Archive for February, 2013

Low Back Pain and Balance

Posted: February 4, 2013 in Back Pain

Statistically, most people (estimated to be about 90%) will seek care for Low Back Pain (LBP) at some point in their lifetime. Last month, we discussed the role foot orthotics play in the management of LBP by improving balance, and it seems appropriate to discuss other ways we can improve our balance, hence the topic this month!

Balance is a skill that is learned as we develop. Initially, as infants, we have not developed the “neuromotor pathways” or, sequence of signals between the brain and our toes, feet, ankles, knees, hips, and so on. The constant flow of sensory information received and processed by the brain prompts motor messages to be sent back to our limbs and allows us to move in a progressively more coordinated manner as we develop. This natural progression of developing motor control starts with crude, rather uncontrolled movement of the fingers, hands, arms, legs, and feet, and soon, we learn to hold up our head, scoot, roll over, crawl, stand, and eventually walk (usually during the first 12 months of life). The learning process of recognizing sounds, voice quality and inflections, and words occurs simultaneously. This bombardment of sensory information to the brain leads to the ability to gradually perform highly integrated functions including walking, running, jumping, and dancing. As part of that learning process, falling frequently occurs. We all recall the challenges of learning how to ride a bike, swim, do a somersault, climb a tree, swing, dance, do gymnastics, ski, and on and on. As time passes and we enter middle age, we become more sedentary. As a result, we start losing our “proprioceptive edge” and become less steady, leading to more frequent balance loss and falls. Eventually, we have to hold on to hand railings or the wall in order to keep our balance and falling occurs more frequently. Couple this gradual loss of balance with bone demineralization (osteoporosis) and the risk of a fracture, such as a hip or vertebra, increases as well.

So the question arises, what can we do to slow down this process and maybe even reverse it? The answer is, A LOT!!! Just like muscles shrink and atrophy if they are not used, so does our ability to maintain our balance. We have to keep challenging our balance in order to keep those neuromotor pathways open. That need doesn’t stop after childhood, and in fact, becomes more important as we age. Last month, we talked about the “normal” length of time people can stand on one foot with the eyes open verses closed. If you tried the test, do you remember the steadiness difference? This “test” can be used at various time intervals, such as once a month, as you add balance challenging exercises to your daily routine. Frequently, people will find that within the first 2-4 weeks, they will feel more “sure” or secure on their feet, and even may not feel the need for a cane, or they’ll reach out less often for a hand rail. Start with simple exercises like standing with your feet together and hold that position for progressively longer times (eyes open and closed). We will continue this discussion next month with more balance stimulating 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.

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Carpal Tunnel Syndrome (CTS) refers to the median nerve being pinched in a tunnel at the wrist. As the name implies, “carpal” refers to the 8 small bones in the wrist that make up the “U” shaped part of the tunnel and “syndrome” means symptoms that are specific and unique to this condition. As we learned last month, CTS can be affected by nerve pinches more proximal to the wrist, such as at the forearm, elbow, mid-upper arm, shoulder or neck. To make matters more complex, there are two other nerves in the arm that can also be pinched in different tunnels, and the symptoms of numbing and tingling in the arm and hand occur with those conditions as well. This is why a careful clinical history, examination, and sometimes special tests like an EMG/NCV (electromyogram/nerve conduction velocity) offer the information that allows for an accurate diagnosis of one or more of these “tunnel syndromes” in the “CTS” patient. Let’s look at these different tunnels and their associated symptoms, as this will help you understand the ways we can differentiate between these various syndromes or conditions.

Let’s start at the neck. There are seven cervical vertebrae and eight cervical spinal nerves that exit the spine through a small hole called the IVF (intervertebral foramen). Each nerve, like a wire to a light, goes specifically to a known location which includes: the head (nerves C1, 2, 3), the neck and shoulders (C4, 5), the thumb side of the arm (C6), the middle hand and finger (C7) and the pinky side of the lower arm and hand (C8). If a nerve gets pinched at the spinal level (such as a herniated disk in the neck), usually there is numbness, tingling, and/or pain and sometimes, usually a little later, weakness in the affected part/s of the arm and hand (or numbness in the scalp if it’s a C1-3 nerve pinch). So, we as chiropractors can test the patient’s sensation using light touch, pin prick, vibration, and/or 2-points brought progressively closer together until 1-point is perceived and then comparing it to the other arm/hand. Reflexes and muscle strength are also tested to see if the motor part of the nerve is involved in the pinch. The exam includes compression tests of the neck to see if the arm “lights up” with symptoms during the test.

