Medical Musings, Health Hypotheses & Therapeutic Thoughts
So, we have discussed how the poor 'design' of the knee joint means it is prone to various injuries and dysfunctions, but what does that mean in your everyday life?
Here we will consider the anatomy of the knee a bit further, and discuss some of the ways our knees can give us grief.
It is important to remember that, like most of the other joints in the body, the knee requires its neighbours to be doing a relatively good job in order to perform its own.
Dr. Edmund Bruce-Gardner
The knee is a pretty badly-designed joint. Evolution doesn't move towards perfection, but function.
As bipedal (two-legged) creatures who evolved from quadrupedal (four-legged) ones, quite a few compromises and fudges have been made.
[The shoulder is another good example. it is a heavily-modified hip (i.e. ball-and-socket joint), but one where the bony shape and supporting ligaments have to allow for such a large range of motion that it relies on the surrounding muscles for nearly all of its support and integrity, as well as on the function of all the other joints surrounding it. You can read more about the weird and wonderful world of the shoulder complex here.]
But anyway, the knee...
It is a hinge joint, the largest joint in the body, sandwiched in between the two longest bones in the human body, the femur (thigh bone) and tibia (shin bone).
This is a fairly bad idea to start with, because long levers generate a lot of force.
Worse, it's not a very simple hinge joint.
If it were, and could only bend forwards and backwards, and we wouldn't be able to walk on broken or uneven ground.
So we have the longest bones (/levers), generating a huge amount of force, going into the largest joint, which is also extremely complex.
Back when we put all of our weight through four ‘knees’ instead of two, this was less of an issue.
We also tend to weight-bear with our knees more or less unbent. This provides a lot more opportunity for trauma. Contrast this with other mammals such cats, dogs, horses, chipmunks, etc. etc.
The bottom of the thigh bone is a bit like the cartoon version of a bone, with two knobbly bits (called condyles) at the bottom. These then (theoretically) meet, or articulate, with the relatively flat top of the shin bone.
This works about as well as you would imagine.
Evolution’s workaround here was to put these two sort of cups, called menisci, on the top of the flat bit of the shin bone (rather poetically called the tibial plateau). These allow the knobbly condyles to sit a bit more firmly on the top of the tibia.
Now, of course, we have another structure that takes a lot of force, and can get injured.
Most sports fans (not to mention players) will have heard of a torn meniscus. I tore mine when I was about fourteen, and still remember it as one of the most exquisitely painful experiences of my life. As you can see in the diagram above, when the menisci (the 'C-shaped' things around the outside) are in place they cover most of the top of the tibial plateau.
But wait! There's more! It's not all about the menisci. In a flash of evolutionary genius, the other main way that the knee is stabilised is by four... ...elastic bands,
Well, not literally, but they might as well be.
The rubber bands (known as ligaments by the medical types) are actually just thickenings of the capsule that surrounds the joint.
Again, sports buffs will probably recognise the terms medial and lateral collateral ligaments. These refer to the ligaments on the inside, and outside, of the knee, respectively.
The anterior and posterior cruciate (or 'cross-like') ligaments go between the femur and tibia, and can be seen (along with the menisci) sandwiched in there on the left.
So we have this large, unstable joint subject to huge forces, that we hold in biomechanically-compromised positions.
Hmmmm, what could go wrong?
All joking aside, we will go into some of the ways the knee (and associated structures) can start breaking bad.
Stay tuned for my series on the knee, which will hopefully be completed at a slightly less glacial pace than the shoulder!
.Headaches can be tricky. There are a lot of reasons to get headaches, these are divided into categories.
These are headaches that are not caused by some underlying medical condition, so they are benign (non-life threatening), although migraine sufferers may disagree! More than 90% of headaches fall into this classification. These include:
Tension-type headaches (TTH) - the most common cause of headaches. It has been estimated that up to 90% of headaches are TTH.
