may look brand new, it will not support your foot as well as when you first bought it. Furthermore, when you see shoes on sale, you may want to ask when that model came out. It may seem like a bargain, but if it is from a few years ago, and you know you are prone to injuries, it will not support your foot as well as a more this year’s model of the shoe.

One thing I find runners are not aware of is that wet shoes do not support as well. While water is not damaging to the shoe, your feet will not have the same support in your running shoes as on a dry day. That being said, one of the worst things you can do for your shoes is put them in the dryer. The heat and banging around in the dryer is not good for them. If it is wet out try to avoid puddles if you can, and later if your shoes are wet, let them air dry.

Getting the most from the design
ignAs I alluded to earlier, the design of running shoes is for not only cushioning, but for support of the arch of the foot which helps prevent injury in the feet, legs, knees and hips. Many people falsely assume that if they are developing an injury from walking or running it is because they need more cushioning (softer shoes) to absorb impact, when they would probably be better off with a more supportive (firmer) shoe. In fact, the majority of people need a stability shoe, not a cushioning shoe. That being said, another way to help support your feet is to make sure you untie and tie the laces properly with each use. Sliding your feet in and out without ever untying the laces will stretch and/or compress the heel cup. This unneeded wear-and-tear on the heel cup will reduce its stiffness over time and therefore its ability to support the heel. Furthermore, if you ensure you tie the laces up properly (not too tight, not too loose) then the laces will pull up on the solid part of the upper on the instep which is there to maintain support of the arch of your foot.

Getting the most from the fit
A new pair of running shoes should be comfortable, should fit well, and not feel as though they need to be “broken in”. In fact, most people who are replacing an old pair of shoes will find an amazing difference in how good a new pair of shoes feels. If the shoes are uncomfortable when you first try them on – try comparing different models, sizes (length or width or both) or different brands. Do not be surprised if buying a new pair of running shoes first takes 30 minutes or longer before you find one that suits you. If you are trying stability shoes for the first time, they will feel different than cushioning shoes because they are trying to affect the way your feet move, but they should not be uncomfortable. This is where having someone (trained staff at a running shoes store or a health care professional experienced with runners/walkers) who can watch your feet while walk or run in the shoes can help. He or she can tell you if you are getting enough support for your foot type and your activity level; you can decide if the shoes fit comfortably on your feet.

So how should a pair of proper running shoes feel? It should feel secure around your heel and the top of your foot (under the laces). That will hold the shoe on your foot without sliding, which might cause blisters. If it is just a little loose in the heel you can try tying a “butterfly know” as in figure 2 which helps if the heel counter is slightly wider than the heel of your foot. Additionally there should be enough width in the toe box to be able to wiggle your toes freely when you are standing up. This space is needed for your feet to function properly. Additionally if you are going to be running in these shoes there should be about a centimeter from your longest toe to the front of the shoes when you are standing in them, or half a centimeter if the shoes are for walking. Do not be surprised if this is a full size larger than your casual or dress shoes. This length is needed as your toes may contact the front of the shoe at the end of the step just before the toes leave the ground. If a toe is contacting the front of the shoe over and over again during your exercise, it can lead to the bruised, blackened toenail (and sometimes temporary loss of a toenail!) that is often seen with long distance runners/walkers.

Getting the most from how you use them
My suggestion is to use your running shoes for just your running or walking. They are designed primarily for the forward/backward motion of these activities. If you are doing activities that involve cutting side-to-side, as in tennis or basketball, the sides of the shoes are not really designed for that kind of wear and tear. And if you only use it for your running or walking then the midsole has time (between exercise sessions) to “rebound” from the compression that has occurred from your exercise. Conversely if you spend a lot of time during the day standing around in your running shoes that adds to the compression and breakdown of the midsole over time even though you are not putting on mileage per se.

I hope you have found the above facts and suggestions helpful. The content is based on some research (there is not much research published), but most of it is from my own personal experience as a runner and experience in treating athletic injuries. I did not include a discussion of foot types and shoes types in detail as that is a whole separate topic. I will say though, that if you do not know what type of shoe is best for you, try asking for suggestions from the staff at a running shoe store (or a health care professional who works with runners and walkers) to have a look at your feet, gait and current running shoes. Finally, if you have tried new shoes and are still dealing with a walking or running injury, it is best to have a proper evaluation and treatment. Happy trails!

John-David Kato is an avid runner and practices as a chiropractor and registered exercise physiologist in the Rosedale neighborhood of dowtown Toronto.

Varicose veins are enlarged veins most commonly found in the leg and thigh, caused by collapsed valves within the veins.

Vein and arteries transport blood to and from the heart allowing for circulation in the body. Arterial blood flows from the heart to the periphery, including the legs. Venous blood flows back to the heart from the periphery. To aid with venous return, valves present within veins prevent backflow of blood allowing for efficient return to the heart. Without proper function of the valves blood may pool in the periphery (most commonly in the legs). Overtime the affected veins stretch, permanently impairing circulation.

