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Articles & News

Welcome to the section of our website dedicated exclusively to patients. Our goal is to equip you with enough information so that you can take health-related matters into your own hands. After all, your experience at our practice can only carry you so far, but ultimately, the choices you make regarding proper health are up to you.

But we're here to help. The content found in this section is intended to be reviewed in your leisure. We strongly suggest that if the experience in our office was the first step in your journey to good health, that you stay updated on developments within the field of chiropractic and wellness. Search for articles related to your specific condition and of course continue to browse our Articles and News section.

The Long-Term Benefits of Chiropractic Care

By Charles Masarsky, DC, FICC

Many patients come in for their initial visit with a clear short-term goal: pain relief. Unfortunately, if that remains their only goal, they miss out on some of the benefits of chiropractic care beyond pain relief. The following patient education article is designed to assist you in discussing long-term goals of chiropractic care. Please feel free to use it on your bulletin board, as a front-desk handout or for lay lectures.

No one thinks it's odd when their dentist recommends regular visits to maintain good oral health for as long as possible, nor do they find it peculiar when their optometrist suggests regular visits to maintain good visual health for as long as possible. And yet many people are puzzled when their doctor of chiropractic recommends regular visits to maintain good spinal health for as long as possible.

Of course, when you are suffering with low back pain, neck pain or tension headache, it is completely understandable that you have one overriding goal - stop the pain. However, once this short-term goal has been accomplished, it is time to consider your long-term spinal health goals. In formulating your long-term goals, it is essential to understand that spinal health is about more than getting rid of pain. Spinal health has a long-term impact on every function affected by the spinal nerves, which influence every organ system in your body.

Breathing is a good example of a function most people do not associate with spinal health. A case published in the 1980s involved a 53-year-old man with a 20-year history of chronic obstructive pulmonary disease.¹ More than 14 months after starting chiropractic care, the amount of air he was able to forcibly exhale in one complete breath (a measure called "forced vital capacity") and the amount of air he could move in the first second of that complete breath (called "forced expiratory volume in one second") had both improved substantially (1 liter and 0.3 liters, respectively). This case is part of a growing body of literature indicating that improved spinal health through chiropractic care is often accompanied by improved lung volumes.²

The long-term implications of the link between chiropractic care and lung volumes cannot be overemphasized. In most adults, even those without pulmonary disease, lung volumes do not improve over time. In fact, lung volumes generally decline with age. Lower than normal lung volumes are associated with shorter lifespans.³ More specifically, depressed lung volumes have recently been linked to increased risk of stroke, heart attack, and other potentially life-shortening cardiovascular problems.^4-6 Conversely, the better your lung volumes, the longer your lifespan is expected to be. Additional biological functions that seem to benefit from improved spinal health include reaction time,⁷ balance and vision.⁸

In the short run, it would be great to get out of pain. Chiropractic care can help most people achieve this short-term goal of spinal health. In the long run, it would be great to retain as much lung capacity, visual acuity, reaction time, balance, and cardiovascular health as possible. Emerging research strongly suggests spinal health has a role to play in these long-term goals as well. Consider this when your doctor of chiropractic recommends regular follow-up visits.

Improving Posture: Create a 24/7 Bubble of Health & Function

By Tim Brown, DC

No matter how well we've mastered our skills as chiropractors and no matter what techniques we use in our practice, our patients' patterned postural habits between office visits can dictate the level of success of our treatment plans.

Score another win for innate intelligence! Over my many years in practice, and with the help and feedback from many incredible mentors, I've developed a "24/7 bubble" of healthy choices that I provide for my patients.

We become over time what we think, eat and do. As I observed patient after patient leave the office with reduced symptoms and increased function, I couldn't help but realize that many didn't even make it to their cars before reinforcement of pathological posture and faulty movement patterns began to undo the benefits of my care.

By the time I would see them a few days later,even if symptoms had subsided, it was apparent that their muscular imbalances, which more often than not were the actual cause of their condition, were recalcitrant to my attempts to correct them, even when the patient insisted they were doing their stretches and exercises.

When I got the chance, I would try to spy on them as they drove away, and to my dismay, car seat after car seat would defeat their posterior chain and allow the classic deformation pattern of the sitting man: lumbar lordosis replaced by increased thoracic kyphosis. The hip flexors and hamstrings would shorten, and the abdominals would go on vacation. I would often use the classic line, "What are you doing to undo what I did, to undo what you're doing?" and remind them of the negative effects of sitting; "and when I say 'sitting,' that includes when you drive!"

I also knew that once they got out of the car, it wouldn't be too long before they found another place to sit and continued their daily process of rewiring the muscles in the front of the body to become overused, shortened and over time, affect movement and joint health, and cause their S-shaped spines to mold into the sad "C." A very real sign of the de-evolution of modern man.

Sitting Bull

Did you know that in the U.S., we sit 9.3 hours a day on average? Heck, we only sleep an average of 7.3 hours a night! Recent studies show the physiological effects of sitting are devastating to our overall health. When we sit for long periods, our mortality rate increases exponentially. And let's not forget that the no-so-attractive C-spine posture pattern also restricts respiration and compresses organs that were designed over millennia to function best while we are upright and in motion. Each time we sit, we reinforce "death by chair." Show me the people who live long, healthy lives, and I'll show you people who don't spend their days sitting.

"Posture Follows Movement Like a Shadow" – Sherrington, 1906.

But it's not just sitting. Our bodies are highly plastic and we mold to the posture and activities we do the most often. So, if our patients reach forward hundreds of times a day (at the computer, in the car or to pick up their kids), and never reach back in the opposite direction to exercise the muscles that hold them up, the countless repetitions in one direction create and feed imbalance and faulty posture. Imagine doing biceps curls all day and never activating the triceps or stretching the biceps. Where would your arm eventually end up? With your fist resting on your shoulder!

Poor posture when sitting also stimulates a sympathetic, fight-or-flight state that, among many other stresses, creates a measurable increase in deadly C-reactive proteins, significantly slows our metabolism, and negatively impacts cardiovascular health, immunity and digestion – and this is just the beginning of the list of poor posture's negative effects on overall health and wellness.

If your patients are looking for some perspective on observing posture and movement the way we (chiropractors) do in our "modern world," just have them watch how a 4-year-old moves and they will understand. Children move without restriction. Observe how a child squats and you will see a perfect hip hinge while they maintain their natural spinal alignment and curvature. They are using efficient, quality movement, the way we were designed to move. Just watch a young child get out of a chair and walk away, and then compare it to someone age 30 or older. If we sit an average of 9.3 hours a day, that means by the time we are 30, we have spent 84,862 hours sitting. It's a wonder we can still move at all.

In almost every case I've seen over the past 25-plus years, there are predictable muscular imbalances (think Vladimir Janda's upper-crossed syndrome) that have most likely been there for years, and have been reinforced by repetition of poor movement habits and postures that over time, limit function in mobility, stability and strength in the muscles that support and protect the health and function of the human spine.

That being said, what happens after your patient leaves the office is one of the greatest challenges to the success of your treatment outcomes. In my experience, along with the treatment we provide in the office, we must build our patients a 24/7 bubble of health, function and good choices for them to heal and flourish within, which also means the patient must be committed to taking an active role in improving and controlling their health, environment and decision-making process.

What You Can Do

Tissue work. Lengthen and relax overused, understretched muscles and fascia for best treatment and training results. Always create tissue length before training for strength. Key muscles include the pec major, pec minor, subscapularis, upper lats, biceps, serratus group, upper traps and anterior scalenes.
Mobilize/adjust the thoracic spine. Thoracic spine hypomobility exists in almost every patient; it increases instability in lumbar and cervical joints, and interferes with normal scapular and shoulder kinematics.
Provide functional postural apparel and/or taping. Supports and cues proper posture and alignment by stimulating the sensorimotor system to retrain posture during activities of daily living. In short, it allows you to functionally reinforce the benefits of your treatment, posture and movement-training protocols.

What They Can Do

Sit less. Use different styles of chairs that encourage movement, like a gym ball, yoga furniture, meditation pillows; and to get up and switch off every half hour. Get up and move more throughout the day. Adjusting position requires movement. They can also talk to their employer about ordering a stand-up desk. And encourage them to sit on the floor on a thick rug or carpet, with pillows for support, whenever possible.
Improve workspace ergonomics. Use visuals; have someone take a picture of the patient in corrected posture. Place the picture of optimal posture in plain sight or tape to their computer monitor. Visual cues are also a powerful component you can use to create change of habit through constant reinforcement.
Move better, move often. Age is not an excuse for poor movement and function; lack of movement is. Yoga, 5-rites, Pilates, tai chi and other exercise routines are fun and easy to follow. My strongest recommendation is to utilize foundation training. Check it out; it's a game changer because it focuses on improving posture and core strength by learning basic movements that activate and connect your posterior chain, from the Achilles to the occiput.

