Low Back Pain and Obesity.

10 Dec

Low back pain (LBP) is a VERY COMMON PROBLEM! Here are some facts about LBP: 1) At ANY given time, 31 million Americans experience LBP; 2) LBP is the single leading cause of disability worldwide; 3) 50% of ALL working Americans admit to having LBP symptoms each year; 4) LBP is the #1 reason for missed work and, the 2nd most common reason for doctor office visits (outnumbered ONLY by upper respiratory infections); 5) Most cases of LBP are “mechanical” and NOT caused by serious conditions like inflammatory arthritis (like rheumatoid), infection, cancer, or fracture; 6) At least $50 BILLION is spent annually by Americans on back pain (and that’s JUST the more easily identifiable costs); 7) At some point in life, experts estimate 80% of the population will experience LBP.

In prior Health Updates, we’ve discussed ways to prevent LBP like exercise, eating right, staying active (avoid prolonged inactivity or bed rest), not smoking, maintaining proper posture, wearing low heeled comfortable shoes (and possibly foot orthotics and/or heel lifts), sleeping on a medium-firm mattress, using proper bending and lifting methods, fixing work station problems (computer key board and monitor placement is important!), and more.

This month’s topic concerns obesity and LBP. How are these related, and does it really matter? Let’s look at some adult obesity facts: 1) Obesity is common, serious, and costly: 35.6% of US adults are obese; 2) Obesity related conditions include: heart disease, stroke, type 2 diabetes, certain types of cancer, and is the LEADING CAUSE of preventable death! 3) An estimated $147 BILLION was spent on obesity related medical costs and the average medical cost for an obese person was $1429 higher than for those of normal weight (Body Mass Index or BMI of 18.5-24.9). 4) Ethnic variations: Non-Hispanic blacks have the highest obesity rate at 49.5% vs. Mexican Americans (40.4%), all Hispanics (39.1%) and non-Hispanic whites (34.3%) [ref. JAMA, 2012; 307(5):491-97]. 5) There was a dramatic increase in obesity in the US from 1990 through 2010. No state in the U.S. met the nation’s “Healthy People 2010” goal to lower obesity prevalence to 15%. Instead, in 2010, there were 12 states with obesity prevalence >30% vs. in 2000, NO state had an obesity prevalence >30%! 6) More than 2 in 3 adults are overweight (BMI 25-29.9) and, 1 in 3 adults are obese (BMI >30). 7) In children 6-19 years old, about 33% are overweight or obese and 17% are obese.

Intuitively, common sense tells us that if we are overweight, it has to affect our low back in a negative way. Well, you are right! In the 1/15/13 journal Spine, an 11 year study from Norway, gathered data between 1995-1997 and again in 2006-2008 of an entire county in Norway which included 8733 men and 10,149 women, aged between 30-69 years old who DID NOT have chronic LBP (>3mo. within the past year) vs. 2669 men and 3899 women who DID have LBP. After 11 years, a significant increase in risk was reported between those with a BMI >30 (obese) vs. those <25 (BMI 18.5-24.9 = normal). They also found that the recurrence rate of LBP was also higher in those who were obese.

Weight management is a goal of LBP care, and we have many strategies that can help you fight this problem.

Tags: , ,

CTS Self-Diagnosis – Is That Possible?

10 Dec

Carpal Tunnel Syndrome (CTS) is technically a “pinched nerve” in the wrist (carpal tunnel) that results in numbness, tingling and later, weakness in the distribution of the median nerve (thumb, index, 3rd, and half of the 4th finger). There is a limited amount of space within the carpal tunnel. In addition to the median nerve, there are 9 tendons and their sheaths, a network of blood vessels, the joint capsules, the bony “roof” and ligamentous “floor.” Any condition that distorts the shape of the tunnel  (inflammatory conditions like rheumatoid arthritis, ganglion cysts, bony spurs, or conditions that result in swelling like overuse, pregnancy, taking birth control pills, hypothyroid, obesity, and/or conditions that create neuropathy like a pinched nerve in the neck, shoulder or elbow, diabetes and post-chemotherapy) can result in median nerve irritation. The carpal tunnel naturally changes its shape when we flex and extend the wrist, so occupations that require wrist bending (especially if it’s prolonged and a fast pace is required) such as carpentry (especially the use of vibrating tools), waitressing, assembly line work, typists, and even sleeping at night with the wrist bent can result in CTS.

