Archive for September, 2011

When you woke up today, you thought this was like any other Friday. You’re on your way to work, and traffic is flowing smoother than normal.  Suddenly, someone crashes into the back end of your car and you feel your head extend back over the headrest and then rebound forwards, almost hitting the steering with your forehead. It all happened so fast. After a few minutes, you notice your neck and head starting to hurt in a way you’ve not previously felt.   When the police arrive and start asking questions about what had happened, you try to piece together what happened but you’re not quite sure of the sequence of events.  Your memory just isn’t that clear. Within the first few days, in addition to significant neck and headache pain, you notice your memory seems fuzzy, and you easily lose your train of thought. Everything seems like an effort and you notice you’re quite irritable. When your chiropractor asks you if you’ve felt any of these symptoms, you look at them and say, “…how did you know? I just thought I was having a bad day – I didn’t know whiplash could cause these symptoms!”

Because these symptoms are often subtle and non-specific, it’s quite normal for patients not to complain about them. In fact, we almost always have to describe the symptoms and ask if any of these symptoms “sound familiar” to the patient.

As pointed out above, patients with Mild Traumatic Brain Injury (MTBI) don’t mention any of the previously described symptoms and in fact, may be embarrassed to discuss these symptoms with their chiropractor or physician when they first present after a car crash.  This is because the symptoms are vague and hard to describe and, many feel the symptoms are caused by simply being tired or perhaps upset about the accident.  When directly asked if any of these symptoms exist, the patient is often surprised there is an actual reason for feeling this way.

The cause of MTBI is due to the brain actually bouncing or rebounding off the inner walls of the bony skull during the “whiplash” process, when the head is forced back and forth after the impact. During that process, the brain which is suspended inside our skull, is forced forwards and literally ricochets off the skull and damages some of the nerve cells most commonly of either the brain stem (the part connected to the spinal cord), the frontal lobe (the part behind the forehead) and/or the temporal lobe (the part of the brain located on the side of the head). Depending on the direction and degree of force generated by the collision (front end, side impact or rear end collision), the area of the brain that may be damaged varies as it could be the area closest to initial impact or, the area on the opposite side, due to the rebound effect. Depending on which part of the brain is injured, the physical findings may include problems with walking, balance, coordination, strength/endurance, as well as difficulties with communicating (“cognitive deficits”), processing information, memory, and altered psychological functions.

The good news is that most of these injuries will recover within 3-12 months but unfortunately, not all do and in these cases, the term, “post-concussive syndrome” is sometimes used.

Advertisements

Have you ever stopped and wondered, “…which type of doctor should I go to for treatment of my headaches?”  In order to make an informed decision, it is appropriate to look at the side effects each treatment option carries and then consider the pros and cons of each treatment.

It has been reported that 45 million Americans suffer from headaches, many on a daily basis. Though some just put up with the pain, others become totally disabled during the headache. Most people initially turn to an over the counter drug such as a non-steroidal anti-inflammatory drug (NSAID) of which there are 3 types: 1) salicylates, such as aspirin; 2) traditional NSAIDs, such as Advil (ibuprofen), Aleve (naproxen); and, 3) COX-2 selective inhibitors, such as Celebrex.

According to the medical review board of About.com, complications of NSAID drugs include stomach irritation (gastritis, ulcer), bleeding tendencies, kidney failure, and liver dysfunction. Some NSAIDs (particularly indomethacin) can interfere with other medications used to control high blood pressure and cardiac failure and long term use of NSAIDs may actually hasten joint cartilage loss, leading to premature arthritis. Another over the counter commonly used drug is Tylenol (Acetaminophen) in which liver toxicity can be a potential side effect (particularly with long term use).

Here’s the kicker – only about 60% of patients respond to a 3 week trial of an NSAID, NSAIDs can mask signs and symptoms of infection, it cannot be predicted which NSAID will work best, and no single NSAID has been proven to be superior over others for pain relief. Moreover, estimates of death associated with NSAID (mostly gastrointestinal causes) range between 3200 on the low side to higher than 16,500 deaths per year in the United States. Another BIG concern is that low daily doses of aspirin, “…clearly have the potential to cause GI injury as 10mg of aspirin daily causes gastric ulcers.”

Others may turn to prescription medication for hopeful pain relief. One of the more frequently prescribed medications for headaches is amitriptyline (commonly known as Elavil, Endep, or Amitrol).  This is actually an antidepressant but was found to work quite well for some headache sufferers. The potential side effects include blurred vision, change in sexual desire or ability, constipation or diarrhea, dizziness, drowsiness, dry mouth, headache (ironically), appetite loss, nausea, tiredness, trouble sleeping, tremors and weakness. Allergic reactions such as rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips or tongue, chest pain, rapid and/or irregular heart rate, confusion, delusions, suicidal thoughts or actions AND MORE are reported.