Varicose veins affect women more often than men and is most prevalent during pregnancy, in those with sudden weight gain and in occupations requiring prolonged standing or walking (i.e. grocery clerks, wait staff, etc.). Dull, heavy, achy, tender pain in the legs and swelling in the ankles are common symptoms. Walking may become difficult and leg cramps can also occur.

Massage therapy can help with varicose veins by promoting circulation, significantly reducing pain and swelling through a variety of techniques, gentle stretches and with remedial exercises.

If you have varicose veins or varicose veins related to pregnancy, please give us a call to find out how massage can help.

Linda Jung is a Registered Massage Therapist and is a member of the Ontario Massage Therapists Association. She practices in at the Rosedale Natural Health Clinic which is located one block south of Yonge and St. Clair in the Rosedale neighbourhood of Toronto.

(The following article is for general information only and is not supposed to replace a proper examination, diagnosis or treatment.)

Plantar fasciitis is the most common painful condition of the heel, and a common cause of foot pain. It often occurs in athletes including runners and walkers, but can occur in sedentary individuals as well. The condition is named for inflammation (“-itis”) of the plantar fascia which is a fibrous membrane of connective tissue (“fascia”) on the bottom of the foot. However, this is no longer considered an inflammatory condition, but rather involves degeneration of the connective tissue. The fascia is attached from the heel bone on the bottom of the foot and continues along the whole length of the foot to the undersides of the toes (see Figure 1). It helps to support the arch at the instep of the foot especially in walking and running when the toes are extended (see figure 1).

Figure 1. Plantar fasciitis and medial arch of the foot.

Figure 1. The plantar fascia and medial arch of the foot: The grey represents the plantar fascia, which is a tough sheet of connective tissue along the bottom of the foot. Without any weight on the foot, there is a longitudinal arch (blue line) formed by the bones of the foot. When the toes extend (as in the right picture) the pull along the fascia shortens the arch. The red indicates the typical location for plantar fasciitis pain.

How does plantar fasciitis occur?
Despite the commonality of this condition the cause is still largely unknown. Some authorities consider it analogous to shin splints but rather in the heel where the fascia ends up pulling and pulling at the site where it attaches to the heel bone. However, there are a number of conditions associated with plantar fasciitis including diabetes, Paget’s disease and arthritis. Additionally, there are a number of factors that are commonly seen with plantar fasciitis in otherwise healthy people. These include a medial arch that is excessively high, called “pes cavus”, or low which is called “pes planus” or as seen with excessive “pronation” of the foot. Pronation of the foot refers to an alignment where the arch lowers and rolls inward as the front of the foot angles out towards the side (see figure 2). High arched feet have diminished ability to absorb the impact of walking/running which is thought to increase the risk of injuries. Conversely low-arched feet (overpronated) allow more stretching of the fascia and therefore pulling at the attachment site on the heel. As high arches tend to be less common than feet with a low arch, high arches are seen less commonly as a cause of plantar fasciitis.

Other factors associated with plantar fasciitis are: having one leg shorter than the other, having old shoes or shoes with inadequate support, overtraining or sudden increase in amount of exercise, tightness in certain muscle groups, and being overweight.

Figure 2: Over pronation of the foot causing plantar fasciitis

Figure 2. Overpronation of the foot: With weight on the foot, the alignment can change to overpronation. In this extreme example the arch has collapsed while the front of the foot points laterally (black arrows). This results in the leg lowering with slight rotation inwards (red arrow). From behind more of the toes are visible (green arrow) and the Achilles’ tendon bends inward (black line).

What are the symptoms of plantar fasciitis?
Usually the pain is felt at the bottom of the heel on the medial side where the fascia attaches to the heel bone (see figure 1), or to a lesser extent in the medial arch of the foot. The classic presentation is sharp pain in at the bottom of the heel during the first few steps in the morning or after the foot has been resting for a while. This pain soon starts to lessen as the person walks around, but returns later after sitting or sleep. Generally speaking there is no numbness or weakness.

Research indicates that risk factors for prolonged chronic symptoms include: waiting a prolonged period before seeking treatment, having plantar fasciitis on both sides, and being overweight.

How is plantar fasciitis examined and diagnosed?
Diagnosis is generally straightforward, but an examination must be done to rule out other possible causes of foot/heel pain (which would require different treatment) such as fracture, bursitis, and nerve entrapments that mimic plantar fasciitis. Diagnosis is based on the description of the pain and examination which should not only include the area of pain but also the biomechanics of the feet and legs. Furthermore, other factors should be explored, such as, training/exercise program, footwear, body weight, previous injuries, walking/running gait, etc.

