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What Type of Back Problem
Do I Have? We show you how to identify the type of back pain you have.

Date Created:  July 2, 2019

The reality is 80% of us will suffer from back pain at some point in our lives. And yet, getting the correct treatment to alleviate back pain can be a frustrating and challenging task–for both patients and healthcare providers alike.

Anytime such a large percentage of the population suffers from an ailment, you can be certain an entire economy will pop up purporting to be able to solve the problem. For this reason, there’s a lot of nonsense out there about new and unique methods to “cure” back pain. As a general rule, the word “cure” is misleading and deceptive, and will leave patients frustrated and disenchanted with their progress. However, with the right treatment approach we can effectively manage back pain and reduce the negative impact it can have on your life.

Many of the solutions marketed to patients treat back pain as a single diagnosis. In fact, the term “back pain” is not really a diagnosis at all, rather a description of a symptom. Treating all patients that present with back pain the same is like prescribing antibiotics to every patient with abdominal pain. Just as there are many diagnoses that cause abdominal pain, there are several distinct types of back pain. A skilled physiotherapist can diagnose your issue by identifying the specific type of problem you have, and customize a treatment plan. Accurately matching the diagnosis to the treatment plan is crucial to ensuring a good outcome. This is a relatively rare skill, requiring training and experience to develop strong diagnostic skills, so finding a qualified physiotherapist is paramount.

Below are some of the more common types of back pain, and many of you may recognize your own symptoms in the descriptions. These are followed by key elements and strategies that should be included in a treatment plan for that particular issue. However, it’s critical to note there is no substitute for a full assessment performed by an experienced physiotherapist.

5 Types of Back Pain


Often, this type of back pain is described in terms of injury to the disc (though not always the case). More importantly, the pain and symptoms tend to follow a familiar pattern:

  • Symptoms are made worse by sitting, bending, lifting
  • Symptoms improve after standing and walking for short durations
  • Can include spine pain, leg pain or both
  • May experience tingling/numbness
  • Can progress to leg weakness
  • Often has pain with cough/sneeze (but not always)
  • Loss of range of motion (difficulty straightening up after rising from sitting)

Effective care for Flexion Dominant pain includes a directional exercise/stretch that you perform at intervals throughout the day to maintain your spinal range of motion and to reduce pain. After performing this stretch, you should have less pain and your back should feel more flexible. The exact stretch that is right for you is best determined by a trained physiotherapist, but often passive, repeated extension of the lumbar spine is a decent place to start. Click here for a video of this exercise. With a skilled examination your physiotherapist can make modifications to your exercise to improve its effectiveness. Treatment may also involve hands-on, manual therapy to help restore your spinal range of motion, and may also include pain-relieving techniques. Some patients find a reduction in pain with acupuncture, which can be used as an adjunct to other treatments.

After the pain has settled down, a skilled physiotherapist will help you discover how the problem began and which changes to make, including:

  • An ergonomic assessment of your workstation to ensure good posture or eliminate occupational risks
  • Education on proper lifting and squatting mechanics
  • Core muscle strength training (if weakness is an issue)
  • Strengthening or stretching abnormally weak or tight hip muscles
  • Spinal mobility exercises


Extension Dominant pain is often described in terms of the joints at the back of the spine called the zygapophyseal joints (or Z-joints). Again, this is often part of the problem, but not always. Extension Dominant pain has a tendency to follow an identifiable pattern:

Signs and Symptoms

  • Pain after standing for long periods
  • Temporary relief from sitting or bending
  • Range of motion is typically stable and does not change in short periods of time. The back may be stiff, but it is always stiff in the same way
  • Pain after high impact activities (running or gymnastics movements)
  • Usually includes localized spinal pain
  • May include leg pain, tingling, or even numbness in severe cases

Care for Extension Dominant pain is guided by finding ways to reduce pressure on the spine in extension, as people who suffer this type of pain often stand with their low backs arched. Gentle stabilizing abdominal exercises and hip mobility stretches (specifically hip flexor stretches) can be effective. Intermittently using flexed postures to relieve pain is also helpful. Pain relieving treatment techniques such as acupuncture or manual therapy may also play a temporary role.

Longer term care focuses on spinal/core stability and hip mobility. Once your pain is under control, the treatment program can be more aggressive, and will be aimed at building muscle around the spine while gaining length in shortened hip muscles.


Neurogenic Claudication is a specific type of Extension Dominant back pain that tends to affect older individuals (60+). It’s caused by the nerves being compressed when the patient is standing and walking, and can significantly limit a patient’s ability to walk for longer distances.


  • Typically no symptoms when sitting
  • Upon rising and walking: pain, numbness or weakness in the legs begins after a predictable amount of time (length of time depends upon severity)
  • Many of these patients have no local spine pain
  • After symptoms begin, the patient must sit or bend forward to reduce symptoms
  • Some patients are seen leaning over a shopping cart, for example, so they can walk without leg symptoms

When patients with Neurogenic Claudication have an acute flare-up, their walking tolerance is greatly reduced and they must take frequent breaks to allow their nerves to recover. These patients should be given a variety of flexion-based stretches and strategies to use frequently throughout the day, and temporarily reduce walking distances. As symptoms decrease, training and exercises to reduce pelvic anterior tilt in standing may be effective. These patients should not try to ‘fight through the pain’ or ‘train’ themselves to walk further, which tends to be like throwing fuel on the fire.

Restorative care for someone suffering from intermittent bouts of Neurogenic Claudication should be aimed at two main priorities: First, abdominal strength must be adequate so the individual can walk without the spine falling into an arched or extended position; second the patient’s hips must be mobile enough that the pelvis isn’t pulled into an anterior tilt in standing/walking. The stronger and more mobile a patient can keep themselves the more likely they are to avoid a decompression surgery to make room for the nerves. A physiotherapist well trained in spinal care can put together an exercise program to reduce sustained lumbar extension when walking.


