Backpain Blog

Helpful information about the neck, back, and other musculoskeletal pain and disorders. Tips for a healthy back and neck.

Tuesday, October 30, 2007

To my Patients: I have a bone to pick with you!!

Many of my patients, while lying on the table looking up at my face upside-down from their point of view ask me how I know just where to adjust them. In essence, how do I "pick the bone" that I'm going to adjust back into place. Is it an exact science or is there just some weird connection between a chiropractor's hands and the spine during that blissful moment when everything seems to magically "pop" back into place? When I answer the question, I am surprised to find that most patients tend to think it's the latter.

There are 3 main ways that we check for exactly which joint needs to be adjusted.

1) Static Palpation: Palpation means to feel with your hands. The neck, midback, and lower back spinal bones are all supposed to stack up one on top of the other. When you are lying on your back or stomach and it feels like we're pressing on each area, what we're feeling for is how the spine lines up in a relaxed neutral (static) body position. If we going along and suddenly feel one or two adjacent bones that feel slightly rotated to one side for example, our attention will then be drawn to that area for further investigation. Muscle tension along the sides of the spine is a major indicator of neighboring misalingment of the spine.

2) Dynamic Palpation: Once an area is of suspect, we then move to dynamic palpation which is feeling the position of a joint as it's moving. This can be accomplished by either pressing on the joint to hold it still while moving the rest of the body, or by feeling the bone as it moves with the body, such as when you are on your back and we move your neck to the left and right to determine the motion of the joints.

3) X-ray: Some areas of the spine sit so deep inside your body that we can roughly feel what the joints are doing, but sometimes there is an abnormal motion or history of injury, arthritis, or chronic pain and an x-ray is taken to visualize the status of the joints. Chiropractors take x-rays in a standing position because we want to see the effects of gravity on the joints. From the x-rays, we often see the deeper positions of joints that couldn't be felt from static or dynamic palpation. We often measure the angles between joints and evaluate where stress and gravity will effect the joints the most. Areas of high stress are targeted for adjustments to improve motion and flexibility. Obviously, we don't x-ray your spine on every visit, so we rely heavily on static and dynamic palpation.

Our goal is to narrow down the areas of misalignment or subluxation to a primary joint within each spinal area and differentiate it between other joints which are merely compensating for the primary joint. And as any patient knows, these areas are addressed with adjustments. Specific quick and shallow thrusts through the bone which is stuck restore its motion and allow normal nerve flow and proper reflexes.

Addicted to Crack? Let's face it; adjustments feel good. The reactions to adjustments range from a deep sigh of relief, to laughing, to clapping after it's done. Some people think that they can become addicted to the popping during the release of pressure during an adjustment that results in the improvement in motion and reduction of pain. While there is a slight endorphin release at the moment of adjustment, there is no known evidence of actual addiction to adjustments. The only addiction is in feeling normal again. Once you know what that feels like, you don't want to feel any other way again. Everyone has their own spinal patterns or idiosyncrasies which tend to mean that you will often be adjusted in similar areas depending on your need. But as you now know, we are always looking for the specific misalignments unique to you.

Friday, August 10, 2007

You're hurting. Does your insurance care?

by Dr. Joseph Pigg, D.C.
When insurance first started covering chiropractic back in the 1980’s, they simply paid for everything for as long as the chiropractor and their patient felt it was necessary. Nowadays that is not the case. Chiropractic is still covered on most insurance plans, however, they now require more documentation than ever before showing proof that the patient is getting better overall and that the care is still having an effect.

In a 2007 article in “Dynamic Chiropractic Newspaper” by insurance specialist Samuel Collins, a review of insurance approvals vs. denials of chiropractic care found that further care was allowed when patients’ function improved. That’s right, I said “function” not “pain”. The insurance does not place much value on whether or not you’re feeling better, but only if you’re functioning better. Function has to do with your range of motion, muscle strength, ability to complete daily tasks at home and work with little problem, etc… Pain, though valuable for us as doctors to understand, is not the driving force when they decide whether or not to allow continuance of care. And if you stop for a moment to think about it, if you ARE increasing your range of motion, strength and flexibility, you would be feeling better in most cases anyway!

So I am going to give you some free advice to teach you a way to improve your lower back muscle strength and function. I like to call this the superman exercise. It’s based on strength and proprioceptive training (a big complicated word meaning “position sense of your muscles”) of the Multifidi muscles of the spine. These are the short skinny muscles running up and down each side of your spine which control balance, posture, and stance. If you’ve ever had back pain that caused tightness in your spine, it was likely coming from these deconditioned muscles. These exercises are designed to be done on a gymball. Most people fit comfortably on a 55cm or 22inch gymball which can be purchased through my office or at most sporting good stores.