Maintaining optimal posture and balancing one's health is a journey, not a destination. Stress progress, not perfection! No matter the treatment method or modality you provide during an office visit, if you don't address functional balance by improving posture and quality of movement, and provide better choices for the environment the patient is living in outside your office, you'd better put on your running shoes. Why? Because then we become just one more symptom chaser in today's health care system and end up constantly repairing the effects of the posture and movement challenges patients face in the other 23 hours left in their day.

Shoulder Pain: Practical Tips for Examination and Treatment

By Kevin M. Wong, DC

I have been fortunate thus far in my chiropractic career to have been exposed to many different types of patients with a variety of ailments conducive to chiropractic care. Although I will always love my roots in spinal adjusting, I really get a charge out of doing extremity work.

Let's focus on one of the most common problem areas people come to see us for: the shoulder.

To set the stage for a moment, we need to get a realistic visualization of how our patients' (and our) shoulders can become painful in the first place. Just a few of the many causes include poor sitting or desk posture, injuries, sleeping on your side, and other activities during which your arms are in front of you (driving, sewing, gardening, etc.). Almost any arm activity can create the potential for shoulder problems. Since we stress and overstress our shoulders in our typical daily living, shoulder problems are a natural consequence.

Take a second and palpate the ball and socket joint of each of your shoulders. What do you feel? Any tenderness or pain? Any asymmetries in how the shoulders are hanging? In most of my patient population, I can palpate the anterior part of the humerus and find tight or hypertonic muscles. Yes, the anterior deltoid, biceps tendon and even the pectoralis muscles in the front tend to be tighter and more sore than the posterolateral areas. Do they feel sore to you?

General Analysis

Remember all of your shoulder joints: glenohumeral (GH acromioclavicular (AC), sternoclavicular (SC), scapulothoracic and rib joints (costovertebral, costotransverse and costosternal). Also recall that you have a battery of orthopedic and neurologic tests available to you when assessing the shoulder. You are not expected to have all of them memorized, so have references available to use when you need to be reminded. These tests can add critical information to your fact finding and treatment plan.

As we are practice, our diagnostic, palpation and kinesthetic skills improve. The more you put your hands on people, the better you get. You may know exactly what is wrong with your patient's shoulder from the history itself, but follow through with the rest of your exam.

Now let's talk about the shoulder joints one by one and how they generally misalign. Keep in mind that this is not intended to be a comprehensive look at every aspect of the shoulders. Let's keep the focus strictly on how most patients typically present with shoulder problems in your office.

Shoulder Joint Misalignment

GH joint: A multi-axial synovial ball-and-socket joint, the GH joint is the articulation between the glenoid fossa of the scapula (shoulder blade) and the head of the humerus (upper arm bone). Due to its shallow socket, the presence of a fibrocartilaginous labrum aids in support. We also see the rotator-cuff muscles attaching on the head of the humerus. The GH joint is the most mobile and least stable joint in the human body.

Our patients understand the GH as the major "shoulder joint" and it is the primary one that gets attention. In our society, we do most of our activities in front of our bodies with the shoulders rounded. As a result, patients often present with an anterior-inferior (AI) humerus.

When the patient is sitting or lying on their back, you can see one of the humerus bones protruding higher than the other, non-symptomatic side. Even touching the front of the higher humerus can be painful. Of course, the humerus can also move posterior or lateral, but those tend to be more of a traumatic circumstance. A lion's share of your patients will have the AI shoulder.

AC joint: This joint is the junction between the acromion (part of the scapula that forms the highest point of the shoulder) and the distal clavicle. The AC joint allows the ability to raise the arm above the head. It is a gliding synovial joint that acts as a pivot point for movement of the scapula, resulting in a greater degree of arm rotation.

Patients refer to this joint at the point or tip of their shoulder. In this area, the distal clavicle will misalign in a superior direction. This movement is not like a shoulder separation, which also occurs at this joint. Shoulder separations involve ligamentous damage or tears and could, in severe cases, require surgery to repair.¹

A good thing to remember is that when someone has suffered a prior fracture of the distal clavicle, it will be obvious when you look at them, as the bones rarely heal straight. Look for that bony callous or deformity; it is hard to miss.

SC joint: The sternoclavicular is a synovial joint composed of two portions separated by an articular disc. The joint is made up of the sternal end of the clavicle, the upper and lateral part of the breastbone, and the cartilage of the first rib.

Ligaments that help attach the proximal clavicle to the sternum are very strong here. We rarely find fractures in this region. We do get misalignments of the proximal clavicle, most commonly moving superior/anterior/medial. Be especially careful when you palpate this joint. Not only can they be particularly tender, but you are also getting close to the chest area. Take the appropriate precautions when working with female patients.

Scapulothoracic joint: The scapulothoracic joint is not a true joint, in the sense that it has no capsule or ligamentous attachments. It is more commonly referred to as an articulation. It is formed between the anterior scapula and the posterior thoracic rib cage (ribs 2-7).

The scapula's attachment to the skeleton is musculotendinous in nature, formed by the trapezius and serratus muscles.

Its gliding movement patterns consist of elevation/depression, retraction/protraction, and superior/inferior rotation. Often, we find that the shoulder blades do not "flare" equally. Fibrous adhesions can occur following a shoulder injury, especially if the joint has been immobilized for a long period of time. This impairs movement of the shoulder.

Costovertebral, costotransverse, and costosternal (rib) joints: Costotransverse joints involve the facets of the tubercles of ribs 1-10, forming joints with the corresponding thoracic vertebrae. These are synovial joints. This articulation is present in all but the 11th and 12th ribs. Ribs 1-10 have two joints in close proximity posteriorly: the costovertebral joints and the costotranseverse joints. The costosternal joints are those involving the cartilages of the true ribs with the sternum. These are considered arthrodial joints, with the exception of the first joint, where the cartilage connects directly with the sternum (synarthrodial).

Ribs are present to help protect the vital organs and assist with inspiration / expiration. Pain felt from ribs out of alignment can be some of the sharpest, most intense pain felt anywhere. Often, sharp rib pain can shoot through the chest and be mistaken for angina. It causes a lot of people to run to the emergency room in a panic.

Treating Shoulder Problems

So, how do you know when to check the shoulder? Beyond the obvious shoulder pain symptoms (the patient is pointing directly at it), you might look at the shoulder when you see any of the following:

Pain in the trapezius, especially the region just above the scapula
Neck pain that can move into the skull
Referral of pain or isolated pain in the lateral or anterior deltoid
Popping or clicking of the shoulder during AROM or PROM
Weakness with muscle or strength testing of the GH muscles
Patients pointing to rib joints as sites of pain. Ribs are often out due to shoulder misalignments
Chronic/persistent C/T pain that is not resolving with spinal adjustments

When it comes to adjusting the shoulder joints, keep in mind what we discussed previously about the directions they tend to misalign.² We have a wide buffet of adjusting maneuvers and techniques available to us, so here are a few pointers, including manual adjusting techniques, drop-table adjusting and instrument adjusting.

Manual adjusting techniques: These can be very effective, but also very painful. Watch out how much stress and force you apply. Whichever position you place the patient in, make sure to feel for the movements you are trying to achieve for each of the joints. Getting a "pop" should not always be the objective.

Drop-table adjusting: Supine drop adjusting is another effective way to address these joints. Remember that the tension set on the table must be light. The joints can be very tender, so watch your depth of pressure with your fingers when you set up and engage the drop piece. The thumbs or the thenar/hypothenar contacts both work well and are generally comfortable for patients.

Instrument adjusting is also great for addressing the shoulder joints. For some patients, especially children, healthy adults in acute pain and the elderly, this is actually the preferred way to start moving the bones. You can always transition them into other light-force techniques, like drop table. Don't be afraid to stick with instrument adjusting if the patient likes it and is responding well.

Chiropractic adjustments and treatments are proven to relieve the pain associated with many common shoulder injuries. "There is fair evidence for the treatment of a variety of common rotator- cuff disorders, shoulder disorders, adhesive capsulitis, and soft-tissue disorders using MMT [manual and manipulative therapy] to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy."³ The most important aspect is to recognize and address all of the shoulder joints during your assessment. Adjust each individual joint, taking into consideration which direction you feel the bones have moved, and see how successful the results are. The goal is simple: provide the most efficient, effective patient care.