Inflammatory back pain is less common than mechanical back pain, but is often misdiagnosed. This type of pain is caused by excessive inflammation in the spinal joints, secondary to a medical condition causing the immune system to attack the joints of the spine. An example of a condition that causes inflammatory back pain is ankylosing spondylitis. However, there are a number of conditions that can result in inflammatory back pain. The physiotherapist’s job is to recognize the pain as inflammatory and refer the patient back for medical evaluation (often by a rheumatologist) and for more testing. However, once the diagnosis is made and medical management is in place, the physiotherapist will help with symptom management.


  • Onset of pain is usually in patients under 35 years of age, and not due to trauma
  • Pain persists for more than three months
  • The back pain and stiffness worsen with immobility, especially at night and in early morning
  • The back pain and stiffness tend to ease with physical activity and gentle exercise
  • Anti-inflammatory medications (NSAIDs, such as ibuprofen or Naproxen) are very effective in relieving pain and stiffness in most patients

Patients should be given a management plan that teaches them positions of relief, as well as activities to avoid when experiencing a flare up. Unfortunately there’s no way to alter the natural path of this condition with physiotherapy, but a gentle exercise program is useful to maintain mobility and reduce pain. When symptoms are well controlled and pain levels low, a patient can use a more aggressive restorative program, designed by a skilled physiotherapist. In addition, some low impact functional strength training can be helpful.


A Pain Disorder involving back pain is one of the more challenging conditions for medical professionals to treat. This patient’s nervous system is interpreting stimuli not normally painful or harmful to the body as dangerous, which the brain then treats as painful. It’s a complex issue requiring a profound understanding of the patient, and what has led him or her to this place; it can be incredibly frustrating for patients when medical professionals repeatedly tell them they see no organic cause for their pain. It’s important to note the pain these patients feel is just as physically real as it is for those suffering from a mechanical injury. The usual treatments don’t help this subset of patients, and so they are best served by working with a muti-disciplinary healthcare team, including a physiotherapist with a strong understanding of pain science.


  • Vary widely
  • Pain does not follow typical anatomic boundaries
  • Location of pain may migrate to include other parts of the body
  • Pain can be made worse by a state of anxiety or depression
  • Increases and decreases in pain are not necessarily linked to mechanical trauma or physically stressful events

Patients suffering from a pain disorder will often experiment with pain relieving techniques to find a combination that works for them. Physiotherapists should help these patients understand their pain and guide them to maintain physical fitness and function. It’s also important to screen for any complicating factors, like anxiety or depression, that can contribute to the problem, and ensure these issues are addressed by a trained professional. Pain disorders of this nature are not common.

Final Thoughts

Within each type of back pain there is no ‘one size fits all’ treatment approach. Even after establishing the correct diagnosis, a skilled physiotherapist will work with the patient on a treatment plan focusing on factors driving the specific issue. If you’re suffering from back pain and are struggling to get answers, an experienced physiotherapist with training in spinal disorders can be an enormous help. If you’re unsure of where to find a physiotherapist, please call us at Cornerstone Physiotherapy. We help over 5,000 people every year to find solutions to complex conditions, including back pain, and we’re happy to offer our services so you can feel better, faster.

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At Cornerstone Physiotherapy we recently interviewed a group of our patients who had sustained significant injuries and made a complete recovery in record time. We wanted to hear their perspective on what it takes to ensure the best possible outcome from a Physiotherapy clinic experience. Some common themes emerged that we think all patients would benefit from. Here is what these Physiotherapy superstars had to say.

1. Do My Research

“Like everything in life a little research goes a long way. I checked out reviews, and talked to friends and colleagues before choosing which physiotherapy clinic I was going to attend. Not all clinics are the same. I wanted to make sure that the clinic I went to had experienced physiotherapists who were experts in the type of treatment that I needed. It was important to me that I spend my time in the clinic working with my physiotherapist one-on-one and that appointments were long enough to accomplish my goals.”

2. Find a Physiotherapy Clinic Near Me

“It is difficult from me to carve time out of my schedule for appointments so it was important to me that the clinic was nearby. I knew that I would need to attend several appointments so it had to be as convenient as possible. I only considered physiotherapy clinics that were on my usual daily commute and easily accessible by transit. This made it easier to follow through on my treatment, and ensured that I didn’t waste any time travelling.”

3. Active Physiotherapy is Superior Physiotherapy

“I had been to physio a few times in the past. The first clinic I went to mostly used machines and treatments where I was doing very little. It was relaxing and felt good at the time, but it did not really help my injury. I have since learned that for physio to work well it must be active. It makes sense! How can you expect your body to change unless you put in the work. So when I was looking for a clinic I made sure to find a place that insisted an active approach to therapy. It is amazing how much you can change your body with a well designed plan of action!”

4. Setting and Measuring My Goals

“I am all about measurement. I knew that if I wanted to stick to a difficult rehab process I needed to measure my progress so that I could be motivated by small changes. My physiotherapist helped me to know what to measure and tracked my progress with me. It made all the difference and motivated me to be diligent with my homework throughout the process.”

5. It is All About Routine

“I find it really hard to fit new things into my busy life. Whether it is exercise, appointments or a new habit I am trying to create. That’s why in the past physiotherapy had not worked for me. This time my physio really focussed on building a routine for me. We talked about exactly when, where and how  was going to do my home exercises. We talked about what equipment was available at home and when in my day I would be able to do it without being interrupted. This small change made all the difference. I was able to stick to my part of the plan and the results were so much better!”