First laying stomach down on top of the ball. Start by pulling your belly button up towards your spine and allow your hips to rotate slightly forward. This is called a pelvic tilt or abdominal hollowing. From this held position, bring both arms out in front of you and lift your upper body up off the ball slightly so that only your hips and waist are in contact with the ball. Hold for 7-8 seconds. Come down and relax. Then repeat 8 times. Once you get good at it, do the whole exercise with your eyes closed to put more demand for balance on the multifidi muscles of the spine. Once you get even better, try it again with only one foot in contact with the ground behind you.

Keller, MD in the 2004 journal Spine showed that this simple exercise was superior to back surgery.

For help in learning this rehabilitative exercise, ask me to personally teach you this exercise the next time you’re in the office.

Thursday, May 31, 2007

The results are in. More IS better.

How many chiropractic treatments are enough?
by Dr. Joseph Pigg, D.C.

This is usually the number two question after "Can you help me with my problem?". Previously chiropractors relied on a combination of their own personal results for various conditions and a basic knowledge of healing times for injuries. There is some disagreement within the profession as far as specific protocols for how often and for how long someone needs to come in.

But in 2004, M. Hass, D.C. and Groupp, PhD published an exciting study in the Journal of Spine 4(5): 574-83 showing results from a randomized clinical trial on this very issue.

They took people with long time lower back pain and put them into several groups. One group received spinal manipulation and the other received spinal manipulation plus passive modalities (heat/ice, ultrasound, electric muscle stimulation, etc...) Each group got different amounts of care. 1, 2, 3, or 4 visits per week over a period of 3 weeks.

There was not much difference between the people getting chiropractic treatment 1 or 2 times per week, but a big jump in pain improvement for the people in the 3-4 times per week groups. This suggests that more chiropractic treatments may be required to reach the optimal benefit.

There are cases where the patient is able to get away with less visits when the doctor can clearly see that a quicker recovery is expected.

Too often, I am reluctant to recommend a large number of treatments because I anticipate the patient may not comply with the recommendations due to scheduling difficulties, financial barriers, or lack of motivation. And sadly, many HMO insurance plans and Kaiser only allow 5 visits for an episode of pain in spite of the fact that research like this clearly shows the most benefit came from approximately 9-12 treatments. As a doctor in practice, it is great to have this research to support my recommendations. It is what we call "Evidence Based Practice". Meaning that we don't make random recommendations or suggest numbers of treatments because they might be nice sounding numbers, but rather based on research and clinical trials that show evidence of a real benefit following a certain protocol.

There are some patients that I have been working with for a long time who are seen very seldom where we aren't getting the results we want and we try a 2-3 week period of very frequent adjustments to "move it up a notch". In almost every case, there has been a drastic improvement during this trial period and it makes the future maintenance care much easier.

If you are one of my patients and think you might benefit from a temporary increase in care, call or email me and let's talk about whether you would be a good candidate for more aggressive care.

Friday, February 02, 2007

The Chiropractor's Role in Managing Sprains/Strains

by Dr. Joseph Pigg, D.C.

Over the years, I have seen patients with sprains or strains in almost every location on the body. I've also heard almost every scenario in which these injuries occur. From sprained back or neck muscles, sprained ankles, skiing injuries, face planting into the sand during surfing, to trampoline accidents, there's never a dull moment.

If you've had a sprain or strain, you know that being educated on the nature of the injury is key. First, it's important to understand the difference between a "strain" and a "sprain".

A strain occurs in muscles and tendons- the structures which contract and allow movement. Muscles and tendons receive constant blood supply. Since swelling is basically increased blood flow to an injured area, and the muscles receive a lot of blood, swelling and pain occur quickly in strained muscles. Besides sudden traumatic injuries, muscles can also be strained slowly from overuse in sports, holding a position or posture for too long, or from prolonged fine motor activity such as when using a computer mouse or typing.

A sprain occurs in ligaments - the shorter structures (pictured above) which hold one bone to another bone. You don't have any control over ligaments. If you remove all your muscles, you'll see that underneath it all, they're basically the rubber bands that hold your bones together. Ligaments receive a very slow blood supply, so even when they're injured, swelling can take days and in rare cases even weeks to occur. This accounts for people who sprain their neck in a whiplash car accident and don't feel much pain, but then a few days later wake up unable to move their neck or back. The swelling takes longer and unfortunately, so does the healing process. While strained muscles take anywhere from 1-6 weeks to heal, seriously sprained ligaments can take up to 3 or more months to totally heal.

