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The Posterior Oblique Sling

The Posterior Oblique Sling

29 May 2024

The posterior oblique sling (POS) comprises the latissimus dorsi and contralateral gluteus maximus which is connected through thoracolumbar fascia, erector spinae, multifidus and bicep femoris. This activation pattern provides stability of the lumbopelvic region by transferring force through the trunk. For insistence, erectus spinae generates force whereas the multifidus creates stability. The posterior oblique sling is thought aid recovery from lower back pain (LBP) and is often a fundamental part of rehabilitation despite minimal research on the topic (Kang and Hwang, 2019). However, most recent research suggests patients with LBP have abnormal motor recruitment in the lumbopelvic region (Kim et. al, 2014); therefore, activating the POS may offer spinal mobility, stability and prevent LBP (Kang and Hwang, 2019).

Prone hip extension (PHE) is a useful measure to assess and activate the POS. In healthy individuals, one should be able to maintain neutral lumbar and pelvic position during PHE, however patients with LBP have been found to have altered lumbar and pelvic movement. This in turn can cause lumbopelvic dysfunction, spinal instability and postural disturbance (Kim et. al, 2014). For example, Kang and Hwang found patients with LBP often have delayed onset of gluteus maximus and earlier onset of bicep femoris (Kang and Hwang, 2019).  When the gluteus maximus does not activate, there is a loss of pelvis control which can cause the contralateral latissimus dorsi to become dominant. Therefore, to aid lumbopelvic control, practitioners can manipulate the PHE to focus on the less dominant muscle (Kim et. al, 2014).

Lee et. al altered the PHE technique to assess the impact this has on POS. The PHE was compared to abdominal drawing in maneuverer prone hip extension (ADIM PHE). The ADIM PHE had increased contralateral latissimus dorsi and ipsilateral gluteus maximus compared to hip extension, whereas PHE had increased ipsilateral erector spinae and ipsilateral bicep femoris ((Lee et. al, 2020). Lee et. al also compared PHE to PHE with hip abduction and knee flexion. They discovered the contralateral latissimus dorsi, ipsilateral erector spinae and gluteus maximus electromyography was higher with phone hip extension with hip abduction and knee flexion than PHE (Lee et. al, 2019). Therefore, depending on the clinical presentation of the patient, practitioners can isolate specific muscle groups within the POS. PHE with hip internal rotation and shoulder internal rotation and shoulder extension with 1lb dumbbell was found to be the optimal PHE variation for POS activation to aid recovery with LBP (Kang and Hwang, 2019).

This research highlights the importance of using PHE as an assessment and treatment tool to identify weakness within the POS and then adapting the PHE to support recovery from LBP.

Reference List

Kang, D. and Hwang, Y.-I. (2019). Comparison of Muscle Activities of the Posterior Oblique Sling Muscles among Three Prone Hip Extension Exercises with and without Contraction of the Latissimus dorsi. Journal of The Korean Society of Physical Medicine, 14(3), pp.39–45. doi:https://doi.org/10.13066/kspm.2019.14.3.39.

Kim, J.-W., Kang, M.-H. and Oh, J.-S. (2013). Patients With Low Back Pain Demonstrate Increased Activity of the Posterior Oblique Sling Muscle During Prone Hip Extension. PM&R, 6(5), pp.400–405. doi:https://doi.org/10.1016/j.pmrj.2013.12.006.

Lee, J.-K., Hwang, J.-H., Kim, C.-M., Lee, J.K. and Park, J.-W. (2019). Influence of muscle activation of posterior oblique sling from changes in activation of gluteus maximus from exercise of prone hip extension of normal adult male and female. Journal of Physical Therapy Science, 31(2), pp.166–169. doi:https://doi.org/10.1589/jpts.31.166.

Lee, J.-K., Lee, J.-H., Kim, K.-S. and Lee, J.-H. (2020). Effect of abdominal drawing-in maneuver with prone hip extension on muscle activation of posterior oblique sling in normal adults. Journal of Physical Therapy Science, 32(6), pp.401–404. doi:https://doi.org/10.1589/jpts.32.401.

Athlete lifting a barbell in a dimly lit gym
The power of words!

The power of words!