Are special tests (like X-rays or MRI) needed?
No. The diagnosis is made based on the presentation of the symptoms and special diagnostic tests are rarely indicated. X-rays do not show the plantar fascia. With x-rays often times heel spurs (a small growth of bone) is seen in the heel with plantar fasciitis but these are generally not the cause of pain and of minimal importance to plantar fasciitis. Ultrasound imaging or magnetic resonance imaging (MRI) may show thickening of the fascia, which support the diagnosis, however, such findings do not change treatment and therefore probably not the prognosis either.

How is plantar fasciitis treated?
Conservative (non-surgical) treatment including rehabilitation and home care is successful in 90% of patients. Surgery should only be considered after 6-12 months of treatment without success. For many people ultrasound with stretching and exercises will go a long way to resolve the problem. Treatment should address any biomechanical abnormalities of the leg or foot (excessively low or high arch) and may include arch supports, changing to a more supportive pair of shoes, and/or possibly using splints at night to prevent shortening of muscles and connective tissue. Finally, the lifestyle and exercise program of the individual should be modified to allow the person to heal but still get sufficient training and help to maintain a healthy weight.

Other therapies include injection of steroids into the foot. This can help to relieve the pain but does not correct any of the contributing factors. So if an injection is used, it needs to be a part of the treatment strategies described above. Another treatment developed for plantar fasciitis is called extracorporeal shock wave treatment (ESWT). This uses pulses of sound waves to reduce pain and stimulate healing and is the same technology that is sometimes used for kidney stones. The effectiveness of this treatment, though, is still controversial. Multiple studies, including a large multi-centre study, concluded that ESWT was ineffective for chronic plantar fasciitis (Haake M et al. BMJ 2003; Bushbinder R, JAMA 2002). More research may be needed to determine the effectiveness.

In summary, plantar fasciitis is a common injury that affects both athletes and sedentary individuals. Despite it prevalence the exact cause is not fully known, but treatment should be comprehensive targeting contributing factors with in-office treatment and self management without undue delay. Research shows that by following these steps the long term prognosis is favorable in about 90% of cases.

John-David Kato is a chiropractor and clinical exercise physiologist practicing near Yonge and St Clair in downtown Toronto, Ontario. If you have plantar fasciitis, or have suffered another injury, please call the clinic at 416-926-0084.

References

1. Buchbinder R, Ptasznik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA. 2002 Sep 18;288(11):1364-72.
2. James L, Glazer JL, Brukner P. Plantar Fasciitis, Current Concepts to Expedite Healing. The Physician and Sports Medicine. 2004 Nov; 32(11)
3. Haake M, Buch M, Schoellner C, Goebel F, Vogel, M, Mueller I, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. Br J Sports Med. 2004 Aug;38(4):382.
4. Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg. 2008 Jun;16(6):338-46.
5. Singh D, Angel J, Bentley G, et al. Fortnightly review: plantar fasciitis. BMJ. 1997;315(7101):172-175
6. Toomey EP. Plantar heel pain. Foot Ankle Clin. 2009 Jun;14(2):229-45.
7. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994 Mar;15(3):97-102.

The iliotibial band (ITB) is continuous part of the connective tissue that surrounds and supports the muscles of the thigh. The ITB is a thickening of this connective tissue which runs down the side of the thigh and adds additional support to the lateral aspect of the knee. It is named for its attachments from the ilium portion of the pelvis (ilio-) to the tibia, which is the leg bone just below the knee. The ITB also has attachments to the lateral epicondyle (see picture) of the femur (thigh bone) and to the kneecap. The muscles that can pull on the ITB are: the tensor fascia lata (TFL) and the gluteus maximus muscles. Pull on the TFL by these muscles can affect movement of the hip and the knee.

Figure 1: Basic Anatomy of Right Knee and Iliotibial Band

How Iliotibial Band Friction Syndrome Occurs
When the knee is fully extended (as in standing) the ITB is in front of the lateral epicondyle. When the knee bends the ITB rubs over the lateral epicondyle of the knee at about 30˚ then ends up behind it. When this action is done repetitively the excessive friction produces an overuse injury at that lateral epicondyle. This causes pain, swelling with fluid buildup in to the space between the ITB and the femur, and over time thickening of the ITB itself.

Activities known to cause this kind of repetitive friction include cycling, skiing, hiking, and running. Curiously running speed does not seem to be a factor, however those who are susceptible to this injury are those with pre-existing biomechanical faults such as tightness of the ITB or weakness in certain muscles of the knee or lateral hip. Other factors include high weekly mileage, running along an incline (such as on a crowned road), and running downhill.