6. Take a Step Back

“The physio I worked with helped keep me on track by helping me step back from my pain and see the whole plan. Once I could see how far I had come and appreciate how the plan we made was getting me better it was much easier to follow through on my treatment. Some days you get so caught up in the small ups and downs that it can be difficult to appreciate the whole journey”

So there you have it. Some insider tips from patients that have had great success with their physiotherapy. A great deal of time and energy goes into your recovery. Make sure you consider all of these points and you will increase your chances of success!

Read our 8 TIPS for Finding the Best Physiotherapist for you, by clicking here!

The post Your Plan to Ensure the BEST Physiotherapy Clinic Experience appeared first on Cornerstone Physio.

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Neck pain can be a debilitating problem that has a significant impact on many people’s lives. For most patients, a well thought out physiotherapy treatment plan can help them to live without pain. To be successful it is important to fully understand the cause of your neck pain and to build a physiotherapy intervention to address, compensate for, and correct those causes.


Did you know that;

• 10-20% of people will experience neck pain in a given year.
• Office workers have a higher incidence of neck pain than the general population.
• Urban dwellers have more neck pain that people who live in rural communities.
• Most neck pain is recurrent, so untreated, it will come and go over a person’s lifespan.
• Women are more likely to suffer from neck pain than men.
• Wealthier countries report higher incidences of neck pain.
• People between 35-49 years of age are most likely to experience neck pain after which the incidence declines.


A thorough assessment of neck pain means discovering what factors are contributing to the patient’s problem, and test which factors can be changed to alleviate the condition. Here is a brief list of possible factors that can contribute to a person developing neck pain.

• Poor posture (standing, sitting, sleeping)
• History of neck trauma
• Sedentary lifestyle and work environment
• History of repetitive neck or upper extremity motions
• Poor ergonomic set up (especially computer stations)
• Weak neck stabilizing musculature
• Poor shoulder blade position, strength or control
• A family history of neck pain
• Thoracic spine stiffness
• Generalized hypermobility (joint stiffness)
• Central nervous system hypersensitivity
• Depression or anxiety

Once we understand the main factors leading to the development of a patient’s neck pain we can do a complete examination including tests of the muscular and neurological systems as well as a physical examination of the joints. Physiotherapists also screen for more serious medical pathology and refer to the appropriate physicians if necessary. Only after we synthesize all of this information can we put together an excellent physiotherapy treatment plan.


Because each patient’s neck pain has different contributing factors, each treatment plan will be unique to that individual’s problem. Research has shown that physiotherapy combining manual (hands on) therapy and exercise works better than either of those treatments alone. It is critically important that your physiotherapist uses the right type of manual therapy directed to the tissues and joints that require it, and marry it with an expertly prescribed exercise program that supports the manual therapy and addresses your specific areas of weakness. This is why it is important to see a physiotherapist with a deep understanding of the origins of neck pain and how to use these tools to make positive changes.

Other types of treatment that may be of some value are;

• Ergonomic advice / assessment
• Work modifications
• Pain reducing modalities (heat, cold, acupuncture, massage)
• Pain science education
• Counselling or Cognitive Behavioural Therapy to address anxiety or depression – delivered by a psychologist or social worker.


Results are not always immediate, and it is reasonable for patients to question whether they are on the right track. If you are receiving treatment for neck pain (or any other condition) we recommend asking the following questions to evaluate the treatment you are receiving.

1) What are the main factors contributing to my problem?

Ideally your physiotherapist would have already explained them to you. But if not, they should be able to list a few contributing factors that ring true to you.

2) What specifically are we doing to address each of those factors?

There should be a component of your treatment plan that is aimed at correcting each of the problems identified in question 1.

At Cornerstone Physiotherapy, we make sure our patients understand their condition and the plan we are proposing right from the beginning. We also re-evaluate along the way and seek feedback to refine your treatment plan. We believe that expert knowledge and skill, coupled with an open dialogue with our patients is what drives excellent results.

Click here to learn why patients choose Cornerstone Physiotherapy Clinic.

Click here to Book An Appointment at one of our Toronto Physiotherapy Clinics.

The post Physiotherapy for Neck Pain appeared first on Cornerstone Physio.

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Cornerstone Physiotherapy is thrilled to be adding a talented and passionate physiotherapist to our team.

We are well-staffed with a large team of full-time physiotherapists (including fully-credentialed McKenzie therapists and 7 FCAMPTs available for mentoring).


Our idea of highly effective physiotherapy involves one-hour detailed assessments and half-hour follow up appointments that combine skilled manual treatment with expertly prescribed exercise therapy. Find out more about Cornerstone Physiotherapy on our website at www.cornerstonephysio.com.

Our new physiotherapists will be passionate about rehabilitation. They will be confident and collaborate with our clinical team, and with our referring physicians. They will bring knowledge and enthusiasm to our bi-weekly clinical mentoring sessions. They will be the sort of therapist that can create positive and lasting relationships with their patients, and they will understand that each patient’s expectations must not only be met but exceeded.

NOTE: Experience in Vestibular Rehabilitation and/or Pelvic Health is an asset.

Cornerstone is a busy, modern physiotherapy practice that has been serving Toronto since 2008. Our patients are motivated and fully engaged, and we enjoy strong support from the local medical community with ties to nearby hospitals and medical centres.


Cornerstone is physiotherapist owned and operated. We are truly physio-centric, so our vision statement, company structure, and policies and procedures reflect this commitment to the profession of physiotherapy.

We are looking for a permanent physiotherapist for our Toronto physiotherapy clinic location. If you are interested in learning more about this opportunity, please email your resume to adam@cornerstonephysio.com

The post Now Hiring Exceptional Physiotherapists! appeared first on Cornerstone Physio.