21 May 2024

Something I always try to personally remind myself when seeing a patient, is how important the use of my language and terminology is in providing them a safe, informative and hopefully, comfortable environment. I think it is fair to say that a large percentage of patient’s withhold some level of apprehension when attending a medical appointment, particularly that first meeting. For me, that first time with a patient is as much about building a strong and trustworthy relationship as it is providing a treatment plan or diagnosis. I am sure each and every medical professional has had those appointments where the time is up and nothing ‘objective’ or ‘physical’ has taken place. Instead, the time has been taken up by conversation, or possibly even one way conversation where the professional’s role has simply been to listen rather than talk. For me, this is still active treatment and often, very beneficial to the patient. On more than one occasion I have been glad to receive an email or contact from a patient with whom this has been the case, where they have simply said ‘thank you’ for giving them the time to tell their story and share their beliefs.

An interesting stat that I have always remembered is that 40-80% of medical information provided by healthcare practitioners is forgotten immediately. The greater the amount of information presented, the lower the proportion correctly recalled and furthermore, almost half of the information that is remembered is incorrect (Kessels 2003)(3). This amplifies the importance of trying to keep terminology simple and keep focus on the most relevant information for that patient. From personal experience, it is more often than not, also the negative information or language used by a health professional that the patient clings to and remembers. Linskins et. al (2023) (2) carried out a randomised control trial on the effects of negative language use of physiotherapists in the treatment of lower back pain. To no surprise, the findings were that the use of negative language heightened a patient’s state of anxiety, with higher rates of belief and concerns that their condition would last for longer. This is not to say we should be unrealistic in what a patient’s possible prognosis may be, however it is definitely an indicator that how we relay that information is key in how they may perceive their recovery or long term management of a condition. I personally always like to ensure a patient leaves their appointment having completed something ‘pain free’ or that they didn’t believe they could actually do prior to that session. It gives a great base for positive reinforcement and the use of positive language, hopefully giving them something to work with and focus on going forwards.

Through my own career to date I have been lucky enough to work with some fantastic doctors and physiotherapists and it is from these, that I believe I have been able to do my best in attempting to maximise my interpersonal and communication skills when face to face with a patient. I was recently asked by a physiotherapy student, what key pieces of advice I would give for taking an effective subjective assessment. My response was based round the following points:

  • Let the patient lead the conversation
  • Do not interrupt the patient when they are speaking – no matter if the clock is ticking
  • Make eye contact with them, not constant eye contact with your computer screen
  • Emphasise you are here as a tool for them, not as a solution – give the patient some self importance and responsibility
  • Do not make the patient feel hurried
  • Use simple terminology
  • address the negatives, but focus on the positives

Franx and Murphy (2018) (1) summarise the importance of language in a medical setting nicely. They state that ‘listening consists of following the lead of language, often along many strange paths, until a proper understanding is reached. In this way, a patient’s true background is opened that is required for an effective intervention.’

Reference List

 

  • Franz, B. and Murphy, J.W. (2018). Reconsidering the role of language in medicine. Philosophy, Ethics, and Humanities in Medicine, 13(1). doi:https://doi.org/10.1186/s13010-018-0058-z.

  • Fieke) Linskens, F.G., van der Scheer, E.S., Stortenbeker, I., Das, E., Staal, J.B. and van Lankveld, W. (2023). Negative language use of the physiotherapist in low back pain education impacts anxiety and illness beliefs: A randomised controlled trial in healthy respondents. Patient Education and Counseling, 110, p.107649. doi:https://doi.org/10.1016/j.pec.2023.107649.

  • Kessels, R.P.C. (2003). Patients’ memory for medical information. Journal of the Royal Society of Medicine, [online] 96(5), pp.219–22. doi:https://doi.org/10.1258/jrsm.96.5.219.

Illustration of a runner surrounded by thought bubbles showing different sports
Why exercise is good for your joints

