Archive for November, 2013

Low Back Pain – Is it on the Rise?

Posted: November 1, 2013 in Back Pain

As stated last month, the prevalence of low back pain (LBP) is REALLY high! In fact, it’s the second most common cause of disability among adults in the United States (US) and a very common reason for lost days at work. The total cost of back pain in the US, including treatment and lost productivity, ranges between $100 billion to $200 billion a year! Is low back pain on the rise, staying the same, or lessening? Let’s take a look!

In the past two decades, the use of health care services for chronic LBP (that means LBP > 3 months) has substantially increased. When reviewing studies reporting insurance claims information, researchers note a significant increase in the use of spinal injections, surgery, and narcotic prescriptions. There has been an increase in the use of spinal manipulation by chiropractors as well, along with increased physical therapy services and primary care physician driven non-narcotic prescriptions. In general, LBP sufferers who are chronic (vs. acute) are the group using most of these services and incurring the majority of costs. The reported utilization of the above mentioned services was only 3.9% in 1992 compared to 10.2% in 2006, just 11 years later. The question now becomes, why is this? Possible reasons for this increase health care use in chronic LBP sufferers may be: 1) There are simply more people suffering from chronic LBP; 2) More chronic LBP patients are deciding to seek care or treatment where previously they “just accepted and lived with it” and didn’t pursue treatment; or, 3) A combination of these factors. Regardless of which of the above three is most accurate, the most important issue is, what can we do to help chronic back pain sufferers?

As we’ve discussed in the past, an anti-inflammatory diet, exercise within YOUR personal tolerance level, not smoking, getting enough sleep, and obtaining chiropractic adjustments every two weeks are well documented methods of “controlling” chronic LBP (as there really ISN’T a “cure” in many cases). You may be surprised to hear that maintenance care has good literature support for controlling chronic LBP. In the 8/15/11 issue of SPINE (Vol. 36, No. 18, pp1427-1437), two Medical Doctors (MDs) penned the article, “Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcomes?” Here, they took 60 patients with chronic LBP (cLBP) and randomly assigned them into one of three groups: 1) 12 treatments of sham (fake) SMT (spinal manipulation) have over a one month period; 2) 12 treatments, over a one month period but no treatment for the following nine months; or 3) 12 treatments for one month AND then SMT every two weeks for the following nine months. To measure the differences between the three groups, they measured pain, disability, generic health status, and back-specific patient satisfaction at baseline, 1-, 4-, 7-, and 10-month time intervals. They found only the patients in the second and third groups experienced significantly lower pain and disability scores vs. the first group after the first month of treatments (at three times a week). BUT, only the third group showed more improvement at the 10-month evaluation. Also, by the tenth month, the pain and disability scores returned back to nearly the initial baseline/initial level in group two. The authors concluded that, “To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.” Other studies have reported fewer medical tests, lower costs, fewer doctor visits, less work absenteeism, and a higher quality of life when maintenance chiropractic visits are utilized. The question is, WHEN will insurance companies and general practitioners start RECOMMENDING chiropractic maintenance care for chronic LBP patients?

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CTS “Facts”

Posted: November 1, 2013 in Carpal Tunnel Syndrome

WHAT is Carpal Tunnel Syndrome (CTS)? CTS occurs when pressure is applied to the median nerve which travels from the neck, through the shoulder, upper arm, elbow, forearm, and through the carpal tunnel where the “pinch” is located. The median nerve innervates most of the palm of the hand, the thumb, the index finger, middle finger, and the thumb side of the ring finger. The carpal tunnel is made up of eight little bones in the wrist that form the arch and a ligament that forms the floor. There are nine muscle tendons, the median nerve, as well as blood vessels that travel through the tunnel.

WHAT are the symptoms of CTS? The “classic” symptoms include burning, itching, tingling, and/or numbness of the second to fourth fingers with the need to shake or “flick” the fingers to “wake up the hand.” When present long enough, or when the pressure is hard enough on the nerve, weakness in the grip occurs and accidental dropping of tools, coffee cups, and so on can occur. Pressure on the nerve increases when the wrist is bent backwards or forwards, especially for long time frames and/or when the wrist is moving in a fast, repetitive manner with jobs like carpentry using vibrating tools, a screw driver, hand drill, a hammer, line production work, waitressing, and so on. Often, symptoms are first noticed at night, as we tend to sleep with our wrists bent and tucked under our chin or neck. Symptoms can also occur during the day, especially when driving or when performing repetitive work. Difficulties buttoning a shirt, making a fist, grasping small objects and/or performing manual tasks are common complaints of CTS.