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Without question, physiotherapy is the gold standard for treating all types of rotator cuff tears of the shoulder. A well designed and executed physio program delivers excellent results for the vast majority of patients. In fact, research has shown that if patients participate in an appropriate rehab program for 6-12 weeks, 85% of them will do as well or better than if they had the tear surgically repaired. Therefore, the key to solving your rotator cuff problem is to ensure you have the right physiotherapist delivering the right program.

Rotator cuff tears are very common. In fact, imaging studies have shown that about 40% of people over 50, 54% of people over 60 and 65% of people over 70 have a rotator cuff tear (1). Not all tears cause pain or weakness though, so much of the population is walking around with a tear that they are unaware of. It is estimated that about one third of non-symptomatic tears will eventually become painful (2).

Causes of Rotator Cuff Tears

There are two main types of rotator cuff tears, traumatic and degenerative.

Traumatic tears occur rapidly when the strain on the rotator cuff exceeds its strength and the tissue fails. These tears are sudden and often painful so the patient is typically aware of having injured their shoulder. Typically, there is a rapid loss of function and pain that begins to improve over the course of a week when the inflammatory response to the injury begins to resolve.

Degenerative rotator cuff tears have multiple causes that can be categorized as factors that are extrinsic (outside of) to the tendon and intrinsic (inside of) to the tendon.

Extrinsic Factors Effecting Rotator Cuff Tears
– Impingement of the rotator cuff within the shoulder
– Shoulder muscle imbalances
– Poor shoulder blade position and stability
– Shape of the acromion and acromioclavicular (A/C) joint
– History of repetitive or overhead shoulder tasks

Intrinsic Factors Effecting Rotator Cuff Tears
– Overall tissue health of the patient
– Concurrent thyroid disease
– Genetic predisposition
– Poor blood flow to the tendon

Physiotherapy Assessment of Rotator Cuff Tears

It’s easy to appreciate that each tear has a different list of factors that have led to the development of the problem. This is why it is critical that recovery begins with an expert orthopaedic physiotherapist who will conduct a detailed assessment of your condition and design a rehab program that addresses the causes of your tear. A thorough physiotherapy assessment for a rotator cuff tear should consist of:

• A complete history of the shoulder problem
• A complete personal medical history to understand how other conditions might have increased your risk of injury
• Examination procedures to rule out other causes of your pain (referred pain)
• Discovery of habits or maladaptive behaviours that are making the problem worse
(e.g. consistently sleeping on the injured side)
• Observation of shoulder and spinal posture in sitting and standing
• Evaluation of functional movements of the shoulder (pushing, pulling, elevation)
• An examination of the rotor cuff length, strength and motor control (movement patterns)
• Examination of the strength, length and motor control of the larger muscle groups of the shoulder
• Examination of shoulder blade position, movement, strength and coordination
• Examination of rib cage and spinal mobility

Only after looking at all of this information is it possible to create a treatment plan that will focus on rapidly changing the factors that are causing your specific problem, maximizing your likelihood of success.

Physiotherapy Treatment of Rotator Cuff Tears

The treatment that is recommended should match with the findings of your assessment. Your progress should be re-evaluated regularly and your treatment plan adjusted. A treatment plan may consist of some of the following;

– Stretching or strengthening of specific muscle groups to correct imbalances
– Manual therapy to correct tissue imbalances and improve shoulder mobility
– Proprioceptive exercises to improve your sense of joint position and motor control
– Spinal mobility or stability exercises
– Modification of posture
– Activity limitation / modification
– Interventions to improve overall health (nutrition, cardiovascular exercise, smoking cessation)
– Treatment of the torn tissue itself with manual therapy and other physiotherapy techniques

A well-designed program will only have the elements that will help you. Participating in a generalized or non-specific program will mean that you will be doing a lot of things that may not have any benefit for you and it may leave out other key components.

Rotator cuff tears can be very painful and debilitating. But rest assured that an expert orthopaedic physiotherapist can have you back in the game in short order. At Cornerstone Physiotherapy we are committed to orthopaedic excellence and our therapists undergo specialized training to learn how to manage complex shoulder injuries. If you are suffering from what you suspect to be a rotator cuff tear, give us a call.


1) Abnormal findings on magnetic resonance images of asymptomatic shoulders.
Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB
J Bone Joint Surg Am. 1995 Jan; 77(1):10-5.

2) Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically.
Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD
J Shoulder Elbow Surg. 2001 May-Jun; 10(3):199-203.

The post Physiotherapy for Rotator Cuff Tears appeared first on Cornerstone Physio.

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For many people headaches are a regular occurrence and have a significant impact on their daily lives. It has been reported that up to 96% of people between 25 and 64 years of age experience headaches at some point in time. However, as common as they are, knowing how to fix a headache can be difficult. There are many different causes and types of headaches, so effective treatment requires a correct diagnosis by a trained professional.

Physiotherapy can be very effective for one category of headaches called cervicogenic headaches (CGH) or neck headaches. These are headaches that are caused by a painful structure in the neck. If diagnosed properly, then alleviating these headaches can be straightforward, and often dramatically reducing their future occurrences.

Diagnosis of Cervicogenic (neck) headaches

A skilled physiotherapist will conduct an assessment with the following goals:

  • ruling out serious pathology as a cause
  • documenting the characteristics of your headaches
  • comparing them to Criteria (see below) for the diagnosis of CGH.

Using this information, your physiotherapist will evaluate the likelihood that your headaches are actually caused by your neck. If your headaches meet this CGH criteria, your physiotherapist will create an appropriate treatment plan to eliminate your headaches.