Migraines - the second most common primary headache. We do not yet fully understand why migraines occur, but current thinking is that they are caused by an interaction between nerve/brain and blood vessel abnormalities.
Cluster headaches - extremely severe, sufferers who are mothers have often described the pain as worse than childbirth. Again, we are not sure what causes them, but it seems it may be something to do with a region of the brain called the hypothalamus.
Cervicogenic (meaning coming from the neck) headaches.
Result from trauma or some other underlying medical condition, such as infection, tumours, or bleeding in the brain. These account for less than 10% of headaches, but some causes may be life-threatening. Early diagnosis of these causes is important to avoid life-threatening complications.
Your osteopath is trained in recognising the different types of headaches, and will refer you on to the appropriate specialist if there is any concern that you may be suffering from a secondary headache.
However, let us assume that you have had your headache assessed by an appropriate healthcare professional. When that headache strikes, what can you do? Read on for our self-help tips and tricks...
1. Rest in a quiet, preferably dark, room
This can be effective for migraines, as well as TTH/cervicogenic headaches. As stress is one of the biggest factors in many headaches, having a rest can help both with the stress, and help tense, tired muscles to relax. TTH and migraine sufferers are also often overly sensitive to sound or light (or both).
Sit or lie down in a quiet, darkened or dimly-lit room. Try to relax the muscles of the neck, shoulders and back.
2. Have a glass of water
Dehydration can cause headaches, or make them worse. Keep yourself well hydrated to avoid these (and for a host of other reasons as well!). Remember, by the time you feel thirsty, you are already dehydrated. As little as 2% loss of body water content can cause loss of mental alertness and bodily fatigue, and it has been estimated that many of us do not even notice our thirst until we are moderately dehydrated (6-10% of body water).
(For reference, above 15% is considered severe dehydration, and may even result in death)
3. Breathing/Relaxation exercises
These work on the same principle as resting in a darkened room, by helping to reduce stress and muscle tension.
Take several deep, long breaths. As you breathe out, feel tense and sore areas relax and get heavy. Bonus points for imaging a peaceful scene (go to your happy place!).
4. Simple stretches and movements.
Phew. This is a big category, so we are only going to give a few examples. If you want more exercises that are tailored to you and your issue, ask your osteopath at Moreland Road Clinic about a personalised exercise program!
(a) Drop your chin down towards your chest, then slowly rotate your head in a half circle, first one way, then the other. Do not put your head backwards, as this compresses the joints in the neck, and tenses the very muscles we are trying to relax.
(b) Bend your head gently to the side. You want to feel a gentle pull in the muscles on the side of the neck. You can use your hand to help guide the head, but do not pull on it strongly or sharply.
(c) You can also intentionally (gently) contract muscles to help them relax. Think of it as bringing them a bit more back under conscious control. This is very effective in exercise (b), above. When you (e.g.) take the head off to the side, gently push back against the controlling hand. Do not use more than 5-10% of your strength - the point is to engage the muscles, not make them work hard. You can do the same thing, gently pressing your forehead into the palm of your hand (This will help relax the muscles in the front of the neck), or the base of the skull backwards into your hand (for the muscles at the back).
(d) Lie on your back, with a rolled up towel where your skull meets the top of your neck. Tuck your chin in, and gently press your head down onto the towel. Your should feel stretching and gentle pressure in the head/neck junction.
(e) Roll your shoulders in nice wide, slow circles. This helps to stimulate blood flow to the tight, sore muscles around the shoulders, upper back and neck, and will help them relax.
Another big topic! We will only give a few examples here. For more techniques, ask your osteopath for advice...
Self-massage is often difficult as it is hard to reach the areas you need to. However, headaches are probably one of the best issues to self-massage, as you should be able to reach most parts of your head and neck (if you can't, maybe you should book an appointment with your friendly neighbourhood osteopath to look at your shoulder problem!).
Use the finger pads (flats), not the tips - you want a nice, comfortable sensation, nothing too 'poke-y'.