Next is the shoulder. Here, the nerves and blood vessels travel through an opening between the collar bone, 1st rib and the chest muscles (Pectorals). As you might think, the nerves and blood vessels can be stretched and pinched as they travel through this opening and can cause “thoracic outlet syndrome.” Symptoms occur when we raise the arm overhead. Hence, our tests include checking the pulse at the wrist to see if it reduces or lessens in intensity as we raise the arm over the head. At the shoulder, the ulnar nerve is the most commonly pinched nerve, which will make the pinky side of the arm and hand numb, tingly, and/or painful. A less common place to pinch the nerves is along humerus bone (upper arm) by a bony process and ligament that is usually not there or resulting from a fracture. Here, an x-ray will show the problem.

The elbow is the MOST common place to trap the ulnar nerve in the “cubital tunnel” located at the inner elbow near the “funny bone” which we have all bumped more than once. Cubital tunnel syndrome affects the pinky side of the hand from the elbow down. The median/carpal tunnel nerve can get trapped here by the pronator teres muscle, thus “pronator tunnel syndrome.” This COMMONLY accompanies CTS and MUST be treated to obtain good results with CTS patients. The radial nerve can be trapped at the radial tunnel located on the outside of the elbow and creates thumb side and back of the hand numbness/tingling.

Hence, you see the importance of evaluating and treating ALL the tunnels when CTS is present so a thorough job is done (which is what Chiropractors do). Try the LEAST invasive approach first – non-surgical treatment – as it’s usually all that is needed!

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.

Fibromyalgia and Neurotransmission

Posted: February 4, 2013 in Fibromyalgia

Neurotransmission is the method by which nerves “speak” to each other so impulses can be sent from one part of your body to the brain and back. For example, when you touch a hot plate by accident, it doesn’t take long before you quickly let go of the plate. The reason you let go quickly is because of neurotransmission. Certain types of neurons or nerves (called afferents) bring information to the central nervous system where the information is processed and then signals are transferred back to the target site (such as your hand touching the hot plate) by different nerves (called efferents) telling you to immediately let go of that hot object. It’s like the flow of traffic into a city during rush hour. People work all day and then drive in the opposite direction on their way home (afferents in the morning going in the city or “brain” and efferents in the evening bringing new information home). This “give and take” process of information coming in, being processed and going out helps coordinate our bodily functions. This allows us to constantly adapt to surrounding changes in temperature, stress, noise, and so on.

Each neuron has as many as 1500 connections from other neurons, but they don’t actually touch one another. Rather, there are “synapses” where nerve impulses stimulate the release of calcium and neurotransmitters, which either inhibit or excite another neuron and each neuron may be connected to many other neurons. If the total excitatory stimuli are greater than the inhibitory stimuli, that neuron will “fire” and create a new connection resulting in an action (like dropping the hot plate).

Okay, sorry for the enthusiastic description and details of neurotransmission. More importantly, how does all this relate to fibromyalgia? A new study (published May 14, 2012 in NATURE by scientists at Weill Cornell Medical College) discovered that a single protein (alpha 2 delta), “…exerts a spigot-like function controlling the volume of neurotransmitters and other chemicals that flow between the synapses of brain neurons.” This study shows how brain cells “talk to each other” through these synapses relaying feelings, thoughts, and actions and how this powerful protein plays a crucial role in regulating effective communication in the brain. They found that if they added or decreased this single protein (alpha 2 delta), then the speed of neurotransmission increased or decreased by opening or closing the calcium channels that trigger neurotransmission release.

The relationship between calcium and neurotransmission has been known for 50 years, but how to “turn on or off” the volume is a new discovery. They hope this finding will help in the design of new medications that will help regulate the neurotransmission in the brain, thus help reduce the increased pain perception found in people suffering from fibromyalgia.

Our aim in sharing this information with you is to keep you informed with what is on the cutting edge of research as we’ve said many times before, a “team” of health care provision is the BEST way to manage FM including chiropractic and primary care!

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

Traction is defined as, “…the act of pulling a body part.” Therefore, it is commonly used in many regions including legs, arms, low back, mid-back, and the neck. We will be limiting this discussion to cervical or neck traction, and the question of the month is, “…does it help patients with neck pain and headaches?” Though I’m assuming you already know, the answer is YES! You may want a little “proof,” so here it goes!