Symptoms of Iliotibial Band Friction Syndrome
Initially it may take days to weeks for symptoms to develop. Some people are mislead because a sudden increase in amount of training seems fine at first and is not initially associated the symptoms because they develop later. The initial discomfort is more diffuse on the lateral aspect of the knee and is often felt during the running just as the heel strikes the ground as the runners extends their leg. If this injury is allowed to persist with continued training then in time the initial achy symptoms will progress to more painful and sharp. People at this point readily localize the pain to the lateral femoral epicondyle or the Gerdy’s tubercle (see picture) on the tibia. They often have to stop the aggravating activity because of the pain. At this point the creaking, like rubbing a balloon, may be felt (or heard) with knee movement. Lateral hip pain from trochanteric bursitis may be associated with ITB friction syndrome because of tightness of the ITB over the hip.

Examination and Diagnosis
An examination will lead to a proper diagnosis of ITB friction syndrome. The examination is also used to rule out other causes of lateral knee pain (popliteal tendonitis, biceps femoris tendonitis, lateral meniscal tear, arthritis, back or hip problems, etc), which could be mistaken for this injury. Laboratory and imaging test such as X-ray and MRI are generally not needed and are often not helpful.

The examination should be done in shorts so that both knees are clearly visible and movement is not restricted. If the patient is a runner then it is often useful for them to bring their running shoes. The examination includes assessing not only swelling and tenderness but for proper alignment and gait. Tenderness is often located about 2 cm above the joint line of the knee. The tension and strength of the different muscles of the feet, knee and hips should then be measured to delineate any weakness or imbalances that will be addressed in treatment. During palpation “trigger points” may be found in the quadriceps muscle, the gluteus medius muscle of the buttocks or the biceps femoris muscle of the hamstrings. Often pressing on these muscles can produce pain referred to the lateral aspect of the knee.

Several orthopedic tests (special manoevres that stretch or compress different parts of the body to identify injuries) are used to assess pain and/or tightness of the ITB. Such tests include the Renne test where the patient stands on the affected leg with the knee bent to 30 degrees. A positive result is a reproduction of the pain, or an increase in tenderness. Noble’s compression test involves having the patient lying on their back with the knees bent. The doctor compresses the ITB against the lateral epicondyle while the patient extends their knee. If this does not reproduce the pain, it suggests the injury is not related to friction of the ITB. The most common test is called Ober’s test. This test is done with the patient on their side and the thigh is lowered by the doctor to see how far the ITB will stretch. It must be done properly or it can be misinterpreted, but the test helps to determine the tension in the ITB. That being said, one can still have an ITB that is not tight but still have ITB friction syndrome.

Once a diagnosis is made and other causes of pain are ruled out, then treatment can be targeted to reduce pain and inflammation, improve the function of the joints and muscles, and recommendations for a more suitable training schedule can be given.

John-David Kato is a chiropractor and clinical exercise physiologist practicing in the Rosedale neighborhood in Toronto. If you have questions about Iliotibial Band Friction Syndrome or how JD can help, please give the clinic a call at 416-926-0084.

Disclaimer: The information is provided for general knowledge only. As each person is different and other conditions cause knee pain, this information may not apply to you. If you are seeking information, advice or treatment please contact the clinic for an appointment.

If you have been to a chiropractor before, you may have heard the word “subluxation.” This word often has a lot of confusion around it because it can mean two or three different things depending on who uses it.

If you dissect the word into two to find its origins, you have “sub” and “luxation”. “Luxation” is a medical term which means “a total loss of articular contact”, in other words, a “dislocation” of a joint. “Sub” in this case means “less than”. Therefore combined the word “subluxation” means a partial loss of articular contact – the two bones of the joint are still in contact, but just not as much as normal. This condition often occurs when the muscles or the connective tissue of the joint has been torn or stretched and the joint ends up being loose.

When chiropractic was first developed, chiropractors used the word subluxation to help describe their theories. One of the main premises of Chiropractic was that the joints in the spine became misaligned, and that chiropractic treatments put the joints back into place. Here the use of the word subluxation is an extension of the original meaning of a partial loss of contact of two joint surfaces. The focus of the term, however, is that as a bone loses some of its connection to the adjacent bone it will also be “out of place”. The adjustment that chiropractors developed was intended to fix these misalignments called “subluxation”. Many chiropractors still hold the philosophy that their treatments are fixing misalignments of joints.

As things in science change and evolve so have some ideas in chiropractic. Many chiropractors believe that the joint gets stuck, or fixated, and that basically much of the benefit of adjusting these joints is the restoration of motion. The adjustments here may not look any different than before and patients’ symptoms still improve or go away, that part has not changed. However the theory of how the adjustments help the joint is different. So here when a chiropractor refers to a “subluxation” of a joint, he or she is describing the lack of motion not a change in position.