 

The diagnosis can be tricky because of all the possible causes (of which, some are described above) and to make matters even more challenging, there can be two, three, or more of the causes all contributing to the problem at the same time! In the clinic, there are certain positions to test how long (in seconds) it takes for the numbness, tingling and/or pain to occur when we place the wrist in extreme flexion or extension. We’ll compress the carpal tunnel (and nerve pathways at the elbow, shoulder, and neck), as well as tap over the carpal tunnel with a reflex hammer creating a “funny bone” sensation usually into the 2nd or 3rd finger. Blood tests for rheumatoid (and other inflammatory) arthritis, diabetes and thyroid dysfunction are very helpful when trying to differentiate between several possible causes. An electrical conduction test called electromyogram (EMG) and nerve conduction velocity (NCV) can also be very helpful in determining the severity of CTS.

 

So the question is, can you “self-diagnose” CTS? The answer is: sometimes. However, with that said, if the symptoms are “classic” (numbness/tingling in the thumb, fingers 2-4, which shaking and flicking your fingers relieves at least partially; it’s waking you up at night especially, if a night splint helps reduce the frequency of waking and intensity of numbness), then you “probably” have CTS. Here are some common questions included in a CTS questionnaire that we often use in the clinic to assist with the diagnosis: SYMPTOM SEVERITY (score each on a 0-4 scale): 1) Pain severity at night? 2) Nighttime frequency of waking with pain? 3) Amount of daytime hand/wrist pain? 4) Frequency of daytime hand/wrist pain? 5) Duration (in minutes) of daytime pain/numbness? 6) Severity of numbness? 7) Severity of weakness? 8) Tingling intensity? 9) Nighttime severity of numbness or tingling? 10) Nighttime frequency of numbness or tingling? 11) Difficulty grasping / using small objects like keys or pens? FUNCTION SEVERITY (0-4 scale): 1) Writing. 2) Buttoning clothes. 3) Holding a book while reading. 4. Gripping of a telephone handle. 5) Opening jars. 6. Household chores. 7. Carrying grocery bags. 8. Bathing and dressing. The maximum score for SYMPTOM SEVERITY is 11×4 = 44 and for FUNCTION 8×4 = 32. To determine the percentage, divide your score by 76 (the maximum possible) and multiply it by 100. In general, scores >50% may be indicative of CTS. However, as previously stated, a definitive diagnosis must include a detailed history, examination, sometimes special tests. Therefore, it is important to see us! If you have CTS, we will outline the type and length of care with you and MOST IMPORTANT, we can usually manage CTS without the need for surgery!

 

Tags: ,

Fibromyalgia and Sleep Interference.

10 Dec

Fibromyalgia (FM) affects the entire body, which makes the diagnosis challenging! A VERY common issue with patients struggling with FM includes problems related to sleep. This goes beyond the number of hours one “tries to sleep” but rather the quality of sleep and feeling “restored” in the morning. That is, quality is more important than quantity! Let’s look further.

1. Common sleep problems: Insomnia, or difficulty falling asleep as well as frequent awakenings to the point of recalling being awake during the night is common with FM. Even more common are instances of waking up during the night but being unable to remember it in the morning. This interrupts “deep sleep” and poses an even more important issue. Common sleep disorders associated with FM include restless leg syndrome and sleep apnea. The goal of sleep is to feel restored when waking in the morning. Sleep deprivation can also be caused by pain, depression, and anxiety, all of which are associated with FM.

2. Restless Legs Syndrome (RLS): RLS is considered a neurologic disorder that usually occurs at night and at times during the day when the body is inactive. It is characterized by an overwhelming urge to move the legs when they are at rest.

3. Sleep Strategies: Developing better sleep “hygiene” is important in the management of FM. This can reduce pain, fatigue, the “fibro fog” and in turn, reduce anxiety and depression. Here are some effective ways to accomplish a better sleep pattern:

Though this sounds counterintuitive, sleep ONLY as much as needed to feel refreshed. Excessively long periods of time in bed relates to fragmented and shallow sleep.

Keep a diary to log how much you sleep each night, when you went to bed and woke up in the morning, when and what you last ate/drank prior to bedtime and any other “triggers” you can think of that may have interrupted your sleep. Follow the “best” pattern!

Try to go to bed at night and wake up in the morning at consistent times, once you determine the “best” pattern. This will strengthen your circadian rhythms and facilitate sleep quality.

Practice relaxation techniques such as gentle massage, deep breathing, and relaxation recordings to enhance restorative sleep. Soak in a hot bath or shower prior to going to bed.

Exercise regularly to enhance sleep quality.

Sound machines can help those accustomed to noise, as loud noises can disturb sleep, even if it’s not remembered in the mornings. Keep the room dark and/or use a sleep mask.

Avoid long daytime naps, as they can interfere with nighttime sleep.