Conservative Treatment of Repetitive-Stress Injuries: Exercise Is the Key By Adam Silk, DC

Repetitive-Stress Injuries: A Significant Health Problem

Advancements in technology have brought about an increase in repetitive stress injuries such as carpal tunnel syndrome (CTS), lateral and medial epicondylitis of the elbow, and general complaints involving the thumb and hand. Chiropractors have very successfully risen to the challenge of treating these common problems without the use of drugs or surgery; and with the growing lack of confidence patients have taking medications, overuse of anti inflammatory drugs to control painful symptoms, and long recovery times involved with surgery and rehabilitation, patients are increasingly open to other treatments.

Resistance and Flexibility Exercises

Directed exercise is the missing link; all conventional exercises force flexion of the hands to grip the weight or machine. In chiropractic college we were told to use rubber bands and do finger extension exercises. Three to five minutes of appropriate exercise helps to strengthen the muscles associated with extension of the fingers and help protect the associated structures of the hand by increasing their ability to handle repetitive stress regularly placed on them. Although it not always possible to correct through exercise alone, this is an effective strategy to help avoid surgery and reliance on OTC medications.

Millions of people suffer each year with tennis elbow and carpal tunnel symptoms. Computer / data entry personnel, dentists and hygienists, auto technicians, machinists, assembly workers, massage therapists, musicians, tennis players, golfers, and yes, chiropractors are all at risk. The common risk factor is the necessity to repetitively grip, squeeze and apply force to closing of the hands in order to accomplish their daily tasks. This repetitive action (hand/finger flexion) required by people in all of the above activities (along with numerous others) perpetuates an imbalance in the relationship between the finger flexor muscles that close the hand and the finger extensor muscles that open the hand. The tendons that affect movement of the hand are long, passing over several joints. The muscle bellies located far away further complicate the relationship.

It is necessary and actually very healthy when there are naturally occurring muscle imbalances among the opposing muscle groups; however as with most things, too much of any one thing can be a problem. In the case of the wrists and elbows, the extrinsic location of the opposing muscles of the hands and wrist are naturally very imbalanced in favor of hand flexion. This imbalance forces the hand to close and squeeze; this hand and wrist flexion puts a near-constant strain on the extensor muscles. Directed resistance exercise and flexibility exercises for the palms help stimulate blood flow and increase the distribution of blood to the distal portion of the tendons involved in movement of the hand, fingers and wrist.

The Chiropractic Opportunity

When dealing with hand and wrist pain, we must take into consideration that the flexor muscles that close the hands are the workhorses of the upper extremity. This constantly overstimulated muscle group creates an unhealthy dynamic and a major imbalance in the hand. The decreased flexibility in the finger flexors and the reducing power in the finger extensors create instability in the structures of the wrist and elbows. As repetitive forces are applied to these structures, pain and limitations can develop. The real answer is to increase blood flow; this helps to bring increased nutrition to the damaged tissues and optimize the healing process.

Corrective chiropractic care plans including exercise techniques applied to all involved areas of the body while increasing flexibility in the muscles that close the hands will allow the patient to handle greater levels of repetitive motion in the wrist and elbows. There are a multitude of devices on the market that aid in strengthening the finger flexor muscles; in many cases, the exercises are not particularly unique, as everything we do in life - holding a phone, eating with utensils, carrying packages, driving a car, riding a bike, holding a tennis racket or golf club - provides similar muscle stimulation to make our grip strong.

With about five minutes a day of directed exercises, my hands and wrists and fingers feel almost perfect. The exercises are the perfect balance and work great for me and my patients. I recommend finger extension exercises to anyone with elbow, wrist or hand pain and stiffness. Give it a try; all you have to lose is the pain. Your patients will thank you.

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55091

Physiological Effects of Therapeutic Massage By Warren Hammer, MS, DC, DABCO

Many chiropractors either perform some type of massage on their patients or have a massage therapist in their office. The term therapeutic massage (TM) is a general, nonspecific term referring to any type of massage, from superficial to deep, that may have a healing effect. Most massage therapists¹ "train in multiple programs and therapies and there is high variability in the training programs and in what therapies practitioners choose to learn."² Methods of massage include, among others, effleurage, petrissage, friction and tapotement. TM also can refer to most hands-on therapies including fascial manipulation, Graston, structural integration, active release, Swedish massage and others.

Claims regarding the effects of TM include changes in hormones, neurotransmitters, blood flow and cortisol, among others. However, as with most other mechanical pressure methods used on humans, there is a paucity of research supporting its efficacy, optimal treatment parameters and underlying physiologic responses. Recent studies have added to the body of knowledge regarding the effects of mechanical load, showing definite physiological and clinical changes^2-3 related to TM. An important effect of TM is thought to be its effect on peripheral blood flow. While skin temperature correlates with skin blood-flow studies, skin probes and their effect on the skin are questionable.⁴ A recent study using dynamic infrared thermography² compared the effects of a 20-minute massage that included a deep muscle combination of friction, gliding (effleurage), kneading (petrissage), direct pressure and passive stretching to the neck and shoulders versus light touch (just the hands placed in contact with the skin) or a control scenario in which the patient rested quietly in the treatment position.

Light touch produced some changes in temperature, but the most significant changes occurred with the deeper massage treatment. What is most interesting is that the areas not massaged (posterior right arm, C6 to C8 dermatomes, and thoracic middle back T1 to T8 dermatomes) showed an increase in skin temperature and peripheral blood perfusion similar to the areas massaged, indicating a possible neural as well as a circulation component. The areas receiving a deeper massage showed increased temperature for 35 minutes and remained above baseline levels after 60 minutes. One of the effects of deep massage is temperature elevation that changes hyaluronic acid molecules, which are responsible for the gel phase causing tissue restriction. The increase in temperature with associated pressure changes the gel to a fluid phase and creates the necessary tissue sliding. One study found that massage to a depth of between 1.5 cm and 2.5 cm caused changes in muscle temperature significantly greater than ultrasound.⁵

Some of the same authors of the above study submitted another significant paper on deep massage that recently appeared in Manual Therapy.³ This study compared the same three groups as the previous study: deep massage and light touch over the neck and upper trapezius areas, along with a control group. This time, the authors measured flexor carpi radialis α-motor neuron pool excitability (Hoffmann's reflex, otherwise known as the H-reflex), electromyography (EMG) signal amplitude of the upper trapezius during maximal muscle activity, and cervical ROM to help assess physiological changes and clinical effects of deeper massage compared to light touch.

The H-reflex is similar to the stretch reflex (knee jerk reflex), but differs in that it bypasses the muscle spindle and is used to assess monosynaptic reflex activity in the spinal cord. Electrical stimulation causing the H-reflex measures the efficacy of synaptic transmission as the stimulus travels along the Ia fibers, through the dorsal root ganglion, and is transmitted across the central synapse to the anterior horn cell, which fires it down along the alpha motor axon to the muscle. This measurement can be used to assess the response of the nervous system to various neurologic conditions, musculoskeletal injuries, application of therapeutic modalities, pain, exercise training, and performance of motor tasks.

In this study,³ even though the upper trapezius area was massaged, the H-reflex for this area is difficult to elicit, so the authors checked the motor neuron pool excitability in an outlying area that was not massaged: the flexor carpi radialis muscle (FCR), which generates a reliable reflex. They reasoned that massaging the trapezius and neck area would affect the cervical and brachial plexus and the median nerve, which innervates the FCR. The H-reflex test did show a decrease in FCR α-motor neuron pool excitability compared to the light-touch and control groups. The fact that there was a decrease in neuron excitability in a non-massaged area suggests the possibility that massage was producing a centralized effect on the nervous system, affecting spinal-cord response in another area. This same neuronal possibility was expressed in the change in peripheral blood perfusion in non-massaged areas in the previous study.²

Another finding was the decrease in EMG signal amplitude in the upper trapezius muscle with deep massage, which did not occur with light touch or control. The EMG change was probably due to the decrease in -motor neuron pool activation, which has an influence on electrical activity. Additionally, compared to light touch and control, deep massage increased ROM in all cervical directions. One caveat is that all of the studies were performed on people without known pathology, but the neurological implications of deep massage affecting circulation and the nervous system are important. The fascial manipulation hypothesis is based on the release of restricted fascia that houses mechanoreceptors and proprioceptors, thereby influencing the CNS' effect on myofascia. Everyone who seriously uses deep massage is aware of positive changes. Science may finally be proving why there are clinical results.

