Archive for July, 2012

Whiplash and Muscle Weakness

Posted: July 2, 2012 in Whiplash

Whiplash, as previously discussed, occurs quicker than the speed at which we can voluntarily contract our muscles in attempt to guard ourselves against injury. Hence, it is nearly impossible to properly brace in anticipation of an impending collision. When muscles, ligament, and joint capsules become injured, there is pain, and as a result, reflex muscle spasm occurs as the body attempts to “splint” the area to protect it. This sometimes sets up a vicious cycle which can make the pain last longer, hurt more intensely and / or hurt more frequently. Because of pain, as well as direct muscle injury that sometimes occurs in whiplash associated disorders (WAD), the natural tendency is to stop doing many activities and guard against motion both because of pain and the fear of it hurting worse. In both cases, the result is the same: muscle atrophy or shrinkage and muscle weakness due to not using the muscle.

There are other reasons that muscles become weak. When an injury occurs, a herniated or “ruptured” disk can injure the spinal nerves exiting the spine. The disk is like a jelly donut where the center is liquid-like surrounded by a thick ring of fibrocartilage and functions as a “shock-absorber” as it sits between 2 vertebral bodies

Think of the spinal nerves like electrical wires that connect a fuse box to a house. The fuse box is the spinal cord and each wire represents the spinal nerves going to different parts of the house (body). In the cervical spine or neck, each wire goes to different parts like the head, shoulder, arm, and hand and innervates specific areas. Patients who have a pinched nerve from a whiplash injury describe their symptoms as numbness, tingling, pain and/or muscle weakness in a specific distribution or area.

There are 8 pairs of nerves in the neck that travel to different parts of the head (C1-3), the shoulders (C4, 5), and the arm (C6-T2). Let’s say a patient has numbness and tingling down the arm to the 4th & 5th fingers and the pinky side of the hand. That immediately tells us as chiropractors that the C8 nerve is injured (pinched) because that’s the pain pattern of the C8 nerve. Certain muscles are controlled by C8 that we can test in our office to determine if they are weak (abnormal) or strong (normal).

We grade the weakness between 0-5 (5=normal). The chiropractic treatment is aimed at un-pinching the nerve which results in a return of normal nerve function or no numbness/tingling and a strong C8 muscle (finger flexion strength). To accomplish this, we may use a combination of treatments such as spinal adjustments, mobilization, traction, exercises, and/or modalities (electric stim, light therapy, ultrasound or others).

We realize you have a choice in where you choose your healthcare services. If you, a friend or family member requires care for whiplash, 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.

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It’s safe to say that if you haven’t had neck and/or shoulder pain, you probably will. Like low back pain, there is a statistical increase in probability that once you’ve had neck pain, the chances of having another episode are significantly increased. A recent study reported that over a 12-month period, 16-18% of the population studied complained of neck and shoulder pain and each year, medical care was obtained by 21-38% of that same group. Moreover, 13-21% lost work time because of their neck and/or shoulder pain. The study reported there was a “…strong episodic nature…” as this condition was found to frequently come and go. Neck pain can arise from a number of structures including muscles, ligaments, bone, joint capsules, and more. Typically, a patient presenting with neck pain is treated for a few weeks and is then quite satisfied with their result… until the next time. Unfortunately, there is usually, “…a next time.” So, the question is, what can we do to prevent neck pain or its reoccurrence?

When considering the many causes of neck pain and the high rate of recurrence, one common finding in those with this popular “come and go” neck/shoulder pain pattern is weakness of the deep flexors muscles located in the front of the neck. One reason for this common finding is that it is very difficult to strengthen the deep, intrinsic muscles of the neck as they are “involuntary.” That means, we cannot consciously “flex” or purposely contract our deep neck flexor muscles. Also, the larger extrinsic muscles tend to be too tight and by reflex, “turn off” or, inhibit the deep neck flexor muscles, compounding the problem.

Therefore, in order to exercise them, we must “trick” the deep muscles into contracting without contracting the larger, extrinsic muscles. This can be accomplished by doing a very specific, controlled exercise with our neck by laying on the back with a partially inflated blood pressure cuff (or, by using a special device purposely made for this test and exercise) placed behind the neck. The inflatable bag is pumped up partially to about 20mmHg and then in a VERY controlled manner, we tuck in our chin and flatten our neck pressing into the bag raising the pressure by 2mmHg and holding that steady for 3-5 seconds. This is repeated in increments by pushing down a little harder until the gauge reads 24mmHg and again, holding that for 3-5 seconds. This pattern is repeated 5x or, until you reach 30mmHg and the process is then reversed releasing the pressure in 2mmHg increments at 3-5 second holds until you reach 20mmHg again. Sound easy? Not quite!!! This exercise requires “fine motor control” to accomplish the task and most of us haven’t specifically addressed these fine moving muscles and end up only exercising the larger extrinsic muscles by doing traditional neck strengthening exercises, which further inhibits the deep neck flexors.