Active Swelling
Immediately after an injury, the body will go through "Active Swelling" reaction which lasts anywhere from 12 hours to 3 days. The swelling can continue if some activity is re-injuring it; such as a person with wrist tendonitis who keeps typing even though it hurts. In that case, the swelling will be perpetual and never go away. The goals during swelling are to use ice and to allow rest and support of the injured area.

For about 4 days following the injury, "Congestion" occurs. Fluid gets trapped in the tissues and causes restricted motion and pain. This is when we want to help people with range of motion through stretching and adjustments. Once the joints are moving with more ease, swelling and pain can drastically decrease.

Repair Stage
From the week after the initial injury to about 6 weeks (give or take depending on the severity) is the "Repair Stage". During this period, ligament and muscle fibers are quickly and randomly laid down. These new fibers do not lie in the direction of the "grain" of the old healthy fibers. Chiropractic adjustments and specific stretching help break up the useless fibers and promote growth of fibers going the right direction. Even after the pain goes away, these fibers will remain if untreated, leaving you weaker and prone to re-injury if not treated.

For the next 4 months up to a year, "Remodeling" occurs in the connective tissue. Remodeling of tissues for better strength and flexibility occurs based on the demands you put on the area. Rehabilitation exercises are crucial if you want to avoid re-injuring the same area again in the future. These exercises are tailored to the individuals particular injury and needs. A chiropractor is qualified to help guide you through the process of carefully selecting exercises that will produce the best strength and prevent re-injury.


Friday, November 10, 2006

Holiday Injuries? Tips for avoiding them

In chiropractic practice, I find that certain injuries are seasonal. For example, there are more car accidents during the rainy months and more back injuries during the summer months when people are doing more gardening. But one of the peak times for new problems to arise is during the holidays between Thanksgiving and New Years.

Here is a list of the common injuries I see during the holidays. See how many you have experienced yourself. The solutions for preventing these injuries are included:

1) Back sprain from carrying Christmas tree purchased from lot.
This can happen when putting the tree on top of the car, putting it up in the house, or taking it down and dragging it to the street for pickup.
Tip: Have someone help you moving the tree around, even if it feels light enough to do by yourself. Wear gloves so you can get a better grip.

2) Car accidents during holiday driving.
Tip: Understand that there will be more traffic around stores and people driving are not thinking about avoiding hitting you. Be patient. Leave extra time for getting to your destination so that you don’t have to rush. Park far away from a store’s entrance if you have to just to avoid the craziness. The walking is good for you anyway. And of course if you’re going to a holiday party where there will be drinking, be sure to stay within your legal limits or have a designated driver with you.

3) Neck strain or wrist tendonitis from carrying store-bought bags of gifts
It only takes about 15 minutes of carrying too many things to begin to hurt a muscle. Our hands are not meant to contract for long periods of time carrying those big department store bags.
Tip:Use a cart if the store has them. Make frequent trips back to the car to drop off gifts.

4) Falls from ladder while putting up decorations.
This can happen when you’re pulling the decoration box out of the closet or garage or when putting them up around the house.
Tip: Any time you’re using a ladder and holding a load, be sure to have someone holding the ladder for you for stability. If the ladder has a warning sign not to stand on the top rung, don’t do it. You are more likely to fall if the ladder is top heavy.

5) Stress.
Whether it’s the crazy drivers or your own family that gives you stress, you’re not alone if you experience this during the holiday season. Stress causes tight muscles which pull spinal joints out of alignment.
Tip: First, remember that stress is only our interpretation of what’s going on around us. Other people can do things to make our lives difficult, but it’s up to our own thought processes whether we become stressed about them or not. Accept the fact that with family, not everything is going to go the way you might have planned or imagined it during holidays. Be patient with one another. This season is about love and about family being together after all. Be sure to leave some time to unwind at the end of the day. Listen to your favorite holiday music. Get plenty of rest. Take extra long showers. If the tight muscles tend to be in your shoulders, be sure to maintain good posture keeping your head over your shoulders. Forward head Posture (FHP) leads to trapezius muscle strain, so do your best to sit up straight.

If you have any of these problems during the season, give the office a call and set up an appointment. Chiropractic can help!

Tuesday, May 16, 2006

Adult Torticollis- Neck pain from "sleeping wrong"

The story is always the same. “Doc, I went to bed fine, but when I woke up I couldn’t turn my head, I had to use my hands to lift my head up this morning, and I feel like I’ve been hit by a truck!”

This is typical of a condition called “Torticollis”. One type of torticollis is “Congenital Torticollis” that occurs in infants and young children. But we will be discussing “Adult or Acquired Torticollis”.