Cervicogenic Headache International Study Group Criteria (CHISG)

The gold-standard outline for evaluating whether a headache is caused by the neck, was developed by the Cervicogenic Headache International Study Group (CHISG). This criteria states that a headache may be cervicogenic if:

  • There are signs and symptoms of neck involvement either by creating the headache with neck movement or positioning, by applying pressure in the upper cervical (neck) region or a loss in neck range of motion combined with shoulder and/or arm pain.
  • Confirmation by injections of anesthetic into structures of your neck. (impractical in most settings)
  • Pain on one side of the head that does not shift sides

Some additional points that are often associated with CGH can help you to feel more confident of your findings, but these are often inconsistent and therefore not required to make a diagnosis. These are:

  • Little benefit from use of common medications (indomethacin, ergotamine and sumatriptan succinate)
  • Female sex
  • Significant history of head or neck trauma
Screening for a More Serious Cause of the Headache

If the answer to the following five questions is no, the likelihood that your headache is caused by a serious disease is very low. It is also important to note that if the answer is yes to just one or two of these questions it doesn’t indicate that there is a serious problem present. Rather, the more “yeses” you have, the more likely your physiotherapist will be to work with your doctor in ruling out serious pathology.

  • Is the headache of recent onset (less than 6 months)?
  • Is there any worsening in the frequency or severity of the headaches?
  • Was the initial onset sudden and severe?
  • Are there any clues suggesting hard or true neurologic signs associated with the headaches?
  • Are there any cognitive changes associated with the headaches (e.g., memory loss, confusion, personality changes)?
Physiotherapy Treatment for Cervicogenic Headaches

After arriving at a diagnosis and screening for more serious pathology, your physiotherapist will use all of the information from the history and physical exam to devise an effective treatment plan aimed at eliminating your headaches. Depending upon the factors contributing to your specific case, your treatment plan may consist of a mix of any of the following components.

1. Manual Therapy for Headaches

A therapist skilled in manual therapy will use gentle but effective hands-on techniques to restore range of motion to stiff joints in the upper neck. You will often be asked to perform some movement or stretch between appointments to maintain the range of motion in the area being treated. This can be extremely effective at eliminating headaches for many patients.

Manual therapy may also be directed at soft tissues of the upper neck. In particular the sub-occipital muscles can become a cause of headaches. Trigger point release and gentle stretching of these structures can be effective at breaking the pain cycle.

2. Exercises for Headaches

Many patients who suffer from neck headaches have weakness of the muscles that support the upper cervical joints and head. This weakness results in the head being maintained in postures that place increased stress on the upper neck. If weakness is present, a focused strengthening program is a critical component of an effective treatment plan.

3. Postural and Ergonomic Changes for Headaches

If the history of your headaches suggest that they are influenced by posture and ergonomics (worse with computer work or driving, or worse as the day goes on) your physiotherapist will make suggestions that will reduce this stress. For example, many headache sufferers notice that their symptoms are worse when they work on a computer for extended periods of time. By making small changes to your seating and workstation we can reduce upper neck stress and reduce your headaches.

4. Pain Modalities for Headaches

Some patients who suffer from cervicogenic headaches for an extended period of time experience a phenomenon called ‘central sensitization’. Put simply, this is when the central nervous system (your brain) becomes increasingly sensitive to stimulation in the head and neck area. This results in pain being produced during movements, activities, and positions that should not be painful at all.  Your physiotherapist may use a number of techniques to desensitize the area including gentle manual therapy, thermal modalities, acupuncture and special exercises.

Final Thoughts

Cervicogenic headaches can have a significant impact on a patients’ quality of life and productivity. With proper diagnosis and treatment most people are able to eliminate their headaches and prevent them from coming back. If you think you may suffer from this type of headache, come in for a thorough evaluation by one of our experienced physiotherapists. If your headaches are coming from your neck we can help.

The post Physiotherapy for Headaches appeared first on Cornerstone Physio.

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Spondylolisthesis is a condition where one vertebrae of your spinal column becomes displaced in reference to the vertebrae directly below it. Your spine is made up of 33 vertebrae that are stacked on top of one another to allow our nerves to travel down through the spinal column without any interference. In the case of spondylolisthesis, the translated vertebrae causes a narrowing of the pathway for the nerves passing through it, and can cause a variety of symptoms depending on the severity of the displacement.


It is important to note that most other orthopaedic spinal conditions share the same symptoms, so the presence of these symptoms does not predict the likelihood of spondylolisthesis.

  • Low back pain and/or leg pain
  • Numbness/tingling that radiates down either or both legs
  • Hamstring tightness
  • Muscle weakness in lower extremities, or possible muscle atrophy
  • Pain brought up with prolonged standing, but not sitting
  • Neurological impairments (ie. Diminished reflexes)


There are several causes that can result in spondylolisthesis so it is important to determine the cause of the condition so your treatment plan can be customized for your specific needs. Below are general classifications of spondylolisthesis.

Isthmic Spondylolisthesis: A slow developing fracture/defect at the pars interarticularis sight which causes the vertebral body to slide forward without the support of the back half of the vertebrae. This type of spondylolisthesis typically occurs in the younger population.

Degenerative Spondylolisthesis: Typically occurs at the L3-L4 level, or L4-L5 level of the spine due to weak bones, and ligaments from aging (typically over the age of 50).

Other: In other cases, spondylolisthesis can be caused by a traumatic event in which another part of the vertebrae is fractured causing displacement of the vertebrae, it can be a side effect from a laminectomy, or it can even be a congenital condition as some people are born with elongated pars interarticularis.