Keep the bedroom temperature cool, as too much heat is sleep disturbing.

If you are hungry at night, a light carbohydrate rich snack may help you sleep.

Avoid nicotine, alcohol, or caffeine in the evenings as they interfere with sleep.

4. Medication and nutritional aids: First, try herbs like valerian root, hops, ginger, turmeric, boswellia, amino acids like melatonin, 5-HTP, tryptophan, magnesium, and/or Kava as NONE of these are habit forming. We can help you with this decision! If the herbal/nutritional approaches are not satisfying, we can refer you for a medical consult for prescription options.

 

Tags: ,

Neck Pain – Where Is It Coming From?

10 Dec

Neck pain can arise from a number of different tissues in the neck. Quite often, pain is generated from the small joints in the back of the vertebra (called facets). Pain can also arise from disk related conditions where the liquid-like center part of the disk works its way out through cracks and tears in the thicker outer part of the disk and can press on nerves producing numbness and/or weakness in the arm. It is possible to “sprain” the neck in car accidents, sports injuries, or from slips and falls. This is where ligaments tear and lose their stability resulting in excessive sliding back and forth of the vertebrae during neck movements. When muscles or their tendon attachments to bone are injured, these injuries are called “strains” and pain can occur wherever the muscle is torn. There is also referred pain. Here, the injury is at a distance away from where the pain is felt. A classic referred pain pattern is shoulder blade pain when a disk in the neck herniates. Let’s take a closer look at two conditions we often diagnose and treat as chiropractors:

Spinal Stenosis: This occurs when the canals in the spine narrow to the point of pinching the spinal cord in the trefoil shaped central canal (called “central stenosis”) or when the nerve roots get pinched in the lateral recesses (called lateral recess stenosis). This can occur from arthritis in the facet joints, disk bulging or herniations, thickening of ligaments, shifting of one vertebra over another, aging, heredity (being born with a narrowed canal), and/or from tumors. Usually, combinations of several of the above occur simultaneously. When this is present in the neck, it can be more serious compared to stenosis in the low back as the spinal cord ends at the upper part of the low back (T12 level) so only the nerves get pinched. Stenosis in the neck however pinches the spinal cord itself. Symptoms can include pain in one or both arms, but it’s more dangerous when leg pain, numbness, or weakness occur (called myelopathy). Rarely, loss of bowel or bladder control can occur which is then considered a “medical emergency” and requires prompt surgery.

Cervical Disk Herniation: As previously stated, the liquid-like center of the disk can work its way through cracks and tears in the outer layer of the disk and press on a nerve resulting in numbness, pain, and/or weakness in the arm. The classic presentation is the patient finding relief by holding the arm over the head, as this puts slack in the nerve and it hurts less in this position. The position of the head also makes a difference as looking up usually hurts more and can increase the arm pain/numbness while looking down reduces the symptoms. We will carefully test your upper extremity neurological functions (reflexes, muscle strength, and sensation as each nerve performs a different function in the arm), and we can tell you which nerve is pinched after a careful examination. This condition can lead to surgery so please take this seriously.

The good news is that chiropractic care can manage both spinal stenosis and cervical disk herniations BEFORE they reach the point of requiring surgery. So make chiropractic your FIRST choice when neck pain occurs!

 

Tags: ,

Whiplash Diagnosis.

10 Dec

Whiplash is, by definition, the rapid acceleration followed by deceleration of the head causing the neck to “crack like a whip” forwards and backwards at a rate so fast that the muscles cannot react quickly enough to control the motion. As reported last month, if a collision occurs in an automobile and the head rests are too low and/or seat backs too reclined and the head moves beyond the allowable tissue boundaries, “whiplash” injury occurs.

When gathering information from the patient, this portion of the history is called “mechanism of injury” and it is VERY IMPORTANT, as it helps us piece together what happened at the time of impact. For example, was the head turned upon impact? Was the impact anticipated? What were the weather conditions (visual, road conditions)? What was the direction of the strike (front, rear, side, angular, or combinations of several)? Did a roll over occur? Was a seat belt used (lap and chest) and were there any seat belt related injuries (to the low back/pelvis, breasts/chest, shoulder, neck)? Any head impact injuries with or without loss of consciousness (if so, how long)? Any short-term memory loss and residual communication challenges (post-concussive syndrome)? All of the answers to these questions are very important when determining the examination path, establishing the diagnoses, and determining the treatment plan.