The pros and cons of chiropractic include a report on children under 3 years of age, where only one reaction for every 749 adjustments (manipulations) occurred (it was crying, NO serious side effects were reported). In adults, transient soreness may occur. Though stroke has been reported as a cause of headache, it was concluded that stroke “…is a very rare event…”, and that, “…we found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.” Another convincing study reported that chiropractic was 57% more effective than drug therapy in reducing headache and migraine pain!  They concluded – chiropractic first, drugs second and surgery last.

Fibromyalgia and the Weather

Posted: September 21, 2011 in Fibromyalgia

Recently, a doctor had a patient tell him she had a “break-through” in her fibromyalgia (FM) symptoms that she was VERY excited to share. Having known this patient for a long time, he was intrigued by her enthusiasm.  She told her doctor that her family had never had an air conditioner before until late last fall before the winter and hadn’t used it yet until recently. She discovered that her generalized, whole body aches were significantly improved by running the AC, even when set at 79°F when the temperature outside may not have required it.

We all know that FM causes many symptoms such as relentless fatigue, muscle pain, depression, dizziness, nausea, and the list goes on.  It’s also no secret that FM symptoms vary considerably between seasons, as well as with certain weather changes, not to mention temperature changes, air pressure or barometric changes, and when it rains. Changes in fatigue, sleep patterns, headache intensity/frequency, muscle pain, severe episode flair-ups are frequently reported by the FM patient. As far back as 1981, a study reported that a large percentage of FM patients may be more sensitive to changes in weather compared to non-FM subjects. In fact, they stated 90% of the FM patients reported weather was one of the most important factors influencing their FM symptoms. Weather changes commonly affect symptoms in patients with other conditions such as rheumatoid arthritis, multiple sclerosis, and osteoarthritis. But, the question remains, how does weather affect fibromyalgia?

There are 5 major weather factors that appear to affect FM symptoms:

  1. Temperature: especially rapid changes in temperature and cold tend to irritate while warm temperatures are less troublesome.
  2. Barometric Pressure: This is the measure of weight (pressure) that is exerted by the air that is all around us. Sunny days create a high barometric pressure while storms result in a sudden drop. These changes can trigger muscle aches in FM patients.
  3. Humidity: This refers to the amount of water vapor present in air. Humidity is associated with headaches, stiffness and widespread pain flare-ups in FM patients.
  4. Precipitation: This refers to any type of water that falls from the sky to the ground (rain, sleet, snow, hail) and is usually associated with a change (usually a drop) in barometric pressure. This can result in increased pain and fatigue in FM patients
  5. Wind: In general, wind usually causes a decrease in barometric pressure regardless of its force and therefore can trigger fatigue, headache, and muscle pain in FM patients.

Though a number of studies are available that support weather’s adverse effects on the FM patient, researchers still are not exactly sure why this occurs but offer several explanations for this. One has to do with our sleep cycle. It appears that changes in the sleep cycle occur at times of extreme temperature – either hot or cold and this can negatively affect the FM patient. Another explanation involves the changes in our Circadian Rhythm that normally occurs with the changes in seasons due to the amount of light our body receives, less in the winter, more in the summer causing fatigue and achiness. The third explanation is the relationship between low temperature levels and an increase in the number of “pro-inflammatory cytokines” in the body, which increases pain intensity. FM patients have reported benefits from dressing in layers, avoiding cold temperatures, and increasing the amount of light inside the house (halogen bulbs, a light box, and also, taking Vitamin D can help too!).

Carpal tunnel syndrome or, CTS, causes pain and/or numbness into the hand and because it’s so common, CTS is often the first and the last diagnosis a doctor makes when a patient presents with these symptoms. The purpose of this Health Update is to consider other conditions that present in a similar way and if not treated correctly, may result in a poor post-treatment result.

In order to understand what CTS is, it’s important to learn about where the nerves originates.  The nerves to the hand start in the neck and merge together like 5 lanes of traffic (C5 to T1 nerve roots exiting the spine) merging into 3 primary lanes (called “cords”) that give rise to smaller roads and eventually continue into the arm as 3 primary nerves (the ulnar, median, and radial nerves).