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55637

Conservative Treatment of Repetitive-Stress Injuries: Exercise Is the Key By Adam Silk, DC

Chiropractic has now reached its 115^th year. During that time, many things have changed, of course, but the mission to get sick people well without drugs has been the course that remains unchanged. Gone are the days when chiropractors were sent to jail for practicing medicine without a license and scope of practice was limited to cricks in the neck or back pain. The modern-day chiropractor is a primary health care provider, a portal of entry to the health care system, with a plethora of techniques and modalities at their disposal. Today's chiropractor uses a whole-body approach and effectively helps patients with a myriad of health conditions ranging from headaches and nutritional issues to arthritis, musculoskeletal problems and even systemic health issues.

Repetitive-Stress Injuries: A Significant Health Problem

Advancements in technology have brought about an increase in repetitive stress injuries such as carpal tunnel syndrome (CTS), lateral and medial epicondylitis of the elbow, and general complaints involving the thumb and hand. Chiropractors have very successfully risen to the challenge of treating these common problems without the use of drugs or surgery; and with the growing lack of confidence patients have taking medications, overuse of anti inflammatory drugs to control painful symptoms, and long recovery times involved with surgery and rehabilitation, patients are increasingly open to other treatments.

Chiropractors are not immune to these health issues, either; the constant pounding our hands and wrists take, along with the repetitive nature of our work, can create CTS-like symptoms at times. Treating these overuse injuries of the hand, wrist and elbow in our patients and ourselves without drugs or surgery should always be the first option.

Resistance and Flexibility Exercises

Millions of people suffer each year with tennis elbow and carpal tunnel symptoms. Computer / data entry personnel, dentists and hygienists, auto technicians, machinists, assembly workers, massage therapists, musicians, tennis players, golfers, and yes, chiropractors are all at risk. The common risk factor is the necessity to repetitively grip, squeeze and apply force to closing of the hands in order to accomplish their daily tasks. This repetitive action (hand/finger flexion) required by people in all of the above activities (along with numerous others) perpetuates an imbalance in the relationship between the finger flexor muscles that close the hand and the finger extensor muscles that open the hand. The tendons that affect movement of the hand are long, passing over several joints. The muscle bellies located far away further complicate the relationship.

The Chiropractic Opportunity

This is probably not the chief complaint or primary issue that brings patients to your office. However, consider that 60 percent of people over age 55 suffer from some type of hand stiffness, wrist or elbow pain. The problem begins with some muscle cramping or feeling of fatigue in the extensor region, many times going ignored. The more these repetitive activities continue, the risk of injury increases, as the finger extensor muscles rarely - if ever - receive any opportunity for conditioning. (If you think about it, this is one of the few areas of the body faced with this problem.)

You can equate this with the effect gravity has on the spine over time. The constant pushing of gravity, if left unattended, contributes to postural issues over time. The solution, as you know, is as simple as preventative measures such as stretching the front and back of the legs and the pectoral region, inversion traction of the spine, chiropractic spinal adjustments and strengthening the muscles of the upper and lower extremities and back.

As chiropractors, we are well-suited to handle these cases with our innate understanding of balance and openness to comprehensive treatment programs that do not place potentially dangerous pain-relieving medication at the forefront of the treatment program. The real answer is to increase blood flow; this helps to bring increased nutrition to the damaged tissues and optimize the healing process. It can take less than 10 minutes a day.

Certainly there will be patients who will require surgical intervention and anti-inflammatory medication; but in many of these cases it may be as simple as tailoring a strategy that includes rest from the activity causing the problem, applying ice to reduce inflammation, and rebalancing the relationship between the finger flexors and finger extensors, specifically addressing the muscles involved with extension of the digits. Corrective chiropractic care plans including exercise techniques applied to all involved areas of the body while increasing flexibility in the muscles that close the hands will allow the patient to handle greater levels of repetitive motion in the wrist and elbows.

There are a multitude of devices on the market that aid in strengthening the finger flexor muscles; in many cases, the exercises are not particularly unique, as everything we do in life - holding a phone, eating with utensils, carrying packages, driving a car, riding a bike, holding a tennis racket or golf club - provides similar muscle stimulation to make our grip strong.

Knee Osteoarthritis: Risk Factors, Diagnosis and Treatment Options

By Meridel I. Gatterman, MA, DC, MEd

According to the American Academy of Orthopedic Surgeons, osteoarthritis of the knee is one of five leading causes of disability among elderly men and women, and the risk for disability from osteoarthritis of the knee is as great as that from cardiovascular disease.¹

Currently, 21 million Americans are affected by osteoarthritis² and an estimated 10 million suffer from knee osteoarthritis, making it one of the most common causes of disability in the U.S.³ It is estimated by the year 2030, 72 million Americans will be at high risk for osteoarthritis.⁴ Patients with chronic joint pain often think nothing can be done to help them, with 23 million Americans reporting chronic joint symptoms that have not been diagnosed with arthritis.⁵ One in five American adults with doctor-diagnosed arthritis underscores the magnitude of this chronic condition.⁶

Factors That Increase the Risk of Developing Knee Osteoarthritis¹

Heredity: There is evidence that genetic factors may make individuals more likely to develop osteoarthritis of the knee.
Weight: Being overweight increases the load on joints, especially the knee.
Age: The ability of cartilage to heal itself decreases as people age.
Gender: Women older than 50 years of age are more likely than men to develop osteoarthritis of the knee.
Trauma: Previous injuries to the knee, including sports injuries, can lead to osteoarthritis of the knee.
Repetitive stress injuries: Activities associated with certain occupations, particularly those that involve kneeling or squatting, walking more than 2 miles a day, or lifting at least 55 pounds regularly, increase the risk of knee OA. Occupations such as assembly line workers, computer keyboard operators, performing artists, shipyard or dock workers, miners, and carpet or floor layers have demonstrated a higher incidence of osteoarthritis of the knee.
High-impact sports: Elite players in soccer, football, long-distance running and tennis have an increased risk of developing osteoarthritis of the knee.
Associated illnesses: Repeated episodes of gout or septic arthritis, metabolic disorders and some congenital conditions can also increase the risk of developing osteoarthritis.
Associated risk factors: Other risk factors being investigated include deficiencies of vitamins C and D, poor posture or bone alignment, poor aerobic fitness, and muscle weakness.

Etiology and Diagnosis

Osteoarthritis of the knee is characterized by a degeneration of the knee cartilage. Cartilage is a smooth, slippery, fibrous connective tissue that acts as a protective cushion between the bones. The joint space between the bones narrows as the articular cartilage in the knee is lost. As the disease progresses the cartilage thins, becoming grooved and fragmented. The surrounding bones react by becoming thicker. They start to grow outward and form spurs as the body attempts to stabilize the joint. The synovium becomes inflamed and thickened, often with acute episodes of debilitating pain. The joint slowly changes over a period of years and in severe cases, when the cartilage is gone bone erosion occurs with deformity of the joint. When the bone ends rub against each other, normal activity becomes painful and difficult.¹

Diagnosis is based on patient-reported symptoms such as pain and disability, and physical signs such as changes in the joints (decreased joint space) seen on radiographs. Symptoms of osteoarthritis of the knee include pain (mild, moderate and severe); stiffness; limited range of motion in the knee; and localized inflammation.

Pain from osteoarthritis of the knee is usually worse following activity, especially overuse of the affected knee. Stiffness can worsen after sitting for prolonged periods of time. Symptoms generally become more severe as osteoarthritis progresses. Pain can becomes continuous rather than only when weight-bearing. More detailed imaging including MRI can provide more detailed information. Arthroscopic knee surgery provides an invasive method of viewing the condition of the knee joint.¹

Lifestyle Modifications to Reduce Disability

While there is no cure for osteoarthritis of the knee, a combination of strategies can reduce the risk of disability.

Weight control: According to Brigham and Women's Hospital, Americans over the age of 50 will lose the equivalent of 86 million healthy years of life due to obesity and symptomatic knee osteoarthritis. Maintaining an optimal weight reduces the stress on the knees. Each pound lost helps. A force three to six times a person's body weight is exerted across the knee while walking.

In other words, being obese increases the force on the knee by 30 to 60 pounds with each step taken while walking. Painful joints, especially when weight-bearing, often lead to inactivity, which makes weight loss more difficult and further compromises joints that are designed to move in order to be healthy.