Risk factors that may also raise your chances of having spondylolisthesis include:

  • Female gender
  • Older age
  • Excessive hyperextension of spine (as in gymnastics participation)
  • Generalized hypermobility of joints and soft tissues
  • Anatomical predisposition
  • Pregnancy


A history along with a physical examination is typically the first step to find any indication of spondylolisthesis. A noticeable depression on palpation may be present during the physical examination. It is very likely that imaging techniques such as an X-ray, a CT scan, or an MRI will be ordered to confirm the diagnoses, and to rule out any other conditions.

The presence of a spondylolisthesis on a static x-ray is not sufficient to assume that it is the cause of the patient’s pain. Flexion and extension views of the spine in standing can discover if the spinal segment is in fact hypermobile. This, coupled with a subjective history suggestive of spinal instability is reasonably accurate.


Physiotherapists have been shown to help with management of spondylolisthesis. Consulting with your physiotherapist, and coming up with a treatment plan that is specific to your needs is vital to the process.

Exercise therapy is one of the main strategies used to help manage pain, and prevent further translation of the vertebrae. These exercises can include stretching, posture education, and strength exercises to help stabilize the area, reduce pain, and reduce risk of further damage.

Activity limitations will be suggested to help you find alternatives to daily activities that are aggravating the condition. Introducing rests periods in a position of comfort into daily routines will help reduce pain and encourage healing.

Passive treatments where you allow the physiotherapist to perform treatment techniques or modalities can be done to manage pain, or relieve muscle spasm. Manual therapy such as massage can be done to help with chronic muscle spasms, or tension that has been building up from the chronic condition. Heat and cold therapies may further reduce pain in the low back.

If the condition is severe, surgery may be recommended. Physiotherapy treatment will be required before and after surgery.


Outcomes for patients with only spondylolisthesis are typically very good. Patients report short- and long-term relief with participation in an appropriate physiotherapy program.


Spondylolisthesis is a challenging condition that is best managed if caught in its early stages. It can cause very severe symptoms if left unattended. It is recommended that you seek out a physiotherapist to perform an assessment if you feel that your symptoms may be linked to spondylolisthesis. Assessment of your symptoms to discover the root cause of the condition will allow for better management, and prevention of further damage to your body. Intervention is not reserved for when symptoms are at their worst. Often the best time to treat this condition is when you are feeling good. This way you can perform strengthening exercises at an intensity that will have a positive impact on your overall spinal stability without suffering an increase in symptoms

The post What Is Spondylolisthesis? appeared first on Cornerstone Physio.

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Your elbow hurts, you’ve been told you have tennis elbow, and yet you haven’t played tennis in years! You need physiotherapy, but first you want to have a good understanding of the problem to make sure you are on the right track.

Tennis elbow, or lateral epicondylitis, is a common condition and is treatable with skilled physiotherapy. However, not all tennis elbows are the same, and they each have to be assessed and treated differently in order to ensure success. Here we will outline some of the common factors that lead to tennis elbow and how to ensure you have an appropriate physiotherapy treatment plan.


Tennis elbow (or lateral epicondylitis) can mean:

  • pain on the lateral aspect (outer side) of the elbow
  • discomfort when   1) gripping objects   2) when bending your elbow or   3) trying to raise your hand upward against resistance when your palm faces downward.
  • damage to the common extensor origin or tendon, which is the area where the tendons from the muscles that extend the wrist and fingers meet.
  • usually a very tender point an inch or so past the bony part of the outer elbow (lateral epicondyle).

Tennis elbow can be a persistent problem and patients are often unsure of how to improve their pain. There are two keys to successful physiotherapy treatment of lateral epicondylitis.

ONE:  Identify your stage of healing and tailor treatment techniques specific to it.

TWO: Understand all of the factors that contributed to the problem, and create a treatment plan that directly addresses these factors. Treatment should always begin with a detailed physiotherapy assessment that reveals the history of the problem and discovers all of these contributing factors.


As mentioned, every case of tennis elbow is a little different, so no two treatment plans will be exactly the same. A detailed physiotherapy assessment will discover what factors are contributing to your specific problem. Here are some of the more common factors that contribute to this condition and how they can be addressed by your physiotherapist.

  1. Repetitive Motions

Tendons are known to break down when the strain that they are required to withstand is more than what their structural integrity can handle or adapt to. This can happen in a single motion where the force is so great that the tendon tears, creating an acute injury OR it can be many small forces over a time-frame that is too fast for the body to safely adapt to.  This is why people who have jobs or hobbies that involve repeated movements of the hand, wrist or elbow are at higher risk for developing tennis elbow. When you increase this activity faster than your arm can adapt, tennis elbow will begin. You wouldn’t expect a runner to roll off the sofa and immediately run a marathon. We know that they have to train by slowly increasing mileage, carefully managing the stress on their body so that they can build strength over time and avoid injury.

This principle is not limited to sports. If your job or hobby involves some type of physical strain, increases in this strain must be managed in stages to ensure you’re adapting safely to the new load. Your physiotherapist will help to identify the repetitive motions that are contributing to your problem and can coach you on how much of this activity you should be doing, as well as how to appropriately increase this over time in a way that your body can handle. While healing, it may be necessary to adjust the movement or activity to reduce stress on your tissues.

  1. Tightness of Forearm Muscles

The tendons affected by lateral epicondylitis are attached to the muscles of the forearm that extend the wrist and fingers as well as help bend the elbow. For normal and safe arm function, it’s important that these muscles are long and flexible enough to perform all of the tasks required of them. If muscle length is insufficient, the load on these tendons are increased with activities that require wrist, hand and elbow mobility.