Why exercise is good for your joints

29 April 2024

Close-up of a person's flexed forearm and elbow
Photo by Towfiqu barbhuiya on Unsplash
It comes as no surprise that exercise has an endless list of benefits for our body; it reduces the risk of heart diseases, helps maintain your blood sugar and insulin levels, improves your mental health and mood, and increases strength and flexibility whilst reducing pains and combatting fatigue. However, the benefits of exercise for our joints is often overlooked.
The most common example of the advantages of exercise for our joints is in people with arthritis. Let’s look at this in more detail.
Arthritis is a common condition that results in substantial pain and inflammation to the joints, with over ten million people in the UK alone suffering from this condition. It can affect people of all ages and is categorised into different types depending on the location of the inflammation. The most prevalently discussed types of arthritis are osteoarthritis and rheumatoid arthritis, both of which we provide treatment for at Opus. We discuss the types of arthritis in more detail here.
During exercise, people with arthritis and joint pain describe a significant reduction in their pain alongside a notable increase in their range of motion. But how does physical activity exert these effects? Below are five benefits that exercise yields and how this is advantageous to the joints:
  1. Synovial fluid lubricates the joint. Each joint in the body is surrounded by soft tissue, also known as the synovial membrane, that is capable of producing fluid. This fluid acts as a lubricant, enabling the bones at each joint to slide past one another in a smooth motion. During exercise, the circulation of this fluid is increased and, therefore, reduces any pain at the joint.
  2. Blood flow increases. During physical activity, our heart increases at a much faster pace. This results in an increase in blood circulation throughout the body, including at the joints. This exposes the synovial membrane to an increased and steady supply of both oxygen and nutrients.
  3. Joint-repair genes are switched on. This is a relatively unresearched area; however, studies have shown that genes play a significant role in joint repair, with these being activated by physical activity and joint movement.
  4. Cellular waste is removed. During exercise, a process called autophagy is triggered. Autophagy refers to the biological process in which damaged cells are broken down and removed. The build-up of these cells at the joint can often cause severe pain and limits movement; therefore, ensuring these are removed can instantly decrease the pain experienced.
  5. Increase in muscle mass. It is no surprise that exercise strengthens muscles, ligaments, and tendons in the body; this includes those surrounding the joints. When these elements are strong, they behave like a brace, protecting the join from harm. Moreover, physical activity also increases your overall range of motion, enabling your joints to withstand more pressure.
At Opus, we can assess the root cause of your joint pain and recommend specific sports medicine-backed exercises to lessen this discomfort. Beyond this, we also provide regenerative treatments that may provide long-term pain relief. Get in touch to discuss how we can assist you on your journey.
Keep it simple? Can simple aerobic exercise assist in the management of lower back pain?

Keep it simple? Can simple aerobic exercise assist in the management of lower back pain?

16 April 2024

The World Health organisation (WHO) stated that in 2020, 619 million people were affected globally by lower back pain, with non specific lower back pain accounting for 90% of these cases, making it the single leading cause of disability worldwide (5).

Based on these figures it is of no surprise that here at Opus, and I am sure at many, if not all other MSK treatment centres, we see a large number of patient’s coming through the door looking for assistance with this matter. As with any injury we see, the case will vary from patient to patient and every individual will require a bespoke treatment plan, aimed at their particular presentation and tailored towards their overall goals. However, is it worth considering that something as simple as low intensity aerobic exercise could be of use to a high percentage of these patients at some point in their recovery?

Lower back pain is a pervasive issue, which can be impacted or triggered by a number of factors including: trauma, deconditioning, muscle imbalances, fatigue, obesity, sustained sedentary positioning and many more . Whilst there are several approaches to managing this issue, one possible tool could be the use of aerobic exercise. Aerobic exercise includes: walking, light jogging, cycling, use of a cross-trainer or aerobics in a swimming pool.

To harness the benefits of aerobic exercise for lower back pain relief, consistency is paramount. NHS guidelines (2), recommend engaging in aerobic activities for a minimum of 150 minutes per week, spread across several sessions. This equates to approximately 30 minutes of moderate-intensity exercise, 5 days a week. However, it’s essential to start sensibly and listen to your body, gradually increasing the duration and intensity as your fitness improves. In those individuals with lower back pain, the pain levels experienced during completion of their aerobic activity will also be an important factor in guiding the duration of their session and whether they need to include small rest breaks or alterations in the intensity of the exercise, to enable them to continue for the necessary time.

Aerobic exercise initiates a series of complex physiological responses within the body. Firstly, aerobic activities stimulate the cardiovascular system, increasing heart rate and promoting blood flow to various tissues, including the muscles of the trunk and lower back as per Sany, S.A., Mitsi, M., Tanjim, T. and Rahman, M. (2022) (3) This enhanced blood circulation delivers oxygen and nutrients essential for tissue repair and regeneration, while also aiding in the removal of metabolic waste products and reducing inflammation. It also triggers a chemical response through the release of endorphins, neurotransmitters produced by the central nervous system, often referred to as the body’s ‘natural painkillers’. Endorphins bind to opioid receptors in the brain, effectively reducing the perception of pain and promoting feelings of well-being and relaxation. This analgesic effect can significantly alleviate discomfort associated with lower back pain.

Research has demonstrated the efficacy of aerobic exercise in reducing the incidence and severity of lower back pain, as well as improving functional status and overall quality of life. The subsequent recurrence of back pain episodes can be reduced by 30% just through the use of aerobic exercise Shiri, R., Coggon, D. and Falah-Hassani, K. (2017) (4). Incorporating aerobic exercise is a cost effective and easily accessible way to attempt to alleviate lower back pain. By adhering to a consistent aerobic exercise regimen, individuals can mitigate discomfort, improve functional capacity, and promote overall well-being Gordon, R. and Bloxham, S. (2016) (1).