As you can see, it is easy to understand why people can become confused, even those within health care. There are three different meanings for one word. One meaning refers to “excessive motion”, one is “out of place” and one means “not enough motion”. In light of this, there are a few things you might find helpful:

• If you tell your doctor that your chiropractor said you have a subluxation in your back, realize that your medical doctor and your doctor of chiropractic may use this word with opposite meanings.
• Some chiropractors may not use the term at all because of the confusion it causes.
• Whatever the definition of the word “subluxation” the chiropractor uses; keep in mind it is a benign state. No one will ever die from a subluxation.
• X-rays are not required in the treatment of every patient. An x-ray is just a picture in time and does not show motion or the ability to move.
• If you change chiropractors, you may notice that they work and explain things differently. One may just focus on treating joint subluxations of the spine, one may treat both muscles and joints together.

Whatever the case may be, if you are unsure of what your chiropractor means, just ask, I am sure he or she would be happy to explain. As for my treatment style, I treat joint restrictions and muscles problems and give exercise prescriptions so that patients do not come in week after week for ongoing care.

]]> http://www.rosedalenaturalhealth.com/2009/11/05/confusion-about-the-word-%e2%80%9csubluxation%e2%80%9d/feed/ 0 http://www.rosedalenaturalhealth.com/2009/11/05/trigger-points-%e2%80%93-a-common-cause-of-pain/ http://www.rosedalenaturalhealth.com/2009/11/05/trigger-points-%e2%80%93-a-common-cause-of-pain/#comments Thu, 05 Nov 2009 22:09:10 +0000 admin http://www.rosedalenaturalhealth.com/?p=388 By John-David Kato
Chiropractor and Clinical Exercise Physiologist

I am often surprised at how often people have never heard of trigger points in muscles. This concept is not new [1]. These trigger points are well accepted by chiropractors, physiotherapists, registered massage therapist, sports medicine doctors, physiatrists and other medical specialists as a common cause of pain. In speaking to patients I will often hear them say “Oh, I think it is a muscle pain…” This is not necessarily always correct or the complete picture, however many people are right that the symptoms they are feeling are coming from muscles. But when I begin to explain that the pain is caused by trigger points, it is a new concept to them. I hope that this article provides some understanding of this common cause of pain people experience.

Myofascial trigger points, or trigger points, have been described as “a hyper irritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to referred pain, tenderness and autonomic phenomena.” [1]. Simply said, this describes a sensitive, often extremely painful spot, in a tight muscle or in the connective tissue that surrounds the muscle (the “fascia”). The muscle will feel “tight” and as fingertip pressure is moved along the muscle belly there is a specific point which is often so tender it can actually make the person suddenly jump. The above definition of trigger points describes interesting physiologic responses including referred symptoms, such as pain felt in an area distant to the trigger point. For example, pressure on trigger points in the muscles on the neck may reproduce a pain around the ear or eye which is a common complaint of headache sufferers. Or another example is pressure on the trigger points in the muscles in the shoulder can reproduce a sensation of pain or numbness in the fingers of that arm. In both cases the area being pressed can be very painful, but there are also symptoms in areas that are not being touched. The concept of “autonomic phenomena” refers to the discovery that often there may be changes in the activity of the autonomic nervous system (causing such things as sweating, tearing, goosebumps, etc).

Other interesting characteristics found with trigger points:

• Trigger points can sometimes be “latent” (as opposed to “active”), which means that they are present in the muscles but do not cause any symptoms unless pressure is applied to them.
• Trigger points are also said to be “electrically silent”. Normally, an electrical signal is sent through a nerve to excite a muscle. This excitation causes the muscle to contract. With a trigger point the band of taut muscle is contracted at rest even though there is no electrical signal.
• When a trigger point is pressed, a brief twitch response is often seen. This twitching is involuntary. Sometimes patients tell me they can feel it, sometimes they cannot, but they are often fascinated when I can show them.
• Trigger points cause the muscle to be weaker and to fatigue quickly.

Patients with trigger points are often misdiagnosed due to the fact that there is no clinically relevant test for trigger points, and the symptoms are often distant from the point of origin. For example a patient may be suspected to have heart disease because of chest pain when in fact the pain was referred from a trigger point in the neck or chest. Or some people have been diagnosed with a disc herniation because of pain referred into their fingers. Examples such as these and many other situations occur all the time as trigger points can form in pretty much any muscle.

So how do you prevent and treat these trigger points? You can help prevent them by following a few different steps. The best way is to engage in a stretching and strengthening program to ensure that your muscles are strong and limber. It is especially important to target stretching in those muscles which tend to get tight and strengthen those muscles which are prone to becoming weak. If done on a regular basis, this will go a long way in preventing trigger points and their symptoms. Furthermore by increasing muscle fitness (strength, endurance and flexibility) muscles are just less prone to injury. This exercise program should emphasize proper posture, proper balance of strength between opposing muscles and postural awareness as problems in any of these areas are common contributors to trigger point development. You should also be aware of activities that have contributed to the development of previous trigger points, and either try avoiding those activities or modifying them. For example spending hours looking down at a laptop computer screen (as seen with students) can cause trigger points resulting in neck pain and headaches. A suggestion would be for the student to try using a separate keyboard and prop the laptop up higher when working at a desk. This simple ergonomic change promotes better neck posture and along with further precautions including periodic mini-breaks and strengthening the core muscles of the neck will prevent symptoms without reducing productivity.