It’s important to note that tightness on the other side of the forearm will also have a negative impact (the sider closer to your body, called the flexor side). When you extend your wrist, if you’re working against shortened and stiff wrist flexor muscles, the load on your tendons is similarly increased. These muscles can become tight when they are 1) overused in a shortened position or 2) not used enough in their fully lengthened positions.

People spend most of their work-life doing repetitive administrative tasks and working with computers rather than more varied manual labour involving a variety of arm positions and angles. This opens the door for muscle tightness to develop. Your physiotherapist will look at muscle length and mobility at your elbow, wrist and hand in various positions and combinations to make sure that you have good tissue length to perform all of your required tasks. Stretches and exercises will then be prescribed to regain mobility in tissues that have become shortened.

  1. Shoulder Tightness

You might be thinking “what does shoulder stiffness have to do with my elbow pain”. Well the answer is quite simple. When we lack movement at one joint, the neighbouring joints tend to have to make up for it. So, with a simple task that would normally be shared between your wrist, elbow and shoulder, a lack of shoulder mobility will overload the wrist and elbow. Given that tennis elbow is especially vulnerable to increased strain at the wrist and elbow at the same time – you end up with pain. The shoulder may be stiff from hours of poor posture, or from a previous injury. Either way, your physiotherapists should assess your shoulder mobility to see if it is contributing its fair share of mobility to your upper extremity tasks.

  1. Neck Problems

Pain, stiffness and dysfunction in the lower neck have been shown to cause ‘tennis elbow like’ elbow pain, even when the neck is not painful. The nerves to the outer elbow exit from the lower cervical spine (or neck joints). As a result, a problem in this lower neck area can refer pain down to the elbow mimicking lateral epicondylitis. This can even cause the classic point tenderness at the elbow and positive physiotherapy muscle tests.

It is important that your physiotherapist examines your neck and takes a detailed history that includes questions about neck pain or stiffness. There are also some very good tests that can help to discover if your neck is involved in producing your elbow pain. If you have a past or current history of neck pain it is important that your physiotherapist considers your neck as a possible source of the problem. If your pain is actually due to an unidentified neck problem, no amount of elbow treatment will provide lasting results!

  1. Ergonomics

To ensure successful recovery, it’s important to use strategies and techniques that address the body’s problem directly, and to optimize the environment that the body has to work within. We mentioned briefly that some activities may need to be modified in order for lateral epicondylitis to improve.

Ergonomics is the study of peoples’ physical efficiency in their working environments; how good is the fit between your body and the job you need it to do, in the place you need to do it. It can play an important role in injury prevention and rehabilitation. When it comes to tennis elbow the following factors should be looked at and altered if necessary:

Seating positon – is the keyboard and mouse height ideal to your elbow position? Do the forearms have appropriate support and does the chair promote good sitting posture and alignment?

Grip Size – when tools are used is the size of the grip appropriate for your hand. If the grip is too small or too big you have to use much more force to perform the same task. This is not only true of tools but of sporting equipment like squash or tennis racquets.

Vibration – do any of the tasks that you need to perform expose your arm to vibration? This can be very stressful on the joints and supporting muscles so these tasks must be performed well, with high quality tools and regularly planned breaks from the task.


You’re now aware of the common factors that cause tennis elbow and how a physiotherapist might address them. Let’s move on to the other important principle of treatment,… timing. A new or ‘acute’ injury needs to be treated very differently than one that is older or ‘chronic’.

Acute injuries show signs of active inflammation; a process that is helping your body to repair. At this time, your therapist needs to reduce physical stress, rest the area and use more gentle techniques that are aimed at ensuring that you get a complete repair. We need to create an environment where your body is allowed to go through the natural healing process that has already begun. And then introduce stresses in a stepwise fashion, when the injury is ready to tolerate increased loads.

Many tennis elbows that come into our clinic are no longer acute but have been a problem for a long period of time. They no longer show the characteristic signs of an inflammatory process, but for some reason they have failed to heal. In these cases, the physiotherapist must use treatment techniques that will kick-start the inflammatory process again in a planned, controlled and responsible manner. Inflammation is the first stage of healing, so physiotherapists are often taking chronic tissue problems and using pro-inflammatory techniques to re-start the healing process over again.

Some techniques that can kick-start healing in a chronic tennis elbow are:

  • Manual Therapy

Your Physiotherapist may use hands-on tissue manipulation techniques to create a small amount of micro-trauma to the area to re-sstart the inflammation process.

  • Exercises

Specific exercises that have a goal of stressing the tissue to just beyond its current capability can be used as a pro-inflammatory technique.

  • Shock Wave Therapy

Extracorporeal Shockwave Therapy (ESWT) can be very effective to help stimulate the inflammatory process. Click here to learn more about shockwave treatment.

These techniques are used at specific intervals of time, to allow the body to go through a natural healing process between treatments.


At this point, it’s easy to see that no two tennis elbows are exactly the same. In order to cure your specific tennis elbow, a skilled Physiotherapist must assess what the contributing factors are and understand which stage of healing you are in. Only then are they able to put together a treatment plan that is sure to reach your goal of a pain-free elbow.

The post Physiotherapy for Tennis Elbow (Lateral Epicondylitis) appeared first on Cornerstone Physio.

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To many Torontonians the idea of running outdoors through the winter seems crazy. With -25 degree temps and -40 degree wind chill, a cozy warm gym tends to be the activity of choice. But, for those of us who like to be prepared for the spring race season, we need to get the miles in to build up a foundation of fitness. And all those miles on a treadmill is worse than -40 wind-chill!

So how do you comfortably run outdoors through the winter? A few tips and a little preparation and you can be out enjoying our Toronto winters without risking injury.

Manage cold weather with layers.