In the majority of the cases, a person wakes up with a stiff and painful neck and sharp pain when trying to turn or tilt towards one side. If you had this condition and looked at yourself in the mirror, you might even see that your head is slightly turned, tilted, or even shifted to one side. For example, you might have pain on the right side of your neck and are tilted and turned slightly towards the left. In this case, turning or tilting your head right would cause excruciating sharp pain and looking up would be painful as well.

What causes it?
Many cases of this condition occur for no known cause, however there are several well known factors that may be related.

Sleeping with the window open:
This occurs most often in the hot summer months when people go to sleep with their window open for air circulation. But then around 4am when the temperature drops the neck muscles stiffen and cramp and lead to a change in the neck reflexes that don’t allow the tight muscles to loosen later.

Sleeping in an awkward position:
Whether you’re over-tired or have had a little too much alcohol, sometimes people will get their head or neck into a position from which they don’t move for several hours. The worst is when people sleep on their stomach and turn their head 90 degrees towards one direction so they can breathe, but also sleeping without a pillow or a shallow pillow can cause it. In the latter case, the neck is tilted too sharply towards the bed. For example, a person sleeping on their left with too shallow a pillow might have the joints on the left side of the neck jam or freeze in place while the muscles and other soft tissues on the right side of the neck are over-lengthened. It can also occur when one sleeps on their back on too many pillows causing their neck to be overly flexed during the night.

History of an unusual activity the day before:
Many times a person will report that they had done an activity outside of their normal routine the day before they woke up with the neck pain. Examples are people who are packing and moving homes, gardening, watching TV or a movie with their head turned one direction for the whole time, or beginning a new exercise in the gym. They don’t usually feel any problem the day of, but wake up feeling it the next morning.

What’s going on inside my neck? – Catch 22
In this type of Torticollis, one or more of the small joints along the back side of the neck called “facet joints” become jammed or locked. The small supportive muscles of the neck that are usually controlled by unconscious reflexes (the muscles you don’t even know you have until you have this condition) contract and hold the joint in a protective manner so as to avoid what it “thinks” is further damage to the joint. There is a swelling reaction around the joint as well. It is the swelling and the prolonged contraction that cause the pain. Here’s the catch. The joint can’t move normally because the muscles are holding their position, but the muscles won’t loosen because they feel the joint out of position.

Can it be treated?
Over the counter drugs such as ibuprofen or acetaminophen can temporarily help the pain and swelling. In severe prolonged cases, injections into the joint are sometimes used. However, most cases are self-limiting and do not require such drastic treatments. An average case of adult torticollis usually lasts from 4 to 7 days. Many people have to take a few days off work because they can’t drive or because the pain is too severe while working. X-rays are sometimes taken, but in typical non-serious cases, x-rays do not show the cause of the torticollis.

Conservative treatment:
Physical therapy employs a technique called Neuromuscular re-education in which proprioceptive neurofacilitation (P.N.F.) is used. After a therapist performs passive range of motion (ROM) in the pain-free range, they then use these longer named techniques which basically involve gentle isometric contraction into or away from the side of pain. The treatment reproduces the pain because it in effect “re-sets” the normal muscle reflexes much in the way that a computer can be “re-booted” when something goes wrong. Other helpful modalities may involve ice, heat, ultrasound, electric muscle stim., and traction.

Is chiropractic safe for treating this condition?
All of the above helps address the muscular reflex and spasm part of the condition, however the deeper joint issue should also be addressed. A chiropractor can help with this, however, it is very difficult to receive an adjustment (even if you’re already used to getting adjusted by a chiropractor on normal days) unless the physiotherapy involving resetting of the muscle reflexes and range of motion is done first. Otherwise, the tendency of the muscles will be to fight the adjustment.
In my own practice, I spend the majority of the time first performing these physiotherapies and then preposition the head in several different positions to see which would be the most comfortable for an adjustment. If there is no position possible without sharp pain, then I either use a light force adjusting tool (Activator) or don’t adjust the person at all at that time. When a patient is able to handle an adjustment, there is usually a sharp pain followed by instant relief and a relaxed feeling in the muscles. However, the muscles usually try to follow their newly learned habit and retighten over a few hours, but to a lesser degree. It is not uncommon for someone with this condition to come in for treatment in the morning, and then return for a follow up the same day in the evening. Typically after 3-4 treatments, the joint moves well enough to allow the muscles to calm down on their own and the person is able to function more normally.

Without treatment, torticollis usually will resolve on it’s own in 5-7 days. With proper conservative treatment, the majority of the condition usually resolves in 2-3 days. There is commonly left over soreness for about 1 week, but 90% of the motion with no sharp pain. It is crucial not to repeat sleeping in the wrong position again during this recovery phase.