If you do suspect you have muscle pain or headaches due to trigger points, there are a number of treatments available. And the good news is that trigger points are often very responsive to care. First though you will need someone experienced to be able to find them. Usually when they are present, they occur in more than one muscle. Examination of muscles takes practice of palpation skills as well as knowledge of the common referral patterns of pain. So the examination would not only include the area you feel pain but other related areas. Furthermore it is my experience that the joints associated with the area of complaint and the areas of the trigger points need to be addressed. Treatment could then include a combination of techniques which may consist of stretching of the taut bands, massage to the muscles, mobilization or adjustment of the joints, physical therapies and instructions for self care, exercise and most importantly prevention.

Prior to beginning my Chiropractic practice in Toronto, I was the director of the Therapeutic Exercise course at the New York Chiropractic College. My master’s degree is in Exercise and Sports Science and I hold the highest level certifications in both the American College of Sports Medicine and the Canadian Society of Exercise Physiology.

1. Travell J and Simmons D, “Myofascial Pain and Dysfunction: The Trigger Point Manual,” Williams & Wilkins, Baltimore, 1983.

]]> http://www.rosedalenaturalhealth.com/2009/11/05/trigger-points-%e2%80%93-a-common-cause-of-pain/feed/ 0 http://www.rosedalenaturalhealth.com/2009/11/04/tension-headaches-and-registered-massage-therapy/ http://www.rosedalenaturalhealth.com/2009/11/04/tension-headaches-and-registered-massage-therapy/#comments Wed, 04 Nov 2009 22:53:55 +0000 admin http://www.rosedalenaturalhealth.com/?p=383 By Linda Jung RMT, BComm
Registered Massage Therapist

The majority of the population has experienced a headache in their lifetime, with tension headaches being the most prevalent. Tension-headaches are often associated with poor posture, immobility and stress.

When held in a certain position for a prolonged period of time, muscles contract and become tight. Within these muscles, trigger points, irritable nodules or “knots”, can develop. Together, they can produce local or referred pain (non-localized pain) and generate a tension headache (if the muscles of the head, neck, and shoulders are involved).

In my practice, I see many patients who have tension-headaches from tight muscles or trigger points. These patients are treated effectively with massage therapy. I work on the affected muscle(s) to enhance circulation, to reduce tension and to release the trigger point(s). By reducing muscle tension and releasing trigger points, patients report that their headaches are diminished in intensity and frequency. They also report improved sleep and a reduction in stress.

To prolong treatment effects, patients are given muscle stretches and strengthening exercises and tips on postural awareness to reduce the occurrence of their headaches. As muscles become “re-educated”, follow-up visits can significantly reduce the chances of a return tension-headache by working on those affected muscles. I also encourage patients to practice and foster good breathing habits everyday to relieve stress and muscle tension.

In addition to massage therapy for the treatment of tension headaches, I find that my patients also benefit from the integration of naturopathic and chiropractic therapies.

Keeping the body agile along with good spinal health, a healthy diet and exercise all play an integral role in improving posture, health and reducing stress. Actively addressing these can make a world of difference in overall well-being, including tension headaches.

I have been working as a registered massage therapist in Toronto for the past 4 years. I treat a multitude of conditions including tension headaches, trigger points, pre and post natal massage, and trauma and complex care (motor vehicle accidents and workplace injuries).

For more information on tension headaches, registered massage therapy, and how our team can help, please give the clinic a call at 416-926-0084.

Please check out the rest of the website for information on other services.

]]> http://www.rosedalenaturalhealth.com/2009/11/04/tension-headaches-and-registered-massage-therapy/feed/ 0 http://www.rosedalenaturalhealth.com/2009/09/24/chiropractic-care-can-help-pregnancy-related-back-and-pelvic-pain/ http://www.rosedalenaturalhealth.com/2009/09/24/chiropractic-care-can-help-pregnancy-related-back-and-pelvic-pain/#comments Thu, 24 Sep 2009 17:11:39 +0000 admin http://www.rosedalenaturalhealth.com/?p=335 By Dr John-David Kato DC, MSc, ACSM-RCEP, CSEP-CEP

Introduction
During pregnancy there are numerous changes that occur to the mother’s body. Unfortunately, some of these changes contribute to pain in the upper back, lower back and pelvis. Research estimates the prevalence of these aches and pains in pregnant women to be between 50 to 75% [1] [2] with up to 75% of women with back pain reporting never having it before pregnancy [1]. This pain can affect sleep quality as well as participation in daily activities [1] [3] [4]. Furthermore, number of women may go on to develop chronic pain lasting years[3].