The first time you try this, you’ll be amazed at how challenging and tiring it is. But, after a few days of performing the exercise, you may find you feel much better! Of course, this depends on the degree of injury one has, but often, once cervical spine stability is improved by strengthening these deep neck flexors, symptoms usually improve. So, the question is, can we achieve good deep neck flexor strength by doing a more practical, upright position exercise rather than requiring a costly apparatus that requires a laying down position? In a recent study, a standing exercise where a similar movement called, a “neck-lengthening maneuver” was performed producing similar results as the laying down exercise (relaxation of the strong, extrinsic – outside – muscles and strengthening of the deep neck flexors). Simply tuck in the chin and stand tall, “lengthening” your neck!

We realize that you have a choice in where you choose your healthcare services. If you, a friend or family member requires care for neck 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.

Exercise therapies have been identified as one of the most effective forms of treatment for Fibromyalgia (FM). Unfortunately, in a study of 121 newly diagnosed FM patient files, less than half included an exercise recommendation. This statistic is alarming! This month’s article will focus on recent FM studies supporting the benefits of exercise.

The first study looked at the immediate effects of a 6-mo. combined exercise program and its impact on quality-of-life, physical function, depression, and aerobic capacity in 41 FM females. Also, it studied the impact of starting and stopping the program. A group of 21 women were placed into the exercise group and 20 into the control group. Questionnaires and a physical fitness screen were used to measure the outcome or benefits of the program vs. no intervention at baseline (initial), and after 6 months of exercise training followed by 6 months of no exercise training over a 30 month timeframe. Results highly favored the exercise training group over the control group in all parameters both during the exercise training (immediate effects) and during the no exercise 6 month time frames (long-term benefits).

A Chicago-based pilot (small-scaled) study evaluated the use of aerobic conditioning (VO2 max.) on 26 FM subjects at baseline and after a 12-week home-based aerobic exercise program. The exercises included a 30 minute program at 80% of the maximum heart rate, and also measured pain, disability, depression and stress. Results showed those who successfully completed the 12-week program demonstrated an increase in aerobic conditioning, and a trend towards less pain, disability and stress reduction. Those who were unable or unwilling to participate had significantly higher pain, disability and a trend toward more depression at baseline vs. those that completed the program. The conclusions suggest aerobic exercises benefits the FM patient’s quality of life and, VO2 max is a useful marker for measuring exercise benefits. Also, those scoring initially high in the pain, disability, depression/stress measures were more likely to fail and may benefit from a more comprehensive guided program.

Another study looked at the effects of a 3x/week, 16-week exercise program in a chest-high pool of warm water measuring global symptoms and exercise adherence (compliance) levels. A group of 60 middle-aged FM women were compared to 20 healthy, similarly age matched females before and after a 16 week aquatic exercise program that included strength training, aerobic training and relaxation exercises. Tender point count, health status, sleep quality, physical endurance, psychologic and cognitive function were measured and, compliance at 12-months was studied. Again, the results revealed statistical improvement in most of the parameters tested in the FM exercise group and, 23 of the 60 were still exercising at 12 months. Again, the conclusions favor the need for exercises in the management of FM.

As noted in the initial paragraph, in spite of all the positive research support for including exercise training in FM patients, less than half of newly diagnosed FM suffers are given exercises as part of their treatment plan. The need for exercises to be part of the FM treatment plan is clear, and training needs to be initially structured to enhance compliance.

If you, a friend or family member requires care for FM, we sincerely appreciate the trust and confidence shown by choosing our services!

Carpal Tunnel Syndrome (CTS) is a common condition usually associated with repetitive strain from jobs that require a fast, constant movement of the arms and hands (such as working on an assembly line). Up to 9% of adult women develop CTS and the incidence increases after age 50. A common medical treatment approach has been a combination of drugs (including corticosteroids), diuretics, splinting at night, and modifying activities, often including a “light duty” status until the symptoms calm down. Prior to accepting surgery as, “…the only option left,” an “alternative treatment” approach of vitamin B6 (and of course, chiropractic manual therapies) is chosen by many. Many treatment approaches have been previously discussed; however, today, we’ll take a closer look at the vitamin B6 /CTS connection.

Research regarding the use of vitamin B6 or, pyridoxine, can be traced way back into the ‘70s and ‘80s when it was reported that B6 is involved in several metabolic pathways, including neural function (“neurotransmission”). This is how it helps CTS patients since CTS occurs as the consequence of a pinched (median) nerve at the wrist. Findings from the initial studies, though quite small in terms of the number of subjects, suggested B6 improved the symptoms of CTS (such as, numbness and tingling into the 2nd to 4th palm-side fingers) by raising the pain threshold (that is, the point when symptoms occurred). Another study reported improvements in pain scores and mild improvements in electromyography and nerve conduction velocity (EMG-NCV) studies. Another study reported that at least 7 patients in their study were B6 deficient when blood tested. Regarding the dose, one study reported that taking only 2mg of B6 was enough to improve the patient’s CTS symptoms, but 100mg was needed for the avoidance of surgery. In a large “retrospective literature review” of 994 CTS patient files, it was reported that when 494 patients were treated with 100mg twice a day, the rate of symptom alleviation was 68%, much higher than group that did not receive B6 (only 14.3%). Yet, controversy is still reported about the effectiveness of B6 and firm conclusions are lacking. Despite this uncertainty, 200 mg of vitamin B6 is frequently included as part of the non-surgical “package” (along with NSAIDs like ibuprofen, nighttime splints, and an ergonomic workstation evaluation).