Warning: If your neck is extremely stiff in every direction or you have lightning shock-like pains down your entire spine and especially if you have an accompanying fever and/or nausea/vomiting, you should seek immediate medical attention as you may be suffering from meningitis or some other severe life threatening neurologic condition. If you are not sure, call 911 or an advice nurse at your nearest hospital to discuss the symptoms. Rare cases of adult torticollis can also be related to fracture, tumor, or infection.

Thursday, April 20, 2006

Conservative Whiplash Treatment

Evaluation after Whiplash
Some people go to the emergency room following a car accident because of pain or just to be on the safe side. It is standard for any doctor checking you whether in a clinic or hospital to perform range of motion checks, orthopedic checks in which they attempt to reproduce any pain you are having to trace the source of that pain, and neurologic checks to rule out problems such as tingling or weakness from nerves and to verify all of your reflexes are intact. In the case that such nerve problems exist or you are in so much pain that you cannot perform any of the tests, x-rays of the neck, back, or area of bodily impact are performed.

Ice or Heat?
After being cleared of any major complications such as symptoms of an unstable cervical spine, a medical doctor will usually release you with a prescription for pain medication and muscle releaxants. Besides this, ice should be used on the area of injury to reduce swelling. The major swelling will occur between 12-72 hours. If you just had an accident, you may feel worse for the next few days than you did right after the accident happened. When icing, apply it for 20 minutes every 2 hours that you are awake. If pain wakes you up at night, you can certainly apply ice at that time as well. Heat should not be applied to a newly injured neck or back for the first several days. Though the heat feels good at first and may have helped reduce tension after a long day in the past, it has a very negative effect on newly injured tissue. It dilates the blood vessels going to injured muscles, ligaments, and tendons allowing MORE swelling to come into the area. Ice prevents more swelling and has a pain killing effect.

Exercise for an injured neck
Early passive range of motion (where a therapist is moving your body for you and you are not exerting muscle effort to move) is very helpful in allowing quicker recovery. After about 3 days or when swelling has reduced significantly, it is then time to do active motions. For example in the neck, you want to turn your head as far left and right as you can go without pain. Then tilting left and right. Then bending forward and backward. Avoid resisted exercise or heavy duty workouts initially.

Different Health Disciplines
Most MD's will tell you to come back if it still hurts after a week or two and to just take the medicine and let it go away. As a chiropractor, I often see x-rays of a 30 year old neck which look totally healthy except for arthritis in one particular joint. After asking the patient, we often find out that they were in a car accident many years ago and were never evaluated or treated for it since the pain went away 2 weeks later. Just because the pain goes away doesn't mean that it healed properly. To allow proper joint and muscle healing, time is of the essence. The repair of damaged tissue happens in the 4th - 6th weeks. Massage helps to keep the muscles from being in constant spasm during this time, physical therapy helps by helping a patient gain better range of motion and reducing swelling with the use of modalities (machines) and educating patients on when they can do certain activities, and chiropractors perform careful adjustments to allow proper lines of healing in joint tissues and muscles so that they heal stronger minimizing future flare ups. In a study published in the "Journal of Orthopedic Medicine" chiropractic was found to be the treatment of choice for whiplash. Most chiropractors utilize massage and physiotherapy techniques in the treatment of whiplash. If you go to a chiropractor who focuses solely on the adjustment portion of the treatment only and does not do any of the other necessary treatments, you should also see a physical therapist and possibly massage therapist in addition to the chiropractor, or just transfer to a chiropractor who does all parts of the protocol for proper healing based on research.

Nutrition for Whiplash-Omega III Fish Oils
There are many natural supplements which help with pain and swelling, but the most promising which is gaining more and more research in the past 10 or so years is Omega III Fatty acids. This is also sold over the counter as EPA/DHA or Fish Oil. The oils in this are key in reducing pain and actually increasing your threshold to handle pain. It also acts as a natural anti-inflammatory (if you don't like taking a lot of Ibuprofen (Advil, Motrin, etc..) Other researchers are studying Omega III for its ability to lower bad cholesterol. In fact, it's so powerful that there are some warnings that one should ask their doctor about taking it if they're already on a prescription cholesterol reducing drug like Lipitor.
Omega III contains EPA and DHA and are usually in a 3/2 ratio. I recommend my patients take it 4 times per day during the entire swelling and repair stage of healing following any injury. It's available at health food stores and in the vitamin section of any drugstore. There's no need for Omega 6 which is sometimes packaged with the Omega III. Omega 6, though needed in our diet is in excess in the average American diet and has the opposite effect on the pain threshold and inflammation.