In their journey into the arm, they travel through tight openings (some of which are called tunnels) at various places which include: the neck (the anterior scalene triangle made up of muscles); the thoracic outlet (in the shoulder where the collar bone, first rib and shoulder blade come together with multiple muscle attachments); the elbow which has 3 tunnels: the cubital tunnel located on the inner side (palm facing forwards) often referred to as the “funny bone,” where the ulnar nerve travels (which brings strength and sensations to the pinky side of the forearm, hand and 4th and 5th fingers), the pronator tunnel located in the middle of the elbow where the median nerve travels (bringing strength and sensations to the middle 3 fingers – digits 2, 3, and thumb side of digit 4); and the radial tunnel located on the thumb side outer elbow where the radial nerve travels (which strength and sensations to the thumb and back half of the index finger); and finally the wrist, which also has 3 tunnels for the same 3 nerves: tunnel of Guyon on the pinky side (ulnar nerve), carpal tunnel in the middle of the wrist (median nerve), and the radial tunnel at the “anatomical snuff box” for the radial nerve for thumb and back side of digit 2/index finger).

Therefore, when we consider all the places where nerves can get pinched, it’s no wonder why the entire area MUST BE thoroughly evaluated BEFORE agreeing to a surgical procedure for CTS or any other peripheral neuropathy. A nerve can get pinched anywhere if a fracture or blunt trauma occurs.  The challenge occurs when there isn’t an obvious injury like a fracture and we have to systematically check each of the many “tunnels” that exist in the neck, shoulder, elbow and wrist as described above.

The “take home message” here is don’t rely on a quick exam where the health care provider barely touches you and quickly diagnoses CTS based on your history of numb hands. Because it’s the most common of the upper extremity peripheral neuropathies, this is frequently assumed and is probably the explanation for those who fail post-surgically. To complicate matters, diabetes and other conditions can create similar symptoms and, more than 1 area may become compressed, requiring treatment in multiple areas.

Low Back Pain and Scoliosis

Posted: September 21, 2011 in Back Pain

Scoliosis is a term used to describe a curvature of the spine that is not “normal.” The normal curves of the spine include an inward curve in the low back and neck and an outward curve in the mid-back when looking at the person from the side (“sagittal plane”). However, there should NOT be any curves when looking at a person from the front or back (the frontal plane), the spine should be straight. When there is a curve in the frontal plane, this is called scoliosis and it’s usually either a singe curve, shaped like the letter “C” or, a double (or more) curve, shaped like the letter “S”. Though there is a diagnostic code specific for scoliosis, it is not in itself a disease or a diagnosis and frequently, there are no or at worst, minimal symptoms associated with it. For this reason, most of the time, scoliosis is not noticed until the curve progresses significantly and a friend or family member makes a comment about it or a school screening picks it up.

The most common spinal location for scoliosis to develop is in the middle to upper back (called the thoracic spine) but it can also be located at the junction between the mid back and low back, as well as in the low back only or more rarely, in the neck only. Since there are rarely symptoms associated with scoliosis, the way it’s found is by observing one or more of the following:

• One shoulder is higher than the other
• One shoulder blade sticks out more than the other
• One side of the rib cage appears higher than the other (called a “rib hump”)
• One hip appears higher or more prominent than the other
• The waist appears uneven
• The body tilts to one side
• One leg may appear or actually be shorter than the other

The use of x-ray usually is appropriate to confirm the diagnosis, to measure the amount of curve, which can then be used for future comparison, and to rule out a possible unusual cause of scoliosis. Rarely is an MRI required – only in cases where neurological signs and symptoms exist and, in younger children (ages 8-11 years old) as scoliosis almost always occurs during the puberty timeframe when hormonal systems are kicking in, such as ages 12-14. When scoliosis occurs at ages less than 11, when there are neurological changes (reflex, muscle strength and/or sensory functions), and/or when the mid-back/thoracic curve bends to the left (as it almost always curves to the right), an MRI is appropriate to rule out spinal cord pressure.

The decision to treat or not to treat is dependent on 2 factors: 1) The “skeletal maturity of the patient” (how much growing is left for the person) and, 2) The degree of the curve. In general, the bigger the curve and the younger the patient, the greater the chance for curve progression or worsening. With that said, curves less 10° reportedly don’t require treatment but over 20° should be watched at 4-6 month intervals. If a curve progresses >5° and/or when the curve is >30° in an adolescent, the person should be treated – most doctors would utilize a back brace. Chiropractors can offer additional care by applying spinal adjustments, reducing leg length deficiencies when a compensatory lumbar/low back curve is present and by offering scoliosis-specific exercises.

We realize you have a choice in who you choose to provide your healthcare services. If you, a friend or family member requires care for low back pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.