(a) Describe gentle circles on your temples, the muscles above the ears (Yes! You have muscles there! You may have noticed them if you have ever smiled too hard for too long), and the side of the jaw. Target any particular painful spots, you will probably find they are tender to the touch as well. Keep it gentle!
(b) Place your thumbs near the base of your skull. Find the thick columns of muscle that run just on either side of the spine, and slide off them to the outside. You should feel these little depressions (hollows) where the neck meets the base of the skull. Press inwards and upwards until you feel a bit of discomfort. Using the pads of your thumbs, massage gently in small circles (keeping the inwards and upwards pressure).
(c) You can also try lifting your scalp up away from the head - if you have long hair, this is easy. Take a broad clump in each hand and gently lift upwards. You should feel almost instant relief. Combine with some gentle circular movements (again, with the finger pads) over the scalp, paying special attention to the sore bits.
NOTE: If you have a willing accomplice, get them to do these exercises for you. That way, you are not using the muscles in your shoulders and arms, which will make the techniques more effective.
6. Try heat and/or cold
A hot shower, or moist heat to the back of the neck may help to relieve the symptoms of tension headaches. Alternatively, try a cold pack (Always wrap cold packs in a towel or similar, so there is nothing too cold making direct contact with the skin) placed on the sore spots (e.g. temples, forehead, base of skull).
If either of these are uncomfortable/hurt, stop! The aim here is to reduce pain!
7. Over-the-counter (OTC) medication
A quick note: osteopaths are not qualified to give advice on drugs in general, so always consult your doctor or pharmacist about any medications you want to take.
Over-the-counter (OTC) drugs such as ibuprofen (e.g. Nurofen), paracetemol (e.g. Panadol), sodium diclofenac (e.g. Voltaren), naproxen sodium (e.g. Naprogesic) and aspirin may all help with headache pain. Interestingly, caffeine seems to make the effects of some of these more effective and rapid, which is why many OTC medications include it. However, please note that caffeine may be a trigger for migraines in sufferers. Also note that using any headache medication for more than three days in a week may cause medication-overuse headaches (these would be secondary headaches). Please consult your GP if you find you are needing medication this often.
Without going into too much detail, there are broadly speaking two main methods of acupuncture for headaches. Traditional Chinese acupuncuncture involves placing fine needles in specific points around the body. These points may be anywhere (i.e. not necessarily close to your head, in the case of headaches), and are chosen based on the idea that pain, dysfunction and disease are due to energy imbalances in the body. Trigger point dry needling (the technique used at Moreland Road Clinic) uses the same needles (and often techniques), but the points chosen are in tight and sore muscles that your therapist has identified as contributing to your headache pattern (so will normally be around the head, neck, shoulders and upper back).
Research indicates that these needles stimulate blood flow to the area, helping tense muscles relax, and may also help to release endorphins, the body's natural painkillers; both of which can help with headaches, particularly TTHs.
Anyone who knows me and my treatment approach has probably been wondering when this one would sneak in!
Research indicates that moderate exercise can help reduce the number and intensity of headaches (and by the same token, lack of exercise can predispose towards chronic headaches). This is probably because exercise is another way of releasing those endorphins (those wonderful pain-killing chemicals!), as well as promoting good overall health. Stronger muscles don't have to work as hard to do their normal job (this includes the heart as well!), and a more efficient cardiovascular system (heart, lungs, blood vessels etc) reduces the stress and strain on your body in general.
Aim for 150 minutes (two and half hours, or half an hour five days a week) of moderate intensity exercise, something that (a) gets your heart rate up a bit and (b) you enjoy!
(b) is really important - if you do not enjoy it, you are less likely to maintain a long-term regime.
Finally, I would like to talk about when to see your doctor about your headaches.
Please contact your healthcare professional if:
-your headaches are extremely frequent, or start increasing in frequency, or last more than a few days.