WHAT are some causes of CTS? CTS is most commonly caused by a combination of factors that result in swelling of the tendons that travel through the carpal tunnel. This includes over working the arm and hand in any of the jobs described above, but it is more likely to happen when conditions that create generalized swelling occur. Some of these conditions include trauma (like a sprained wrist), hypothyroidism, an over-active pituitary gland, during menstruation or pregnancy, menopause, rheumatoid arthritis, diabetes, mechanical wrist problems, repetitious work (work stress), or the repeated use of vibratory hand tools. It is also possible to develop a cyst (like a ganglion) or a fatty tumor within the tunnel. CTS is also more common with obesity, but sometimes, no logical cause can be identified!

WHO is at risk of developing CTS? Women are three to four times more likely to develop CTS. This may be because of the hormonal aspects described above and/or the relative smaller wrist, which results in a smaller carpal tunnel. There’s also an increased risk of CTS in people over the age of 50. Other at risk individuals include diabetics, people with hormonal imbalances (taking birth control pills, pregnancy, hypothyroid, etc.), and people who work on assembly lines.

How is CTS diagnosed? EARLY diagnosis and treatment is KEY to a successful outcome! The physical exam includes assessing the structures of the neck and entire upper extremity, as the pinch is often in more than one place. A blood test for thyroid disease, diabetes, and rheumatoid arthritis is also practical. Other tests that may help us diagnose CTS can include and EMG (nerve test) and/or x-ray/MRI. Next month, we’ll discuss treatment and prevention!

Fibromyalgia and Nutrition

Posted: November 1, 2013 in Fibromyalgia

Fibromyalgia (FM) is truly a challenging condition to manage, as anyone with this condition will attest to! In the past, we’ve discussed many management strategies, including dietary suggestions. Although much of the nutritional information available about FM management is not supported by a lot of “scientific study,” the National Institute of Health through the NCCAM (National Center for Complementary and Alternative Medicine — formed by Congress to evaluate and appraise alternative treatments) provides information on dietary recommendations and supplements. They also provide dietary guidelines and define the benefits and effectiveness for FM patients and us doctors to follow. This month, we will dive deeper into nutritional considerations as this can REALLY make a huge difference for the FM patient!

Since fatigue, sleep quality, and muscle pain are three VERY common FM complaints, the FM patient can track their response to different dietary approaches as they add, modify, or delete various foods and/or supplements from their diet. We recommend “grading” these three symptoms daily on a 0-10 scale (0=good and 10=bad) as this can REALLY help the FM sufferer keep track of various changes that are made in the diet and is extremely useful for future reference.

FOODS: Since many FM sufferers have “sensitivities” to certain foods (reported to be as high as 42% of all FM patients), eliminating these foods makes GREAT sense.

First, it is REALLY IMPORTANT that you KEEP A FOOD JOURNAL for future reference (using the 0-10 scale) as it is impossible to remember all the reactions or responses to various foods even a day or two later, but especially a week or month later! Some common food offenders include MSG (commonly found in Chinese food – simply ask for the MSG to be NOT included when you place your order), certain preservatives, eggs, gluten (grains like wheat, oats, barley and rye), dairy, as well as other common allergens (such as chocolate, nuts, shellfish, and others). Common symptoms may include headaches, indigestion (irritable bowel syndrome), fatigue, and sleep interruptions. When using an “elimination diet,” it is important to make sure you’re getting the essential nutrients in your diet, in which supplementation can help.

Secondly, make it easier to eat in a healthful way! Have fruits and vegetables cut up and ready to eat so when you’re hungry, you can QUICKLY satisfy that urge. Lean meats or proteins are also VERY important! Remember, a well balanced diet gives you the “ammo” needed to fight fatigue, hurt less, help you sleep more deeply, and give you energy. By doing so, you will be able to stay more active and productive. Accept the fact that unless you pre-prepare the foods, you will instinctively reach for pre-packaged, no prep time, “fast food” options that most likely have poor nutritional content. Look for healthy foods that do not require a lot of preparation such as buying pre-washed, pre-cut vegetables. Some deli sections have pre-prepared foods like beet salad or quinoa that can be purchased in small quantities to add variety to your diet.