Exercise: Encouraging the patient to stay active is an essential part of management of osteoarthritis of the knee.⁸ If walking is too painful, cycling, swimming and water aerobics are good choices. Keeping the leg and thigh muscles strong improves knee function, and exercise also can help increase range of motion and flexibility.⁹ Being active and staying active can reduce pain and make movement easier.⁸

Diet: Dietary supplements that promote healthy cartilage are important factors in the management of osteoarthritis. Vitamin C is essential in the development of normal cartilage. A deficiency of vitamin C can lead to the development of weak cartilage. Dietary vitamin C is most widely available in citrus fruits. Supplementation with a vitamin C tablet is advised if sufficient dietary vitamin C is not consumed.¹⁰

Vitamin D deficiency has been shown to increase the risk of joint space narrowing and progression of disease in osteoarthritis. Supplementation of 400 IU daily is recommended by many doctors. Fifteen minutes of daily exposure to the sun is a natural way to increase vitamin D levels. Deficiency of calcium can be caused by vitamin D deficiency. Adequate calcium is necessary to maintain sufficient bone density.¹⁰

Glucosamine and chondroitin are controversial nutritional supplements8 that have been studied in Europe and more recently in the United States.¹⁰ While 50 percent of patients get relief from the symptoms of osteoarthritis attributable to glucosamine and chondroitin supplementation, the AHRQ questions their efficacy, stating that these supplements are not regulated as drugs in the United States and therefore their quality may vary.⁸ Glucosamine and chondroitin can help reduce swelling and tenderness, as well as improve mobility and function. At least two months of continuous use is necessary before the full effect is realized.⁹

Other Potential Treatment Options

Supportive devices: A variety of supportive devices are available to patients limited by osteoarthritis. A cane, energy-absorbing shoes or inserts, and a brace can be helpful. A brace can help support the entire knee load, or if the arthritis is centered on one side of the knee, an "unloader" brace can shift the load away from the affected portion of the knee.

Topical applications: Other measures may include topical applications including heat and ice. When the knee is inflamed, ice can reduce the inflammation and relieve pain. When the joint pain is not acute, heat can be soothing and help to relax surrounding soft tissue. Topical analgesics and liniments can offer temporary relief. Elastic bandages can offer limited support and remind the patient to be cautious when moving the knee.⁹ The patient must be taught to unweight the knee before moving to avoid aggravating the damaged joint.

Acupuncture and magnetic pulse therapy have also been helpful in treating osteoarthritis of the knee. Employed nontraditionally, acupuncture uses fine needles to stimulate specific body areas to relieve pain or numb the area. Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field.⁹

Less Conservative Methods

Corticosteroid injections: Corticosteroids are powerful anti-inflammatory agents that can be injected into the joint. They are given for moderate to severe pain. They can be useful if there is significant swelling, but are not very helpful if the arthritis affects the joint mechanics. Corticosteroids are hormones produced by the adrenal glands. They can provide pain relief and reduce inflammation; however, the effects are not long-lasting, and no more than four injections a year are recommended. With repeated injections or over an extended period of time, joint damage can actually increase rather than decrease.⁹

Viscosupplementation with hyaluronic acid: The exact mechanism of action of viscosupplementation is unclear. Prospective, randomized, controlled trials have demonstrated mixed results. Some studies have found minimal or no benefit, while others suggest beneficial effects over placebo. In a meta-analysis of eight hyaluronan trials involving 971 patients, outcomes in patients treated with hyaluronan were superior to outcomes in patients treated with placebo at the end of treatment cycles and after six months.¹¹

The cost of hyaluronic acid is significant. Third-party reimbursement varies and Medicare pays for injections every six months. Most insurance companies now cover viscosupplementation.¹²

Drug treatment: Several types of drugs can be used in treating arthritis of the knee. Because every patient is different and because not all people respond the same to medications, a one-size-fits-all drug program should be avoided. Anti-inflammatory medications can include aspirin, acetaminophen, or ibuprofen to help reduce swelling in the joint. These over-the-counter drugs can be very effective in reducing pain. All drugs have potential side effects, however, and simple analgesics are no exception.⁹

Surgical treatment: If the patient's condition is not sufficiently relieved by conservative therapy, a number of surgical options are available. Arthroscopic surgery utilizes fiberoptic technology to enable the surgeon to see inside the joint, clean it of debris and/or repair torn cartilage. Arthroscopic knee surgery generally does not reduce the pain of osteoarthritis and is used more effectively for knee problems from trauma such as sports injuries.⁹

Knee replacement or total knee replacement is misleading and can scare some patients when they believe that the entire knee is to be replaced. A total or partial knee arthroplasty replaces severely damaged knee joint cartilage with metal and plastic.⁹ The replacement implants include a metal alloy on the end of the femur and polyethylene on the tibia and patella. Knee replacement is major surgery and is generally reserved for those patients who have tried all other treatments available for osteoarthritis of the knee. Knee replacement surgery is generally very successful, but success is dependent on active postsurgical rehabilitation.

Your Role in Managing Knee OA

The role of the doctor of chiropractic in treating patients with osteoarthritis of the knee is one of minimizing disability in mild to moderate cases and presenting options for those patients whose degenerative changes have reached a stage at which more invasive therapy is necessary to preserve optimum quality of life. As a first step, encouraging patients with osteoarthritis to stay active and lose weight where indicated is in their best interest.⁸

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Headache Solutions: Save Billions With Chiropractic Care?

By Mark Studin, DC, FASBE(C), DAAPM, DAAMLP

It was reported by Doheny in 2006 that migraine headaches cost U.S. employers more than $24 billion annually, including direct health care costs and indirect expenses such as absenteeism.

Doheny went on to report that according to Michael Staufacker, director of program development for StayWell Health Management in St. Paul, Minn., "The programs are so few and far between because many companies 'don't perceive it as a priority.'"¹

Much of the public perceive headaches and migraines as normal occurrences. For example, a patient will enter a doctor's office and report that they experience "normal" headaches, not realizing that pain is never a normal occurrence. Symons, Shinde and Gilles emphasized the nature of pain, quoting this statement from the International Association for the Study of Pain: Pain is "'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."² As a result of the public not taking many types of headaches as potential serious problems, they let the condition linger, leading to negative sequella.

According to Munakata, Hazard, Serrano, Klingman, et al., "neuroimaging studies have provided compelling evidence that suggests progressive brain changes in persons with migraines ... migraine frequency is associated with posterior circulation infarcts and diffuse white-matter lesions ... Welch, et al., showed that impairments in iron homeostasis in periaqueductal grey areas that were associated with migraine duration and chronic daily headache."³

Munakata, et al., also reported that the economic impact of migraines in both direct health care costs and indirect costs of absenteeism is a huge economic burden.³ The direct cost of migraines ranges from $127 to $7,089 per victim, and the indirect cost due to absenteeism $709 to $4,453 per victim, making migraines an economic burden to the individual, the insurer, the employer, as well as local, state and federal entities who experience a lowered tax base from lost wages. It was also reported that between 2005 and 2006, there were 1,729,555 physician office visits, 186,603 advanced imaging procedures, 59,589 other diagnostic procedures, and 22,168 hospital days with a primary diagnosis of migraine or headache; all of which are paid by private or public insurers, or out of the pockets of individuals. In short, the costs are staggering and a burden to the economy.

Friedman, Feldon, Holloway et al., reported that acute headaches account for 5 percent of emergency department (ED) visits in hospitals. They also reported: "[T]he ED environment that may also contribute to unsatisfactory treatment response include limited physician contact time that may preclude a detailed history, overuse of ED by patients with substance abuse problems, the need for rapid triage, the competing distraction of patients with life-threatening conditions, and directives (or lack thereof) for care dictated by the referring physician. ...Thus, the treatment of migraine patients in the ED appears to be suboptimal and the high rate of recurrent headache may be attributed to underutilization of relatively 'migraine specific' treatment."⁴

Nelson, Suter, Casha, et al., reported on randomized clinical trials that took place over an eight-week course of treatment. The results showed there was minor statistical differences in outcomes for improvement during the trial period for chiropractic care, amatriptyline or over-the-counter medications for treating migraine headaches. It was also reported that there was no statistical benefit in combining therapies. However, the major factor to consider is that in the post-treatment, follow-up period, chiropractic was 57 percent more effective in the reduction of headaches than drug therapy. In addition, it was reported that, with the drug group, "58% experienced medication side effects important enough to report them. In the amatriptyline group, 10% of the subjects had to withdraw from the study because of intolerable side effects. Side effects in the SMT (Spinal Manipulative Therapy) group were much more benign, infrequent, mild and transitory. None required withdrawal from the study."⁵

Although this study was conducted 13 years ago, a more current study by Chaibi, Tuchin and Russell reported that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally as effective as propranolol and topiramate in the prophylactic management of migraine,⁶ supporting the previous findings. Although more research is desperately needed, the above conclusions suggest a clear direction when it comes to managing migraines and headaches.