- Please seek advice if your headaches are accompanied by change in co-ordination or balance, fits, faints, blackouts, seizures, confusion, blurred/double vision, numbness, severe nausea or vomiting, dizziness or vertigo, fever, stiff neck, or shortness of breath.
- If your headache is sudden, severe, occurs immediately after an accident (especially head trauma), or is "the worst you've ever had", seek immediate medical attention.
Dr. Edmund Bruce-Gardner, Osteopath
Please note, you should not rely solely on books/the internet/my mate Jim at the pub for your health information. Please do not use this information to diagnose or treat yourself, and seek medical advice for any symptoms that concern you. The aim of these blogs is to increase peoples' self-reliance and ability to self-manage, but always assumes you are doing so in collaboration with your healthcare team.
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I have been seeing a fair amount recently on the ongoing vaccination debate. I am not going to stick my oar into that one, apart from to say that I feel there isn’t really a debate at all; two centuries of data show that immunisation works.
The area that piqued my interest was the number of people who do feel that they can weigh in to the debate. From lay persons to GPs, homeopaths to personal trainers, chiropractors, osteopaths, and the like, there are a lot of opinions going around. While I strongly encourage people to do as much reading as they can to inform themselves about issues such as these, my concern is that far too frequently, people are commenting outside of their area of expertise.
Immunology, the science that studies the immune system (and hence vaccination and related technologies), is an incredibly complex discipline, one which we are only just starting to understand. The immune system is also intimately related to the nervous system, the ‘command and control’ system for the body, which in turn is interlinked with the psyche (how we think, feel etc).
That being the case, even immunologists, who spend their life's work researching the immune system, do not necessarily know exactly what is going on. Importantly, they are generally happy to admit the shortcomings of their knowledge about the underlying processes and interactions of the immune system, and suggest areas needed for future research.
So who should we listen to?
It certainly does not make sense to take the 'expertise' of people such as myself, whose knowledge of immunology may consist of an undergraduate course or two. Who am I to suddenly start to claim expertise in why one should/should not vaccinate? I know just enough about immunology to know that I don’t know much about it!
This is where the relying on the consensus of the scientific community becomes really important. The important word in that sentence is ‘consensus’. The way that scientific knowledge moves forward is by suggesting an explanation (‘hypothesis’) for something we have observed about the world. This hypothesis needs to be testable, that is to say, we need to be able to check whether or not it can explain what we need it to. We do this through experiments.
Now, not all experiments are created equal. The ‘gold standard’ in clinical research is what is called the ‘randomised double blind’ controlled trial. In this, there are groups who receive the treatment or medication (or whatever) that is being tested, and those who receive different treatments, or nothing at all. Neither the person receiving the treatment, or the clinician administering it, knows which group the individual is in. This increases the likelihood that the results of the experiment are ‘objective’, or not biased.
As I said, not all experiments are created equal, and not all research is good. There will always be people who have an axe to grind or a point to prove, and whether unconsciously or not, a lot of research reflects this bias. That is why the process of ‘peer review’ is so important. What that means is that other experts in the same field examine the design of the experiment, and the data that are gathered, to decide whether or not the results of the experiment can be ‘trusted’.
Just because you have managed to find an article published in a scientific journal, does not mean it is ‘good science’. A good example where this has gone wrong with regards to immunisation is the study published by Wakefield et al (1998) that indicated a link between the MMR (measles, mumps, rubella) vaccine and autism in children. This study was retracted by the Lancet (the journal which originally published it) when it became clear that the main author was being funded by lawyers for families who were suing vaccine companies. There were later claims of outright data falsification (about the biggest sin possible in the scientific community), and most of the study’s co-authors also retracted their conclusions. In spite of all of this, and numerous subsequent studies that demonstrate there is not a link between autism and MMR, this original study is still quoted widely by proponents of the anti-vaccination lobby.
Just one person saying something is so does not make it so. It is also the case that just because everyone says something is true, does not make it so.
