Alternating Headache: C2-3 guilty or not?
Unilateral headache and the behaviour of unilaterality underpins diagnostic criteria in the medical classification of headache. However, the medical model of headache admits to a lack of understanding of the mechanism of unilateral alternating headache. A (medical) attempt was made in the late 1980s which hypothesised involvement of (intracranial) structures in or closely adjacent to the midline, with the pathologic state being duplicated contralaterally as it spreads across the midline. Alternating side-locked headache mimics alternating lateral lumbar list / shift which is thought to be a result of alternating aberrant lumbar intra-discal behaviour; could C2-3 intra-discal disc behaviour be responsible for alternating headache? My clinical experience suggests that it is responsible. Undoubtedly though, lumbar and cervical discs are structured differently, which suggests extrapolation from lumbar to cervical discs is tenuous. However, this review of contemporary research, which dispels widely held beliefs of intervertebral cervical (and ageing of) discs, not only supports, but strengthens my hypothesis.
Is the plantaris tendon a contributing factor in mid-portion Achilles tendinopathy?
Some cases of load-resistant Achilles tendinopathy may be due to interference of the plantaris tendon on the medial Achilles tendon. There is clinical, imaging and morphological evidence implicating the plantaris tendon in mid-portion Achilles tendinopathy. Recent studies suggest the plantaris tendon is stiffer than the Achilles tendon potentially leading to differential movement between the tendons and peritendinous inflammation or compression. Moreover, anatomical difference in the course of the plantaris tendon may predispose to greater interference between the plantaris and Achilles tendon leading to greater compressive forces. Although the optimal treatment is unknown, recent studies suggest that loading into mid-range may reduce the compressive forces on the Achilles tendon. Case series of surgical excision of the plantaris has been performed by various groups with good outcomes. However, as the exact mechanism by which surgical excision has a positive clinical effect is unknown, higherlevel studies are required to support the use of surgery.
Inside-out: the role of the viscera in musculoskeletal patient presentation
Musculoskeletal physiotherapists are increasingly required to have a broader and broader skill set and knowledge base in order to manage more complex patient presentations. This paper explores some of the mechanisms behind visceral pain and looks at common presentations and examination techniques that may help in identifying spinal pain of visceral origin.
Advances in clinical neurodynamics
Clinical neurodynamics has undergone many advances in the last couple of decades and classical lines of reasoning and application of neural techniques now include progressions for the severe to the less irritable and include off-loading (first aid) to graded application of force (rehab) to maximal load and movement in a way that emulates the patient’s high-end needs (performance). Two key ways of achieving these goals are by reducing force or protecting neural tissues in the acute painful phase and to personalise force and movement for the patient in the performance phase. This article highlights the importance of neural and musculoskeletal mechanisms in diagnosis and treatment of pain and disability problems that involve both systems.
A quick roundup of the various aspects of our 2018 annual conference