We also discussed last month the WAD classification or, Whiplash Associated Disorders, which was coined in 1995 by the Quebec Task Force. Types I, II, and III are defined by the type of tissues injured and the history and examination findings. In 2001, the Quebec Task Force found that WAD II (loss of range of motion or ROM/negative neurological findings) and WAD III (both ROM loss and neurological loss) carried progressively greater risk of prolonged recovery compared to WAD I injuries (those with pain but no loss of motion or neurological findings).

Establishing a strong diagnosis allows for accuracy in prognosis and treatment plan recommendations. For example, in WAD II & III injuries, flexion/extension x-rays are needed to determine the extent of ligament damage as normally, the individual vertebrae should not translate or shift forwards or backwards by more than 3.5mm. Similarly, the angle created between each vertebra in flexion & extension should be within 11 degrees of the adjacent angles, and if that’s exceeded, ligament damage is likely to have occurred. So often, ER records describe little to no information about the historical elements reviewed in the 1st paragraph and if x-rays were taken, they rarely include flexion/extension stress x-rays.

Headaches are another component of WAD. Here, the first three sets of nerves that exit the uppermost levels of the spine (C1, C2, and C3) innervate the head. When a patient describes headaches that start in the upper part of the neck and radiate up into the head, the distribution of the pain by history can tell us which nerve(s) are most affected. In the examination, applying manual pressure to the base of the skull can reproduce pain when a nerve is injured. Tracking these findings on a regular basis can tell us how the condition is healing. Chiropractic is at the forefront of diagnosis for WAD!

Tags: ,

CTS “Facts”

9 Dec

How is CTS treated? For the best success, treatment should begin as early as possible. Unfortunately, most people wait a long time before they get to the point where the symptoms interfere with daily activity enough to prompt them to act quickly and make an appointment. Once the cause or causes of CTS are determined, treatment can address ALL the presenting contributing conditions. The FIRST course of care should be NON-SURGICAL, though this is not always practiced – so be aware! Non-surgical care includes the following:

Chiropractic:

Manipulation: This usually includes adjusting the small bones of the hand, the wrist, the forearm, elbow, shoulder, and/or the neck.

Soft-tissue therapy: This includes loosening up the overly tight forearm muscles where the median nerve runs through (on the palm side of the forearm).

Modalities: Such as electrical stimulation and/or laser/light therapy can be very beneficial in reducing swelling or inflammation. In chronic CTS, ultrasound may be helpful as well.

Nutritional: Nutrients such as vitamin B6 have been shown in studies to be effective in some cases. Also, anti-inflammatory herbs (ginger, turmeric, bioflavinoids) and / or digestive enzymes (bromelain, papain, and others) taken between meals are quite effective.

Anti-inflammatory: The first important distinction is that ice can be very effective depending on how long the CTS has been present. In particular, ice cupping or rubbing ice directly on the skin over the carpal tunnel is the most effective way to use ice as an anti-inflammatory agent. When doing so, you will experience four stages of cooling: Cold, Burning, Achy, Numb or, “C-BAN.” It’s important to remember this as you are REALLY going to want to quit in the burning/achy stages when it feels uncomfortable. Once the skin over the wrist / carpal tunnel gets numb (which takes about four to five minutes) QUIT as the next “stage” of cooling is FROST BITE! Most medical practitioners promote the use of NSAIDs (non-steroidal anti-inflammatory drugs) like Advil, aspirin, or Aleve. However, these carry negative side effects including gastritis (burning in the stomach that can lead to ulcers), or liver and/or kidney damage. Try the nutritional anti-inflammatory approach FIRST as they are extremely helpful without the bad side effect potential!

Diet: An ant-inflammatory diet, like the Paleo-diet or gluten free diet, serves as a great tool in reducing the inflammatory markers in the body. Though only 7-10% of the population has celiac disease (gluten intolerance), it’s been estimated that over 80% of us are gluten “sensitive.” Reducing systemic inflammation can make a BIG DIFFERENCE in the management of many conditions including CTS!

Mechanical: Wrist “cock-up” splints can also be REALLY HELPFUL, especially for nighttime use. The reason for this is because when our wrist is bent forwards or backwards, which frequently occurs when sleeping, the pressure inside the carpal tunnel increases, and over time (minutes to hours), the increased pressure in the tunnel exerts compression on the median nerve which then creates numbness into the thumb, index, third and half of the fourth finger, which can wake you up out of a sound sleep. Keeping the wrist straight at night prevents you from curling your wrist under your jaw while sleeping.

Ergonomic Modifications: Changing your work station (computer station, line position, machine controls, pace or rate of repetitive movements, and more) is VERY effective.

NOTE: ALL of the above can be managed through the services offered at our clinic!!!

Tags: ,

← Older Entries
Newer Entries →