Available Treatment
Despite this common complaint amongst pregnant women, quality research on treatment of pregnancy related back and pelvic pain is sparse. Many mothers-to-be prefer a natural non-pharmaceutical approach to treatment because of fears of possible serious side effects. However, most of the usual physical therapies (ultrasound, electrical stimulation, etc) are contraindicated due to the potential harm to the developing fetus [5]. Additionally, a scientific review published a few years ago of physical therapies (which involved research on mainly exercise and patient advice) concluded that there is no strong evidence to support the efficacy of these therapies for the treatment or prevention of pregnancy related low back or pelvic pain [6].

Another alternative is chiropractic care. Chiropractors often treat women during pregnancy. Intervention starts with a thorough assessment, diagnosis, and development of an individualized treatment plan. Interventions included in chiropractic care may include things such as: joint mobilization; massage; therapeutic exercise; education on ergonomics, posture & body mechanics to help adjust to the pregnancy related changes the body is undergoing; reassurance; and recommendations with regards to self-management, lifestyle, and nutrition. However the treatment for which chiropractors are best known for is manual manipulation, otherwise known as chiropractic adjustments, which are a kind of therapy directed at the joints.

A scientific review of manual manipulation published this year concluded that, although the research is still “emergent”, the evidence suggests this is a safe and effective treatment for pregnancy related low back and pelvic pain [7]. For example, one case series in this scientific review reported on seventeen pregnant women suffering from low back pain [8]. These women initially rated their pain an average of 6-out-of-10 in severity, which reduced to 1.5-out-of-10 as a result of chiropractic care. On average, it took 2 visits (range from 1-5 visits) to the chiropractor over about a 5-day duration for a significant improvement in pain. Treatment lasted up to 2 months. No adverse effects were reported by any of the women. Although this case series does not have the strength of a clinical trial and cannot be interpreted to mean that treatment for all pregnant women will follow the same course, it nonetheless provides evidence that chiropractic treatment is effective for reducing the pain of pregnancy related low back pain. Furthermore, a joint committee of the American College of Physicians and the American Pain Society recommended manipulation (again only one aspect to chiropractic care) as a scientifically-based, non-pharmaceutical treatment that is safe and effective for both acute and chronic low back pain [9].

Modifications of Treatment for Pregnant Women
Contrary to what some might think, there are no chiropractic specialties or specialists in the fields of pediatrics or obstetrics in Toronto or, for that matter, Ontario (for a list of Chiropractic specialties, please see: College of Chiropractors of Ontario Policy on Chiropractic Specialties).

However, modifications to the treatment of pregnant women with chiropractic adjustments have been published [10] [11] and a list of contraindications for the use of joint manipulation during pregnancy have also been proposed [12].

Modifications to treatment can be made depending on the findings of the assessment, the length of gestation, the size of the mother’s abdomen and her comfort level. The use of pillows can help support the larger abdomen making side-lying adjustments of the lower back comfortable. Furthermore, as the joints are often more lax, especially in the later stages of pregnancy, adjusting is done in a more gentle fashion. Joint manipulations to the lower back reduce any restrictions in motion, decrease pain and relieve muscle tightness.

Adjustments to the thoracic spine (the upper back) are often done with the pregnant mother lying on her back. This way is usually more comfortable and allows her to relax as it minimizes pressure on her abdomen and breasts as the breasts are often tender during pregnancy.

Summary
During pregnancy the majority of women experience pain in the pelvic, lower back and upper back regions. And although there is a demand for drug-free, non-invasive therapy, the research of treatment of these complaints is limited. There is, however, emerging evidence that chiropractic care, including adjustments, can safely and effectively provide relief.

Dr. Kato practices at the Rosedale Natural Health Clinic in Toronto. He regularly sees pregnant patients requiring chiropractic care.

References
1. Skaggs C, Nelson M, Prather H, Gross G. Documentation and classification of musculoskeletal pain in pregnancy. J Chiro Educ 2004;18:83–4.

2. Kristiansson P, Svardsudd K, von Schoultz B. Back pain during pregnancy: a prospective study. Spine 1996;21(6):702-9.

3. Mens JMA, Vleeming A, Stoeckart R, et al. Understanding peripartum pelvic pain: Implications of a patient survey. Spine 1996;21:1363–70.

4. Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: Prevalence, risk factors, and outcomes. Obstet Gynecol 2004;104:65–70.

5. Borg-Stein J, Dugan SA, Gruber J. Musculoskeletal aspects of pregnancy. Am J Phys Med Rehabil 2005;84:180 –92.

6. Stuge B, Hilde G, Vollestad N. Physical therapy for pregnancy related low back and pelvic pain: A systematic review. Acta Obstet Gynecol Scand 2003;82:983–90.