So, how much B6 is “enough?” The recommended daily intake is only 2 mg or less for all ages, genders and lifestyles with an upper limit set at 100 mg/day. The main toxicity issue is sensory neuropathy, which (oddly) is very similar to the symptoms caused by CTS! The good news is that CTS symptoms rapidly disappear at doses < 1000 mg/day and most studies indicate no toxic neuropathy by taking doses between 40 and 500 mg/day. Hence, it is recommended to never exceed 500mg/day and most recommendations are in the 100-200 mg/day range. If symptoms improve, a gradual reduction in the dose after about 3 months is advised. Closer monitoring of symptoms in those taking >200mg/day is recommended, especially since the symptoms of toxicity and CTS are so similar. Other B6 toxicity symptoms include depression, fatigue, impaired memory, irritability, headaches, altered walking, and bloating. So, keep your eyes open if doses >200mg/day are taken. Other micronutrients to consider that are anti-inflammatory in nature include omega 3 fatty acids, vitamin D, magnesium (often in combination with calcium), Co-Q10, proteolytic enzymes, and herbs such as ginger, tumeric, boswellia, white willow bark and more.

We realize you have a choice in who you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend or family member require care for CTS, we would be honored to render our services.

Low back pain (LBP) has been a challenge to treat for centuries and evidence exists that back pain has been a concern since the origins of man. Chiropractic offers one of the most patient satisfying and fastest treatment approaches available. But, when you go to a chiropractor, there seems to be a lot of different approaches utilized from doctor to doctor. Is there any evidence that suggests one approach is favored over another? How are the patient’s goals addressed?

Let’s look at what chiropractors actually do. Sure, we manipulate the spine and other joints in the upper and lower limbs using a variety of techniques, which seems to be the “brand” of chiropractic. This is good as joint manipulation has consistently been reported to be safe, effective, and with few side effects. Since this is the “staple” of chiropractic, it’s safe to say that regardless of our preferred or chosen technique, obtaining a good result is highly likely.

But, chiropractic includes SO MUCH MORE than just joint manipulation! For example, we focus on the whole person, not just their isolated issue or complaint. Using low back pain as our example, a “typical” evaluation includes a detailed history of the patient’s general health, past history, illness history, family history, personal habits including sleep quality, exercise habits, dietary issues, quality of life measurements and a review of systems. By gathering this information, we can identify areas that may be directly related to low back pain care, indirectly related, or possibly not related at all, but interferes with the person’s quality of life which, in turn, increases LBP. It’s really difficult to separate our low back from the rest of our body.

For example, if a person has plantar fascitis, a heel spur, an ingrown toe nail, diabetic neuropathy in their feet, pes planus or flat feet, an unstable ankle from multiple sprains, knee or hip problems, the gait pattern or, the way a person walks will be affected and the “domino effect” can trickle up to change the low back/pelvic function — resulting in low back pain! Proper management must address all of the issues that are affecting the patient’s gait if long-term success in low back pain management is expected, rather that just putting a “band aid” on the problem.

Let’s talk about what treatment goals we like to address when we treat our low back pain patient population. The most obvious first goal is pain cessation or getting rid of pain! Since this is what usually drives the patient into our office, patient satisfaction with the care received will not be significant unless the pain is managed. This is achieved through advice, reassurance and training. We often recommend ice (vs. heat) aimed at reducing inflammation, activity modification (teaching proper bending, lifting, pulling, and pushing techniques) and gentle stretching exercises when LBP is present in this acute stage.

Once the pain becomes more manageable and activities become less limited, the second goal is structural restoration. This usually includes managing the flat foot possibly with foot orthotics, a short leg with a heel lift, sole lift or combination, an unstable ankle, knee or hip with exercise often emphasizing balance challenge exercises, and sometimes an orthotic that can be as simple as an elastic wrap to a more elaborate brace. This goal also includes “functional restoration” or transitioning the patient back into real life activities they may be afraid to try such as work, golf, gardening, walking or running, etc.

The third goal is prevention oriented. This may include nutrition (including vitamin/mineral recommendations), weight management (though this is also part of the 2nd goal), exercises (aerobic, stabilization, balance, stretch), and stress management (yoga, lifestyle coaching, etc.). We treat ALL of you, not just your parts!