Third, plan for WHEN you eat. It is well known that eating small meals frequently during the day helps increase energy levels, such as at 9-10am and 2-3pm, especially if you’re feeling tired. Make sure the word “SMALL” is understood or else you’ll gain weight and not be hungry for the next meal! ALSO, DON’T SKIP BREAKFAST, AND DON’T EAT LATE AT NIGHT!!! Our metabolic rate (which regulates how efficiently we digest and breakdown our food) is highest in the morning and slowest at night. Try to include some protein and whole grains with your breakfast such as a boiled egg and oatmeal as this keeps the blood sugar from spiking and provides energy that lasts longer. Next month, we will look at supplementation including vitamins, minerals, and herbs that GREATLY help as well.

Is it a Migraine?

Posted: November 1, 2013 in Headache

There are MANY different types of headaches, of which migraines are a common type. This discussion will concentrate on some unique characteristics that are associated with migraine headaches. This information may help you understand what type of headache you’re having. A unique feature of migraine headaches is that prior to the start of the headache, there is often a pre-headache “warning” that the migraine is about to commence. This is often referred to as an “aura,” and it can vary from a few minutes to a few hours, or in some cases, two days prior to the start of the migraine. Here are some of the more common “warning signs” that you are having, or are about to have, a migraine:

• Neck pain. In an online survey, the National Headache Foundation found that 38% of migraine patients “always,” and 31% “frequently” had neck pain accompany their migraine headache.
• Frequent urination. This can precede the migraine by an hour or as much as two days.
• Yawning. A 2006 article in the journal Cephalgia reported that about 36% of migraine sufferers describe yawning as a common pre-migraine warning. This can occur quite frequently, such as every few minutes.
• A “sensory aura” may occur on half of the body, moving from the finger tips through the arm, across the face, or elsewhere and usually includes a temporary lack of feeling as if the body region is “half asleep.”
• Nausea and vomiting. This is a common aura. According to the American Migraine Study II (a mail survey of more than 3,700 migraine patients) 73% reported nausea and 29% vomiting. Another study reported that migraine sufferers who have nausea/vomiting usually have more severe migraine headaches and get less relief from migraine medications compared to those who do not get nausea or vomiting.
• Other common auras or “sensitivities” during the migraine include bright light, noise, and/or smells (like perfumes), and many migraine sufferers seek refuge in a dark, quiet room and try to sleep.
• Physical activity. Routine activities such as walking, climbing steps, running, weight lifting, or sexual activity can trigger a migraine and/or increase the intensity of an existing migraine headache.
• Trouble speaking. Difficulty “getting the words out” or formulating thought (staying on task) can be another warning sign of an impending migraine. Obviously, if this is the first time this symptom has occurred and it’s “…out of the ordinary,” we’ll have to make sure it’s not something more serious (…like a stroke)!
• Weakness. This may occur in an arm or leg or entire half of the body (left or right side) and also could be a more serious sign of a stroke, but it is also a fairly common pre-migraine aura.
• Visual aura. This can include double vision and / or vertigo (balance loss with a spinning feeling). This often occurs in a special type of migraine called a “basilar-type migraine” and symptoms can include dizziness, double vision or loss of vision. The balance loss is often associated with a “bad migraine” and occurs when the migraine is stronger or more intense than usual.
• “Headache hangover.” This usually occurs after the migraine has passed and people describe a feeling of being “wiped out.” Symptoms can include fatigue, difficulty concentrating, weakness, dizziness, lightheadedness, and extreme energy loss.

In many cases, adjustments applied to the neck and upper back, especially when delivered BEFORE the migraine, can reduce the intensity and in some cases STOP the migraine from even starting!

Whiplash – Rest or Treatment?

Posted: November 1, 2013 in Whiplash

Whiplash, or WAD (whiplash associated disorders) results from the rapid movement of the neck and head resulting in injury. This is the net result of the “classic” motor vehicle collision, though other injury models (like slips and falls) can result in similar injuries. Last month, we listed basic facts, of which one was better results (less long-term pain and disability) occurred from initial active treatment of the neck with mobilization/manipulation, exercise, and encouraging movement vs. placing a collar on the patient and “resting” the injured neck. Though there are a few studies that suggest there is no difference in results, the majority state that it is BEST to actively treat the patient and encourage movement (of course, assuming no unstable fractures have occurred) rather than to place the patient into a collar and limit activities. The first question that we’ll address this month is, why is this important?