Now none of the above is to say that other types of exercise: strength training, pilates, yoga, mobility, aren’t of benefit or in fact more suited to some patients. What it does suggest though is that even when someone feels they are severely limited in what they can do, whether it be due to the lower back pain itself, or the time and resources available to them, something as simple as a walk, jog or bike ride can physiologically benefit them and reduce their pain levels.

Reference List

 

Man stretching at a standing desk beside a window at home

The impact of fatigue and why optimal recovery is so important.

The impact of fatigue and why optimal recovery is so important.

24 March 2024

Optimal recovery from training and competition is most definitely a subject that we are seeing more frequently discussed and addressed in elite sport and the sports medicine world. Away from sporting competition, we can also inform and educate individuals on how to ensure their recovery is as good as it can be to enable them to be on the top of their game in their day to day life whether that be at home or at work. With useful data collecting tools such as; the Whoop, Oura ring and Apple watch, it is becoming much easier for people to keep an eye on their vital metrics and determine when rest is needed or when is a good time to place their body under higher strain through training, competition or a stressful life event.

Here at Opus, we often have the ‘optimal recovery’ discussion with our patients. It tends to be part of a greater conversation of how we assist in managing that individual’s training load and or managing their current state of physical and mental health. By doing this we can reduce the risk of injury and illness and aid in the patient performing to the best of their ability in whatever task it may be that matters to them.

So what is optimal recovery? The fact is, it is not just any one thing, but instead a combination of a number of components that contribute to restoring a person’s physical, and mental well-being after a period of physical or mental exertion. By ‘optimising’ as many of these components as possible, we can in turn reduce the potential risk of both illness and injury.

Two specific musculoskeletal injuries linked to fatigue which have been researched in depth are hamstring and ACL injuries. One study by Mclean and Samorezov (2009) (2), reported that the inhibitory action of the fatigued muscles in landing activities,  increases the possibility of ineffective perception, decision, and movement execution strategies therefore increasing risk of injury to the ACL. Small et. Al (2009)(3) focused their investigation on the risk of hamstring injury at the ends of each half of a football match. Their findings suggest that due to decreased flexibility of the hamstring muscle group during fatigued sprinting, with a reduced maximum combined hip flexion and knee extension angle observed during the late swing phase of the sprinting cycle, the strain on the hamstring muscle group is increased in this fatigued state and the risk of hamstring injury is amplified.

Jones et. Al (2016)(1) looked more into the impact of training load on the risk of illness due to fatigue. They found that during periods of training load intensification, or where there was a greater accumulation of training load, the risk of acquiring illness increases.

So what are these key components of optimal recovery and how can they impact an individual? Some of those we discuss regularly with our patents at Opus are:

  • Getting sufficient rest and good quality sleep are fundamental for recovery. Sleep is when the body repairs tissues, consolidates memories, and regulates the hormones which are crucial for recovery and overall health.
  • Being hot on your nutrition. A good diet focused around the right food types, supports the body’s recovery processes and replenishes energy stores, repairs tissues, and supports immune function.
  • Maintaining proper hydration levels. Water is crucial for transporting nutrients, regulating body temperature, and facilitating various biochemical processes in the body.
  • Opting for ‘Active Recovery’ when necessary. A pool session, stretch and mobility routine or flush on the watt bike, can enhance circulation, reduce muscle stiffness, and promote recovery by aiding in the removal of metabolic waste products from muscles.
  • Managing stress. Using techniques such as meditation or deep breathing exercises, can help reduce stress levels and promote recovery. Alternatively if that’s not for you, surrounding yourself with friends and family and taking part in activities that you find fun and relaxing can be of great help.

So in short, what we do away from the more strenuous or testing activities in our day to day life, is vital in ensuring our performance is at its best. Optimal recovery leads to reduced risk of injury and illness and in turn, optimal performance.