Using the 57 percent increased effectiveness that chiropractic has over drug therapy (leaving out the overlap that chiropractic could help without drugs) and the $24 billion U.S. employers pay for headaches and migraines annually, the savings from chiropractic care would approach $13.7 billion annually. Now imagine the reduction in the staggering costs currently incurred by the public, government and other entities for headache/migraine if that same percentage (57 percent) were applied. In addition, if chiropractic reduced the necessity for emergency room visits by 57 percent, ED doctors could focus on what their primary purpose is, to save lives in urgent scenarios.

With these cost savings, chiropractic benefits the federal government, local government, employers, private and public insurers and the public. It eases the burden on emergency rooms and prevents unnecessary side effects of drugs that are not clinically indicated, with a more viable and proven drugless solution. Although much more research is desperately needed to explore the benefits of chiropractic for migraines and headaches, the available research suggests chiropractic offers immediate solutions.

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Good Foot Care - Help Keep Your Diabetic Neuropathy Patients Healthy

By John Hayes Jr., DC, MS, DACBO

Unfortunately, diabetes is one of the fastest growing illnesses in America. That means if you don't currently have patients with diabetes (unlikely, but possible), you will soon. And that means you're going to be treating patients with diabetic neuropathy, particularly diabetic neuropathy affecting their feet.

According to the American Diabetes Association, one in five diabetes patients ends up in the hospital with foot problems. All too often those foot problems lead to amputation or raging systemic infections. The best way to prevent these problems is by educating your diabetic neuropathy patients on how important it is to take care of their feet and to intervene as early as possible when they do develop problems. Determine the extent of your patient's problems and then educate them on proper foot and diabetes care.

Step One – The Thorough Foot Examination

If you have patients with diabetic neuropathy, even if they don't present with foot issues, you need to be proactive as their physician and ensure that you see them at least once a year for a complete foot examination. When you're examining their feet, make sure you do the following:

Examine each foot between the toes and from toe to heel. Make extensive notes in the chart of any problems by drawing or labeling the finding on the foot diagram. If your patient has skin that is thin, fragile, shiny and hairless, they could have problems with their circulation and that means possible nerve damage.
Ask the patient if they've noticed any change in how their feet sweat. If their feet don't sweat as they normally would, they can develop dry, cracked skin and those cracks can become infected.
If your patient is wearing nail polish, request that they remove it. Check for ingrown toenails, deformed nails or any type of nail fungus.
Make notes on the diagram and in the chart of any areas on their feet that are noticeably dry, red or warm to the touch.

Step Two – Patient Education

In order to prevent serious problems, your diabetic neuropathy patients need to know how to care for their feet and what to watch for so they can come in to see you before they reach a point of no return. Here's what they should do:

Check their feet every day. They should look at their bare feet to make sure they don't have any sores, blisters or swelling. If they can't see the bottoms of their feet, they should use a mirror or ask someone else to check them.
Wash their feet every day and dry them completely to eliminate the possibility of fungus growth.
Use a good lotion on their feet to keep skin smooth and prevent dry, cracked skin. They should not use lotion between the toes – it will keep the skin there too moist, and that moisture will breed bacteria.
Trim their toenails, but not too short. Cut them straight across and file the edges with a nail file to prevent ingrown toenails.
Always wear shoes and socks – even inside the house. If they have neuropathy, it's just too easy to step on something and injure their feet without even feeling it.
Wear comfortable shoes, preferably shoes designed for people with diabetic neuropathy. Check their shoes before they put them on and make sure the lining is intact and smooth, and that nothing is in their shoes. Talk to them about Medicare assistance with purchasing special shoes.
Never put their feet in hot water. Check the temperature with the elbow before stepping into it.
Never use hot-water bottles or heating pads on their feet. Neuropathy makes it harder to sense extreme temperatures and they can burn their feet without even knowing it.
When sitting down, they should prop their feet up to keep the blood circulating; move the toes and ankles to keep the blood pumping; and never cross their legs when sitting.

Don't just tell them what they need to do and take it for granted that they understand what you're telling them. Ask your patient to demonstrate the steps to proper foot care so you know they know what you're saying and that they are physically capable of doing what you're telling them to do.

Offer patients an ongoing monitoring and follow-up program. Keep in touch and watch for any of the symptoms of diabetic neuropathy in the feet. Diabetic neuropathy impairs the ability to feel pain in the extremities; patients may not notice the problem until it's too late for successful treatment. It never hurts to have a fresh pair of eyes (yours) keeping watch over them.

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Shoulder Pain: Practical Tips for Examination and Treatment By Kevin M. Wong, DC

General Analysis

Remember all of your shoulder joints: glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), scapulothoracic and rib joints (costovertebral, costotransverse and costosternal). Also recall that you have a battery of orthopedic and neurologic tests available to you when assessing the shoulder. You are not expected to have all of them memorized, so have references available to use when you need to be reminded. These tests can add critical information to your fact finding and treatment plan.

Shoulder Joint Misalignment

GH joint: A multi-axial synovial ball-and-socket joint, the GH joint is the articulation between the glenoid fossa of the scapula (shoulder blade) and the head of the humerus (upper arm bone). Due to its shallow socket, the presence of a fibrocartilaginous labrum aids in support. We also see the rotator-cuff muscles attaching on the head of the humerus. The GH joint is the most mobile and least stable joint in the human body.

Ligaments that help attach the proximal clavicle to the sternum are very strong here. We rarely find fractures in this region. We do get misalignments of the proximal clavicle, most commonly moving superior/anterior/medial. Be especially careful when you palpate this joint. Not only can they be particularly tender, but you are also getting close to the chest area. Take the appropriate precautions when working with female patients.

The scapula's attachment to the skeleton is musculotendinous in nature, formed by the trapezius and serratus muscles.

Costovertebral, costotransverse, and costosternal (rib) joints: Costotransverse joints involve the facets of the tubercles of ribs 1-10, forming joints with the corresponding thoracic vertebrae. These are synovial joints. This articulation is present in all but the 11th and 12th ribs. Ribs 1-10 have two joints in close proximity posteriorly: the costovertebral joints and the costotranseverse joints. The costosternal joints are those involving the cartilages of the true ribs with the sternum. These are considered arthrodial joints, with the exception of the first joint, where the cartilage connects directly with the sternum (synarthrodial).

Treating Shoulder Problems

So, how do you know when to check the shoulder? Beyond the obvious shoulder pain symptoms (the patient is pointing directly at it), you might look at the shoulder when you see any of the following:

Pain in the trapezius, especially the region just above the scapula
Neck pain that can move into the skull
Referral of pain or isolated pain in the lateral or anterior deltoid
Popping or clicking of the shoulder during AROM or PROM
Weakness with muscle or strength testing of the GH muscles
Patients pointing to rib joints as sites of pain. Ribs are often out due to shoulder misalignments
Chronic/persistent C/T pain that is not resolving with spinal adjustments

Chiropractic adjustments and treatments are proven to relieve the pain associated with many common shoulder injuries. "There is fair evidence for the treatment of a variety of common rotator- cuff disorders, shoulder disorders, adhesive capsulitis, and soft-tissue disorders using MMT [manual and manipulative therapy] to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy."³ The most important aspect is to recognize and address all of the shoulder joints during your assessment. Adjust each individual joint, taking into consideration which direction you feel the bones have moved, and see how successful the results are. The goal is simple: provide the most efficient, effective patient care.

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Chronic Pain and Self-Care

Chronic pain has been defined by the International Association for the Study of Pain as "pain that persists beyond normal tissue healing time, which is assumed to be three months."¹ When chronic pain is not associated with cancer or end-of-life care, it is often referred to as chronic non-cancer pain (CNCP); over the past 20 years, the use and misuse of opioids for CNCP has increased significantly. This is because "guidelines are not universally accepted by those involved in pain management and pain treatment seems to be driven mainly by tradition and personal experience."² Many physicians and most patients hold unrealistic expectations with regard to the potential effectiveness of treatment with opioids and should be informed that total pain relief is exceedingly rare. In fact, clinical trials have demonstrated that pain scores improve less than two to three points on a 10-point scale, and often even less.³

Chronic Pain: The Consequences

A Finnish study of 5,646 patient visits identified pain as the reason for visits to a doctor 40 percent of the time. The low back, abdomen and head accounted for the most common locations, and 50 percent of confirmed diagnoses were musculoskeletal. Twenty percent of the patients had experienced pain for over six months and demonstrated considerable limitation in various activities of daily living.⁴ Another large sample, this one consisting of 28,902 working adults in the United States, found that 52.7 percent of workers reported having headache, back pain, arthritis or other musculoskeletal pain over a two-week period, 12.7 percent of whom lost 3.5 to 5.5 hours per week of productive work. Attributed losses in productive time at work were highest for headache (5.4 percent), back pain (3.2 percent), arthritis pain (2.0 percent) and other musculoskeletal pain (2.0 percent). There appeared to be no difference in the proportion of workers who lost productive time at work in terms of sex, age, residence, occupation, length of time on the job, or health insurance status. Workers with less education, high-demand / high control jobs, as well as those with four or more co-existing pain conditions, lost the most time.⁵

Pain occurs in a variety of forms, including monophasic events (e.g., due to injury), chronic episodic conditions (e.g., migraine headache) and chronic problems (e.g., persistent pain from arthritis). Sixty-nine percent of people over the age of 65 have two or more chronic illnesses. Moreover, it has been estimated that more than 40 percent of people with chronic illnesses have at least one co-morbidity that can often lead to increased disability and diminished physical well-being, reduced quality of life, increased use of health services and increased mortality.⁶

Pain Management Strategies

Effective management of chronic pain and chronic illness is complex and requires significant participation in self-care by patients and their families. However, patients who attempt to manage their multiple health conditions are faced with conflicting demands and competing priorities. The daily routines required by patients to manage their pain can be burdensome, but should include:

Engaging in activities that promote physical and psychological health;
Interacting with health care providers and adhering to treatment recommendations;
Monitoring personal health status and making the necessary care decisions;
Managing the impact of illness and pain on physical, psychological and social functioning.