1. REDUCES DISK PROTRUSIONS: In 2002, a medically based study found traction to be very effective in the treatment of cervical radiculopathies (pinched nerves in the neck that radiate pain into the arms). A 2008 study using MRI (images) described the effect traction had on the disk protrusions in the neck reporting 25 of 35 (or 71%) were reduced while in traction with a 19% increase in the spacing (disk height) and improved neck range of motion after the traction was applied. They postulated that by pulling the vertebrae in the neck apart, there was a suction-like effect pulling the disk material back in place.

2. RECOMMENDED BY GUIDELINES: Around the world, guidelines have been published giving doctors information that allows us to know how well certain forms of treatment work for different conditions. In a 2008 publication, it was reported that, “Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain.”

3. CLINICAL PREDICTION RULES: These help us determine who is most likely to benefit from a certain type of treatment (in this case cervical traction and exercise). If 3 of 5 variables are found, the likelihood of success with traction & exercise was reported to be 79%, and if 4 of the 5 are found, 90%. The 5 variables are: 1. Radiating neck to arm pain in certain positions; 2. Positive shoulder abduction sign; 3. Age >55years old; 4. Positive limb tension test; 5. Relief of symptoms using manual distraction test (if pain is relieved while the neck is being pulled).

4. INTERMITTENT AND CONTINUOUS TRACTION: Either way, significant improvement in neck and arm pain, neck mobility, and nerve function occurred with both approaches.

5. TRACTION VS. SURGERY: In this study, patients with radiating arm pain and positive neurological findings on exam were offered a course of traction before surgical options. They reported 63 of 81, or 78%, of the patients experienced significant or total relief, 3 could not tolerate traction and 15 simply didn’t respond. They concluded that when neck and arm symptoms with neurological deficits were present for 6 weeks, that 75% will respond to neck traction over the next 6 weeks.

There are MANY additional studies available that show well beyond doubt that cervical traction is a GREAT option in the management of neck and arm pain and sometimes headaches. Next month, we will discuss “HOW TO” apply cervical traction.

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.

Whiplash Avoidance (…continued)

Posted: February 4, 2013 in Whiplash

Last month, we discussed car safety features, proper headrest position, how to prepare for a crash, and to seek immediate treatment as ways to minimize the chances of suffering from whiplash in the event of an accident. Here are four more ways to avoid or minimize whiplash:

PAY ATTENTION WHILE YOU DRIVE. Too often, we get distracted while driving. Any time our eyes leave the road, the potential for an accident increases significantly. This can occur when changing the radio to a different station, eating while driving, reading while driving, talking on the phone, texting (equals the effects of 2-3 alcoholic beverages), driving under the influence of certain prescription medications (pain killers for example), driving under the influence of alcohol or other chemical agents, and turning your head during conversation. We have a responsibility when we are driving to keep our eyes on the road, as many accidents occur within split seconds of time. If we are not paying attention, we will not be able to avoid a potential collision.

THE CONCEPT OF “NO CRUSH, NO CRASH INJURY” IS SIMPLY NOT TRUE. In fact, just the opposite is true. That is, the greater the amount of crushing metal at the time of collision, the greater the amount of energy absorption that occurs, resulting in less force transferred to the contents inside the vehicle (namely you or me). This is why, many times, people are injured in low speed collisions because there is no energy absorbed by crushing metal as noted by the absence of or, minimal damage to the car.

FOLLOWING YOUR DOCTOR’S ORDERS. It is very important that we do not inadvertently hurt or harm ourselves further by NOT following the advice of our health care practitioner. This means initially using ice to reduce inflammation and swelling, possibly wearing a soft cervical collar during the first few days after the injury to “rest” the injured structures, following proper nutritional advice for optimal healing benefits, and following exercise recommendations. This last treatment approach is vital in the prevention of long term, chronic neck complaints. Other ways you can REALLY help are to follow cervical traction orders. Cervical traction is a very effective method of reducing muscle spasm, separating the joint spaces, improving disk nutrient transfer and water content, reduce the pinching effect of the nerves, and as a result, speeding up the recovery process. Follow your treatment schedule; that is, DON’T SKIP APPOINTMENTS! During office visits, it is necessary to discuss not only what is working well, but also what may not be working so modifications to your care plan can occur on a timely basis. The primary goal of whiplash management is to prevent the condition from becoming chronic and long-term, and the first few weeks of treatment are critical!

ERGONOMIC MODIFICATIONS. An important part of managing whiplash injuries is preventing daily irritations from tasks that we have to do. Hence, we will discuss adjusting your work station for optimum positioning and avoidance of poor posture, such as using office chairs with arm rests, sitting posture modifications, and computer monitor positioning. Proper sleep positions and pillow design are also reviewed.