7. Khorsan R, Hawk C, Lisi AJ, Kizhakkeveettil A. Manipulative therapy for pregnancy and related conditions: a systematic review. Obstet Gynecol Surv. 2009 Jun;64(6):416-27.

8. Lisi AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. J Midwifery Women’s Health 2006;51:e7–e10.

9. Chou R, Huffman LH; American Pain Society; American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504.

10. Esch S, Zachman Z. Adjustive procedures for the pregnant chiropractic patient. Chiro Tech 1990;3(2):66-71.

11. Bartol K.M Considerations in adjusting women. Top Clin Chiro 1997;4(3):1-10.

12. Borggren CL. Pregnancy and chiropractic: a narrative review of the literature. J of Chiro Med 2007;6:70-4.

]]> http://www.rosedalenaturalhealth.com/2009/09/24/chiropractic-care-can-help-pregnancy-related-back-and-pelvic-pain/feed/ 0 http://www.rosedalenaturalhealth.com/2009/07/20/screening-posture-or-leg-length-with-dual-scales/ http://www.rosedalenaturalhealth.com/2009/07/20/screening-posture-or-leg-length-with-dual-scales/#comments Mon, 20 Jul 2009 22:38:55 +0000 admin http://www.rosedalenaturalhealth.com/?p=280 Dr John-David Kato DC, MSc, ACSM-RCEP, CSEP-CEP

Recently I have been asked by a few people what my opinion was about the use of dual scales for an assessment of posture. If you have never seen one of these before, it involves a portable platform with two identical scales. The person being assessed then stands with one foot placed precisely on each scale to measure the weight distribution of each foot when standing. Usually there is a rigid frame which has a kind of plumb line and adjustable wires that run horizontally. These horizontal wires are placed at landmarks on the body (eg. the shoulders) as way of evaluating posture by comparing the heights of the landmarks from one side to another.

This kind of device is not something I use in my office. To my knowledge, is not a tool taught in chiropractic colleges, at least not where I went to school in California, nor where I taught in New York. My colleagues who studied Chiropractic in Canada did not use it in school either. However, being curious to know more I searched the Pubmed database of scientific articles. I used search terms such as posture, posture assessment, dual scales, double scales, bilateral scales, weight distribution, and even the brand name of a device I have seen, but I was unable to find any recent research.

A search of a manufacturer’s website did find some interesting results. They have a monograph about the use of their dual scale equipment for assessing leg length and how that fits into their system of detecting and treating postural problems. This work is based on publications mainly on leg length inequalities (not on posture or the use of dual scales). An anatomical leg length inequality is where one leg is physically shorter than the other (for a better understanding of leg length inequalities and the different types (anatomical, functional, environmental) – see the post coming soon). In the monograph the author(s) point out that measuring leg length with a tape measure has a lot of error (which is common opinion). However their system to detect an anatomical short leg is better determined by:

• one side of the pelvis being higher (on the longer leg side)
• and if the body is shifted to one side

They propose that once you determine there is a short leg, then the information gained by the two scales can help determine if the difference in leg length is greater than or less than 6mm. They explain that a person with a leg length difference of 6mm or less tends to have more weight on the short leg, but someone with a leg length difference greater than 6mm tends to have more weight on the longer leg. They base this premise on three research studies:

• One study does not involve leg length inequality at all so its findings cannot be used to support their claim. However one thing observed in the study is the normal random postural swaying of body weight from one side to the other. This shifting of body weight actually refutes the use of dual scales as it demonstrates a person’s weight continuously changes side moment to moment.
• A second article investigated the immediate effect of standing with one foot raised by a heel lift. The authors of this study clearly warn that their results would not specifically apply to someone with an anatomically short leg. So this does not support the use of dual scales either.
• The third article noted that people with a shorter leg by 1-4 mm tend to put more weight on the shorter leg and those with a leg length difference of 6 mm or more tend to put more weight on the longer leg. However the data in the study indicate that this premise would probably be incorrect in about 1-in-3 people.

The manufacturer’s monograph does not describe their treatment program, for that you would have to buy their equipment, but they do imply treatment would include exercise and/or foot orthotics with possibly a lift to raise the shorter side. But using dual scales would not determine exactly how thick a heel lift you would need. To find that I assume you would need then you would then have to either measure each leg with a tape measure or prop the short leg up by a known amount to try to make the pelvis level which makes the use of the scales redundant.

My opinion is that the research for the dual scales is weak at best. The idea that a person with a short leg may put more weight one side does seem plausible, but there are too many other factors and very little evidence to rely on a dual scale device. Furthermore, if an anatomical leg length was suspected you would have measure the difference somehow anyway otherwise you would not know how much you would have to correct. Based on what I can tell the two scales does not add any clinical information which is probably why it is not endorsed by chiropractic colleges.

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