"Dual task theory" proposes that patients will most often perform those tasks first in which they have the greatest emotional investment, such as acute symptoms and serious illness, at the expense of the more chronic conditions. Similarly, there is currently an increased focus by many health care providers on "acute care," effectively delaying or "triaging" treatment for the diverse and complex needs of patients with chronic pain and chronic health conditions.⁷ There are many barriers to self-care. Some of the most common include physical limitations, lack of knowledge, financial constraints, logistics of travel, social and emotional support, aggravation of one condition by symptoms of/or treatment of another condition and problems with multiple medications.

The Latest Guidelines

According to Passik and Kirsh, "Good pain management should lead to some decreases in pain perception combined with a corresponding increase in ability to function."⁸ The American Society of Anesthesiologists Task Force on Chronic Pain Management has released its 2010 practice guidelines, which propose to:

Optimize pain control, recognizing that a pain-free state may not be attainable;
Enhance functional abilities, physical and psychological well-being;
Enhance the quality of life of patients;
Minimize adverse outcomes.

The list of single-modality interventions mentioned in the guidelines is extensive; here are the top 12, in no particular order:

Ablative techniques including chemical denervation, cryoneurolysis or cryoablation, thermal intradiscal procedures and radiofrequency ablation
Traditional acupuncture and electroacupuncture
Joint and nerve or nerve-root blocks
Botulinum toxin injections
Transcutaneous electrical nerve stimulation, subcutaneous peripheral nerve stimulation and spinal-cord stimulation
Epidural steroids with or without local anesthetics
Intrathecal drug therapies
Minimally invasive spinal procedures including vertebroplasty, kyphoplasty, and percutaneous disc decompression with nucleoplasty or coblation
Pharmacologic management includes anticonvulsants, antidepressants, benzodiazepines, N-methyl-D-aspartate receptor antagonists, opioids, skeletal muscle relaxants, and topical agents such as lidocaine, capsaicin or ketamine
Physical or restorative therapy, including specific exercises
Psychological treatment
Trigger-point injections

The task force describes the difference between multimodal and multidisciplinary interventions as follows: "Multimodal interventions constitute the use of more than one type of therapy for the care of patients with chronic pain. Multidisciplinary interventions represent multimodality approaches in the context of a treatment program that includes more than one discipline. The literature indicates that the use of multidisciplinary treatment programs compared with conventional treatment programs is effective in reducing the intensity of pain reported by patients for periods of time ranging from four months to one year."⁹

Chiropractic has achieved increased credibility and amassed an important body of evidence in support of the non-surgical, non-pharmaceutical treatment of acute and chronic musculoskeletal pain conditions. We have also demonstrated a willingness to follow clinical practice guidelines and collaborate in multidisciplinary care pathways.^10-13

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A Clinician's Guide to Managing Neck Pain

Practical summary of the Neck Pain Task Force's evidence synthesis

By Peter W. Crownfield, Executive Editor

The nonprofit occupational health and safety research organization Institute for Work & Health, working with Canadian Memorial Chiropractic College, the Ontario Chiropractic Association and executive committee members of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders, has compiled the Neck Pain Evidence Summary, effectively a clinician's guide covering appropriate assessment and treatment of neck pain patients. The recommendations are based on research completed by the task force several years ago and published in a special edition of Spine (February 2008).

"It's exciting to see the chiropractic community take up the work of the task force this way," commented Dr. Sheilah Hogg-Johnson, IWH senior scientist and task force member. "The Neck Pain Evidence Summary provides a way for health-care professionals to review the evidence easily in their practice, and if they need further information, they can refer to the full research papers."

The evidence summary features background on the task force, a "new conceptual model of neck pain" developed by the task force, general messages, treatment messages, a comprehensive grading system (including symptoms/signs and initial assessment by grade), and several figures and tables that illustrate appropriate assessment and treatment of neck pain patients. Key messages from several of these sections are summarized as follows:

General Messages

While most people who suffer neck pain continue usual activities, up to 11 percent of adults are limited in activity performance and up to 1 percent suffer disabling pain.
Multiple factors usually contribute to neck pain, including physical and mental health, work, and daily activities. Most cases of neck pain do not reflect serious illness/disease; diagnostic imaging tests (X-rays, CT, MRI, etc.) are only required in a minority of cases, and routine imaging does not enhance understanding of pain causality.
For patients presenting with traumatic acute neck injuries, the Canadian Cervical Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low Risk Criteria (both of which appear as appendices in the evidence summary) are recommended for identifying patients who do not require imaging.
Vertebrobasilar (VBA) dissection/stroke is "extremely rare" and is no more likely to occur following a chiropractic visit than following a visit to a medical doctor. Pre-existing VBA dissection is a risk factor for stroke, but there is "no practical way to screen neck pain and headache patients for this problem."

Treatment Messages

There is no "best treatment"for neck pain. A combination of treatments may be necessary, and even then, benefits may be "modest or short-lived." Longer treatment time is not associated with more substantial improvements, and all treatment should be based on the patient's grade of neck pain (see general grading descriptions below).
The patient's informed treatment preferences and attitude regarding risk should dictate treatment. Practitioners should provide the patient with an informed choice of effective options and involve them in decision-making.
Most neck pain is of the Grade I (no signs of major pathology and no or little interference with daily activities) or Grade II (no signs of major pathology, but interference with daily activities) variety.
When treating non-traumatic neck pain, effective treatment options include manipulation, mobilization, supervised exercises, manual therapy plus exercise, acupuncture, low-level laser therapy and analgesics. Effective treatments for acute traumatic neck pain are educational videos, mobilization, exercises and mobilization plus exercise.
Certain treatment options are not likely to be effective for Grade I or Grade II neck pain. For non-traumatic neck pain: advice from health-care providers on its own, collars, passive modalities (heat therapy, ultrasound, transcutaneous electrical nerve stimulation [TENS], electrical nerve stimulation), exercise instruction and botulinum toxin A; for acute traumatic neck pain: pamphlet/neck booklet alone, passive treatments (heat, cold, diathermy, hydrotherapy, ultrasound, TENS), referral to fitness or rehabilitation program, frequent early health-care service, methylprednisolone, exercise instruction, botulinum toxin A, and corticosteroid injections; for non-acute neck pain: passive treatments (heat, cold, diathermy, hydrotherapy, ultrasound, TENS), and corticocosteroid injections.
Grade III neck pain (neck pain with neurological signs and symptoms) merits extreme caution in terms of treatment. According to the evidence summary, "There is little research on non-surgical interventions for Grade III neck pain. Consider epidural corticosteroid injections for temporary relief of radiculopathy. Consider surgery in the presence of serious pathology or persistent radiculopathy."And regarding Grade IV (major structural pathology) neck pain, the summary notes: "Aggressive surgical treatment of many of these conditions is generally accepted as effective and often strongly advised. Refer to literature of specific pathological conditions."

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Osteoporosis, Vertebroplasty and the Aging Spine: Chiropractic Considerations

By Nancy Martin-Molina, DC, QME, MBA

Osteoporosis vertebral fractures are a common cause of pain, disability and increased mortality. Approximately 750,000 new vertebral fractures occur in the United States each year. Among adults over the age of 50, up to a quarter will have at least one vertebral fracture in their lifetime.