The simple answer is that you, as an advocate for an injured friend, family member or as a patient yourself, may NOT be offered “the best” treatment approach by the ER or primary care physician. In fact, one study cited a survey regarding the management of whiplash injuries in an ER and reported that between 23-47% of physicians prescribed a soft cervical collar for acute whiplash rather than promoting immediate active treatment. By knowing this information, the knowledgeable patient can refuse the collar method of care and seek care that emphasizes the use of early mobilization and manipulation, like chiropractic! Though referrals to chiropractors are increasing as more research becomes available, chiropractic care is still significantly ignored or not considered by many practicing ER and primary care physicians. As always, you need to be your own “best advocate,” and the only way to do that is to be informed, hence the intention of this Health Update! Some studies even report that the use of a collar may have deleterious or “bad” side effects and can actually make you WORSE (this was reported by the Quebec Task Force)! The majority of studies on the subject of whiplash report that encouraging “normal activity,” as opposed to immobilization, IS the best approach. We will certainly help steer you in the right direction!

Next, let’s talk about WHY does this method works better? The research supports that soft tissues injuries heal better and with less scar tissue formation when patients receive active treatment/early activity types of care (like manipulation / chiropractic). In general, any treatment approach that reduces patient suffering sooner, encourages one to return to “normal activities” faster, and promotes independence and self-care methods earlier is the best approach!

A chiropractor’s role in treating a person is not limited to only addressing their musculoskeletal system. In fact, it is best to use the “triangle of health” concept with patients. There are three equal sides to address: the “physical,” the “emotional,” and the “chemical” aspects of health and well-being. If any ONE of the three sides becomes distorted or out of balance, all three aspects of health are negatively affected. Although chiropractic typically embraces the “physical” aspects of the person, care must also help bring the emotional/spiritual side AND the chemical side into balance. These three aspects of health do not exist by themselves. The triangle of health approach follows the recommended treatment guidelines known as the “biopsychosocial model” of health care. We do not have the luxury of separating these three aspects of health, and each patient who presents with low back pain, neck pain, headaches, a rotator cuff strain, or a knee injury must be managed wholistically in order to obtain optimal and satisfying outcomes/results. Frequently, there are barriers that can block or prevent a person from improving in a timely manner. Since each person is different, there is no way of knowing what barriers (if any) exist that may prevent them from recovering as one would expect. When this occurs, it’s usually because some other aspect of their health is preventing their condition from improving or resolving. The focus today is on the “chemical” side of the triangle of health and the associated chiropractic management strategies.

Using a case study approach, let’s say a patient presents with “typical” localized low back pain (LBP). During the course of the initial evaluation (which includes a “review of systems” that tells us about their general health), in addition to their low back problem, we find out that they have other health issues that include headaches, difficulty sleeping, flushing of the skin, muscle aches, tenderness and weakness, general fatigue, drowsiness, dizziness, nausea or vomiting, abdominal cramping/pain, bloating/gas, diarrhea and/or constipation, and they have a rash. They are also complaining of memory loss, mental confusion, and have high blood sugar (Type II diabetes). This type of patient may NOT improve to a satisfying level because of the other health issues creating a barrier, blocking recovery from their LBP. So HOW do we figure out what’s going on? We sometimes perform blood tests and/or work with other health care providers who do. That may be a good place to start. Also, many times, people have had blood work done recently and we can simply send a signed release and obtain a copy of the records, including their blood work.

We’ll also gather a list of their medications and can look for side effects or drug interactions. This may be important, especially when so many complaints involving multiple systems are present. In this case, we’d look to see if they have elevated LDL’s (“bad” cholesterol), a high HDL level (“good” cholesterol), or are taking a medication like Lipitor (a statin medication that reduces cholesterol). If there is myositis (muscle pain caused by inflammation), we may order a muscle enzyme test (called CPK or creatine phosphokinase) which, if elevated, may determine the reason for nearly ALL the side effects listed above (not just muscle aches and weakness). A dangerous side effect of statin medications is “rhabdomyolysis” (protein breakdown in muscles causing muscle damage). In this case, discontinuing the medication is ABSOLUTELY necessary to stop these side effects before the damage becomes permanent (especially kidney damage!). Through weight management (such as a gluten free diet), proper nutritional counseling, and whole person care, we can NOW find a remedy for that LBP that was not responding and for a good reason. With statins being one of the most prescribed medications on the market (about 17 million users) and 1 in 10,000 developing the rhabdomyolysis as a side effect, it’s NOT an uncommon finding!!!