However, if you have a ‘general consensus’ within the scientific community (who, let’s face it, hardly ever fully agree on anything!), it is much more likely to be correct than the view to which only one or two individuals subscribe.
Whew! What a long-winded way of saying that you should listen to the experts!
While experts can be – and are – wrong, those who are not experts are more likely to be. If you are an osteopath, you are an expert in musculoskeletal conditions, not pharmacology and immunology. If you are a radiologist, you are an expert in medical imaging, not reproductive medicine.
If any of your healthcare professionals recommend a course of treatment or an approach that lies outside their expertise, please ask them why they think that is the case, and check with another professional!!
Always get a second opinion, whether from your GP or specialist.
And if you are a healthcare professional reading this blog, please feel free to give your advice, but qualify it! I know that a good number of my patients ask me about areas of healthcare that quite frankly are not within my area of expertise. It is extremely touching that they have enough faith in me to ask, and I will always answer to the best of my knowledge, but will preface my response by saying “This is not my area of expertise, so please consult your doctor/specialist etc etc, however my understanding is ... "
Mon 07/02/2017 - well, it looks like other people have the same concerns as I: the Chiropractors Association of Australia (CAA) has previously come under fire for not unequivocally condemning those outlying practitioners who continue to sound off about an area not within their professional expertise, However, the CEO has just come out and stated that the organisation's new vaccine policy bars chiropractors from giving vaccine advise to patients, and requested that the Australian Vaccination-skeptics Network remove all links to the CAA website from theirs.
A response to this on a prominent anti-vaxx site had this to say, "It appears that [chiropractors] are rapidly becoming as uninformed as qualified medical doctors".**
I will overlook the overall sentiment of the comment (I have no idea about the knowledge base of chiropractors in general, let alone in historical vs. current context), but just note the contradiction at the end. "as uninformed as qualified medical doctors". I would argue that being a qualified medical doctor is pretty much the definition of 'informed' with regards to vaccination.
** I will not link the site in question, because I don't want to give them more traffic than they already have!
New research on acupuncture in helping pain
New research being conducted by Melbourne hospitals has found that acupuncture is as effective as medication in the treatment of lower back pain, migraines and acute ankle injuries.
In the randomised controlled trial, participants who went to the Emergency Departments with these ailments were randomised to receive either a) acupuncture alone, b) pharmacotherapy alone (medication including Endone, Panadeine Forte, Voltaren and Valium) or c) a combination of acupuncture + pharmacotherapy.
According the an interview with one of the lead researchers published in The Age, the results suggest that acupuncture is a safe and effective in improving pain management; after one hour of treatment, the level of pain relief was the same for each of the three groups. Also, those patients who had acupuncture tended to have a shorter stay in hospital. These findings may be helpful for patients who do not want to take medications (e.g., pregnant), or would like alternative pain management choices. The results also help inform the impact that acupuncture treatment may have upon health resource utilisation in Emergency Departments.
The final results are still being prepared for publication, but you can view the study protocol for the trial by clicking here.
Acupuncture & Dry Needling
Acupuncture is based on an Eastern conception of how the body, health and disease works, where energy, or 'qi', flows along channels called meridians. Imbalances in this energy flow are thought to cause 'dis-ease'. Traditional acupuncture involves the placement of needles into acupuncture points (or 'acu-points'), which are specific points along these meridians that help to balance this flow, and hence restore health.
Dry needling is a specific form of acupuncture in which the needles are inserted into 'trigger points', which are dysfunctional areas of muscle, which form discrete, tender nodules or bands which a skilled therapist can identify using their sense of touch, or palpation (and the fact that when they touch them, you say 'ow'!!). Dry needling helps to resolve these trigger points, which are so-called because they often 'trigger' pain or sensations in other parts of the body.
Dry needling has been shown to be effective in the treatment of myofascial (muscle and connective tissue) pain and acute injuries.
The Wikipedia page on trigger points is not bad, if you want some more information.
Speak with your osteopath if you think this may be relevant to your condition...