There is a reason you never see anyone running in a parka! Being warm when you run is all about managing moisture (sweat). A proper base layer that wicks moisture away from your skin is essential. It should be followed by a mid-layer that has some insulating qualities and is not made of cotton. And lastly an outer-layer that is resistant to wind and moisture. Most of us skip the mid layer on the bottom half. You will not be as cold as you think – you will be running after all. Don’t forget some thin moisture wicking gloves and hat as well as quality running socks to keep those digits from freezing. Yes you will have more laundry…but it is a small price to pay for a winter of great running!

Prevent Slip and Falls with shorter strides

Toronto winters come with ice and snow and we all know that you cannot count on sidewalks or even roads to be cleared in a timely fashion. This means you will be running on uneven and sometimes slippery ground. To avoid falls that can result in significant injuries shorten your stride up to about 2/3 of your normal running stride. This allows you to keep your centre of gravity well within your base of support at all times and greatly reduces the likelihood of a fall. At first you will feel like you are taking quick baby steps but in no time, you will adjust and find your groove.

Get a grip!

On those snowy days make sure you have the traction you need. There are lots of products that you can use to supplement the soles of your runners. We personally use a set of pull-on winter studs that stretch over the sole of our runners and help bite into the ice and snow.

Reflect on your clothing choices

Winter has shorter days which means that many of us have to run when it is dark out. Dark colours are very hard for motorists to see and can end in disaster. Make sure drivers can see you with reflective outerwear and/or LED lights.

Bring a friend

If you love running enough to train through a Toronto winter, there is a large community of runners who share your passion for pain. Connect with a running group and find people to train with. Especially if you will be running in remote areas or on trails where a fall could leave you injured and in need of help. Your friends will make training more fun as you commiserate over the weather. It also helps drag you out of bed when you have to go and meet your training partner.

Cross train for performance and injury prevention

This is a great time of year to work in some resistance training, pool training or flexibility work. A quick visit to your runner/physiotherapist can help find areas that you need to improve upon to avoid injury. These supplements to your regular running will pay dividends in the spring and can be done in the cozy warmth of the gym or your home.

Don’t be a hero

You will not be setting any personal records in winter conditions so don’t try to…..period. This is the time of year to get a good volume of miles in so that when the northern hemisphere tilts toward the sun, you’ll be ready to push yourself without risking injury.

Follow these tips and you can run safely and comfortably even in the harsh Toronto winter. If you commit to it for just 3 weeks we’ll bet that you’ll love it. Join the many runners that look forward to winter once they have the routine down. So hit the road Toronto. See you out there!

The post The Physiotherapist’s Guide to Pain-Free Winter Running appeared first on Cornerstone Physio.

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The first time you wake up with low back pain can be distressing. You immediately realize that a pain free back is required to do the simplest things like getting out of bed, putting on your socks or even brushing your teeth. You begin to think “will it always be like this? and Is this my new normal?”

The First Rule of Back Pain – Don’t Panic!

The first thing you should know is that the vast majority of back pain is not an indication that you have a serious problem. For most people, this condition will get better with time and if you commit yourself to treating it properly you are very likely to get better. Anxiety is known to make a person’s perception of pain worse. So, try not to entertain catastrophic and stressful thoughts. Instead remind yourself that this is temporary.

Slowly get moving.

Movement is painful at first but typically improves after a few minutes. There are several exercises that your Physiotherapist can teach you to restore normal pain free mobility of your spine. If you have not seen your Physiotherapist yet, take 15 minutes to get your spine moving with a brisk walk on flat ground. It may hurt a bit at first, but most people will find that after a short time, things begin to improve. This is a strategy you can use throughout your day. Typically, people will find that their back becomes painful and stiff after sitting or standing in one place for longer than 15-20 minutes.

Things to Avoid When Experiencing Back Pain

In the early stages of an episode of back pain things will feel very fragile and unstable. Rest assured that your spine can do more than it seems. If you avoid a few key things it will help to ensure that the activity you are taking on is not making your pain worse.

  • Do not stay in bed! Being idle in bed is a sure-fire way to make your back pain last longer and be more intense. So even if it is painful try to get up and get moving.
  • Do not lift heavy objects. Give your spine a break from heavy loads. When you need to lift smaller objects, keep them close to your body and lift with your spine straight and both feet firmly planted shoulder width apart on the floor.
  • Avoid sitting for longer than 20 min. at a time and choose firm chairs with good support.

Tips to Help Get Through an Episode of Back Pain

Here are a few things you can do to help move through your back pain more quickly and comfortably.

  • Gentle movement – I know I already said it, but it bears repeating. The more you remain active with low impact movement the better your back pain will be and the shorter this episode of pain will be.
  • Use your arms! When you have to lean over a counter (such as prepping food or brushing your teeth) place your hand on the counter as another point of stability. This will help to reduce the strain on your back.
  • Use lumbar support when sitting. When sitting you will find that if your spine is maintained in the same position that it is when you are comfortably standing, you will not stiffen up nearly as much.
  • Heat for pain relief. You can apply some mild heat to your back a few times a day to help alleviate some of your pain. Apply heat for 10-15 minutes and allow your skin to return to its normal temperature before reapplying.

Call Your Physiotherapist

A Physiotherapist with experience in back pain is an invaluable resource. While the advice above is safe for any back pain, it is not specific to the type of back pain you have. A qualified Physiotherapist will do an assessment to determine what type of back pain you are experiencing, develop a treatment plan to solve the problem faster, and reduce the likelihood of recurrence.  Our staff at Cornerstone Physiotherapy in Toronto have specific post-graduate training to expertly treat spinal conditions including low back pain.  We can help! Click here to contact us today.

The post Help! I Woke Up With Back Pain appeared first on Cornerstone Physio.

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