Reference List

 

  • Jones, C.M., Griffiths, P.C. and Mellalieu, S.D. (2016). Training Load and Fatigue Marker Associations with Injury and Illness: A Systematic Review of Longitudinal Studies. Sports Medicine, 47(5), pp.943–974. doi:https://doi.org/10.1007/s40279-016-0619-5.
  • MCLEAN, S.G. and SAMOREZOV, J.E. (2009). Fatigue-Induced ACL Injury Risk Stems from a Degradation in Central Control. Medicine & Science in Sports & Exercise, 41(8), pp.1661–1672. doi:https://doi.org/10.1249/mss.0b013e31819ca07b.
  • Small, K., McNaughton, L.R., Greig, M., Lohkamp, M. and Lovell, R. (2009). Soccer Fatigue, Sprinting and Hamstring Injury Risk. International Journal of Sports Medicine, 30(08), pp.573–578. doi:https://doi.org/10.1055/s-0029-1202822.
Man drinking water outdoors while carrying an exercise mat

The Different Approaches to Treating Scoliosis through Physiotherapy

The Different Approaches to Treating Scoliosis through Physiotherapy

22 February 2024

Physiotherapy Scoliosis Specific Exercise (PSSE) is the umbrella term and model that encompasses specific education, physiotherapy exercises, psychological support and bracing for scoliosis (Berdishevsky et. al, 2016). PSSE approach has become a more accepted form of conservative treatment due research showing an improvement in cobb angle, posture and breathing function (Seleviciene et. al, 2022). The PSSE model incorporates a multidisciplinary approach and can be used as an adjunct to medical treatment (Berdishevsky et. al, 2016). There are currently 8 scoliosis schools which use PSSE, however the Schroth method, Scientific Exercise Approach to Scoliosis (SEAS) and Barcelona Scoliosis Physical Therapy School approach (BSPTS) are the most researched and shown to be the most effective in reducing Cobb angle and quality of life (Seleviciene et. al, 2022)

Schorth method

The Schorth method is the most studied approach with research demonstrating reduced prevalence of surgery, improved self-image and quality of life. This method uses ‘body blocks’ to help explain the scoliosis and therefore determine the most appropriate treatment. For example, the spine is split into hips, lumbar, thoracic and shoulder blocks to help assess the curvature and rotation of the spine. This provides a clear exercise programme and prioritises the manual therapy techniques. Education is used throughout the various exercises to help teach the patient to elongate the concave areas in order to improve posture. The four most common exercises include:

  • 50 X pezziball – The ’50 X pezziball’ involves the patient sitting on a swiss ball in front of a mirror and using a wall bar to self-correct the spine alignment. The patient uses the mind body connection and cues to aid spine elongation and core engagement.

  • Prone exercise- This exercise uses shoulder traction and counter traction to aid the thoracic curve while activating the iliopsoas for the lumbar curve.

  • Sail exercise- Sail involves stretching and elongating the thoracic cavity.

  • Muscle cylinder- This involves side lying on the convex side to engage QL and correct the lumbar curve against gravity. (Berdishevsky et. al, 2016)

SEAS

The SEAS approach focuses on increasing spine stability and is often used alongside wearing corrective braces to maintain range of motion and muscle tone. This approach is more functional by encouraging postural correction in different activities of daily living. Equipment such as balance boards are regularly used to aid muscle endurance and neuromotor function. (Berdishevsky et. al, 2016)

BSPTS

The BSPTS approach is based on the Schroth method and focuses on challenging the trunk with or against gravity. This includes supine exercises which remove gravity and allows the patient to focus more easily on posture corrections, as well as side lying exercises which concentrate on lumbar concavity by working against gravity. The various exercises use corrective pads and cueing to promote elongation, traction/counter traction and muscle activation to improve posture. (Berdishevsky et. al, 2016)

Despite the various research conducted on these approaches, there is still a lack of research (Seleviciene et. al, 2022); therefore, it is important to incorporate each method into clinical practice to aid posture and quality of life (Berdishevsky et. al, 2016).

Reference List

Berdishevsky, H., Lebel, V.A., Bettany-Saltikov, J., Rigo, M., Lebel, A., Hennes, A., Romano, M., Białek, M., M’hango, A., Betts, T., de Mauroy, J.C. and Durmala, J. (2016). Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. Scoliosis and Spinal Disorders, 11(1). doi:https://doi.org/10.1186/s13013-016-0076-9.

Seleviciene, V., Cesnaviciute, A., Strukcinskiene, B., Marcinowicz, L., Strazdiene, N. and Genowska, A. (2022). Physiotherapeutic Scoliosis-Specific Exercise Methodologies Used for Conservative Treatment of Adolescent Idiopathic Scoliosis, and Their Effectiveness: An Extended Literature Review of Current Research and Practice. International Journal of Environmental Research and Public Health, 19(15), p.9240. doi:https://doi.org/10.3390/ijerph19159240.

Doctor examining a patient lying on a treatment couch