Every year, about 1.4 million vertebral compression fractures come to clinical attention worldwide. Numerous case series and several small, unblinded, nonrandomized, controlled studies have suggested the effectiveness of vertebroplasty (VP) in relieving pain from osteoporotic fractures, but data about VP from high-quality randomized, controlled trials are lacking.¹ Furthermore, chiropractic clinical guidelines for the management of vertebroplasty patients are elusive and lack revision frequency and provider education.

Assessment

The patient is a 91-year-old right-handed, retired, caregiver mother of 14 children who presents in a wheelchair on a medical referral for chiropractic. Her chief complaints are biaxial lumbar pain at the beltline, and bilateral lower-extremity pain anterior aspect below the knees and above the ankle. Medications include Reglan 5 mg, Requip 3 mg and Lovastatin. Supplements include fish oils, cal-mag-zinc multivitamin, and vitamin C 1,000 mg. She had a prior lumbar vertebroplasty, multi level.

Physical Examination: She stands 5'2" and weighs 145 lbs. Blood pressure is 120/78. LA RR: 16; P: 56. Distal and proximal pulses are full, regular and strong. No signs for dural tension or nuccal rigidity are exhibited. Gait is normal yet slow. She reports wheelchair use due to alternate physician appointments today; no drop foot or steppage gait observed. Heel and toe rise are intact. Seated deep-tendon reflexes of the upper and lower extremities demonstrate +2 symmetrically using the Wexler Grading Scale with reinforcement maneuvers. Capillary refill less than two seconds distal extremities. Testing sensory discrimination to pain sensation is normal in lower extremities; no pedal or pitting edema. Range of lumbar motion markedly diminished consistent with age, degenerative changes and prior radiographic evidence of multi-level lumbar vertebroplasty.

Diagnosis: Lumbar vertebroplasty, multi-level with moderate complexity lumbosacral neuritis with myofascial and osteoarthrosis components. This individual uses her arms to propel; no foot propel combination. Transfer to and from the wheelchair is by assisted stance. The wheelchair seat is too high; she slides down in the seat in order to rest her feet, creating poor posture. This can cause further long-term damage to the spine. A more immediate problem is shallow breathing as a result of folding the diaphragm in half. She is observed to lean forward repeatedly.

Her osteoarthrosis in the spinal and lower extremity regions is significant and since cartilage itself is not innervated, her pain is presumed to arise from a combination of mechanisms, including osteophytic periosteal elevation; vascular congestion of subchondral bone, leading to increased intraosseous pressure; synovitis with activation of synovial membrane nociceptors; fatigue in muscles that cross the joint; and overall joint contracture.

In addition to the underlying pathophysiologic changes described above, her joints have undergone mechanical deformation, with resultant malalignment and instability and ankylosis. This is easily observed about the medial knee joints and the PIPs and DIPs. Throughout the exam, she repeatedly rubs these areas.

Recommendations

Percutaneous vertebroplasty involves the vertebral injection of polymethylmethacrylate cement. Although there is some indication that this procedure is safe and effective for treating osteoporotic compression fractures, "Medicare promulgated no national coverage policies for this procedure after reviewing the available nonrandomized evidence. Nevertheless, local Medicare contractors in multiple jurisdictions have covered vertebroplasty for various indications since as least 2001."^2-4

Traditionally, osteoporosis has been underdiagnosed and undertreated following a low-energy fracture in an elderly patient. Although treatment rates may be improving through public health initiatives, the majority of patients with osteoporosis remain inadequately treated. Patient intervention programs that focus on patient education about osteoporosis and treatment options can lead to significant increases in intervention and treatment.

Reducing the risk of skeletal fractures in patients susceptible to osteoporosis involves improved chiropractic education on the risk factors and management of osteoporosis, as well as informing patients on the significance of dual-energy X-ray absorptiometry testing and medical treatment so they may serve as their own health care advocates.

Plan of Care

Instruction on the need for wheelchair cushions to provide padding for lumbosacral support. Discussion of home care with a geriatric medicine approach to diet, moist heat and NSAID methods. Moist heat pack for low back use. Discontinue home dry-heat methods, as they worsen condition by dehydrating muscle. Review and implementation of home exercises. Cautionary conditions are recognized but could still be a candidate for mid- or low-back adjustment and could benefit from low-force pressure-point techniques.

Any new developments in chiropractic management of osteoporosis with/or without vertebroplasty should be added to care guidelines at a two-year frequency. Chiropractic care guidelines and updates should be considered mandatory as a part of the provider education process.

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The Psychology of Chronic Back Pain

Psychological risk factors for chronicity and our challenge as clinicians: finding the right treatment mix. By David J. Brunarski, DC, MSc, FCCS(C)

In 1986, Nortin Hadler commented in The New England Journal of Medicine that regional back pain had a tendency to become worse the more it was treated.¹

And the Scandinavian Journal of Rheumatology quotes Aage Indahl: " The multitude of different treatments offered to patients must be regarded as pain-modulating modalities and not as cures for low back pain. There is no treatment that has been proven to be highly effective."² A systematic review on the effectiveness of physical and rehabilitation interventions for chronic nonspecific low back pain, published this year in the European Spine Journal, concluded that "only multidisciplinary treatment, behavioural treatment, and exercise therapy should be provided as conservative treatments in daily practice in the treatment of chronic low back pain."³ A June 2011 update of a Cochrane review regarding spinal manipulative therapy for chronic low back pain stated: "[T]here was no clinically relevant difference between spinal manipulative therapy and other interventions for reducing pain and improving function in patients with chronic low-back pain."⁴

Back pain was "medicalized" for most of the 20th century in terms of an "injury model." Disc disease and degeneration were identified as the culprits, so victims were advised to rest, avoid strenuous activity and medicate. When that approach logically failed, surgical treatments became de rigueur for decades.

Alternative treatment, including chiropractic, became popular as education and personal wealth improved. The "wellness movement" has empowered patients to manage their own health care needs and share decisions with health care providers of their choice. Cognitive behavioural treatment (CBT) and educational approaches increasingly emphasize a "non-injury model" of back pain, which articulates "that the back is strong, that loads normally do not cause any damage despite occasional temporary pain, that reducing the focus on pain might facilitate more natural and less painful movements, and that it is beneficial to stay physically active."⁵

However, despite this early optimism, nearly 34 percent of individuals who suffer an episode of low back pain will continue to experience recurrent episodes.⁶ With so much evidence and expertise available, is the problem all in their heads? The fear-avoidance model (FAM) suggests that a unique minority of individuals do possess an exaggerated pain perception and a robust psychological avoidance strategy that often contribute additional physical and psychological layers to their original musculoskeletal complaint.⁷

As doctors of chiropractic, we know that even with appropriate care, some patients retain such high psychological distress that their clinical outcomes are poor. These patients demonstrate negative appraisal of their internal and external stimuli, leading to poor self-efficacy and suboptimal performance of requested tasks. These patients often exhibit pain intensity that is atypically elevated. Their escape/avoidance behaviour becomes enhanced such that their movements are intensely guarded, leading to deconditioning and disuse. The result is that the patient's physical impairments are increased and their disability prolonged.^8-9 Wideman and Sullivan describe the process as a cascade of pain-related fear that devolves into pain catastrophizing, depression and long-term disability.¹⁰

The extent to which the appropriate patient receives the correct treatment mix is the new clinical challenge. Evaluating the various psychological risk factors against the patient's physical capacity for change and improvement may be enhanced through the use of validated psychological measurement tools. These tools have been found to be useful in classifying chronic pain patients into more homogenous groupings that encourage better treatment plans, outcome management and continuing care.

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Decompression: Basic Classification Overview By Jay Kennedy, DC

It is apparent by the myriad studies over the past decade that "diagnosing" back pain is probably not possible in the vast majority of cases. According to the work of Deyo and others, at least 70 percent of pain is generated from sprained tissues and overall 90 percent of LBP is at present idiopathic.

Grieves suggested in his book Mobilization of the Spine (1986) that the term prediction is probably more accurate than diagnosis when it comes to back pain. The generally accepted definition of a sprain is damage to a ligament structure (perhaps including the disc's annulus, which Bogduk and others have proposed is liable to sprain). A strain, on the other hand, is damage to a muscle or its tendon structure (which Bogduk suggests are rarely the source of chronic LBP). Now the rub in all of this is the implausibility (and impracticality) of actually determining which is which. The International Association of Spinal Pain has set forth specific criteria for determining the source of pain. Valid and reliable tests are necessary for any diagnostic accuracy; this is true of cancer, diabetes or back pain. The problem is that there are at present no demonstrably valid or reliable tests that conclusively prove or allow us to reach diagnostic prevalence for most back pain.

Fortunately, in our world of private practice, patients are not holding us to this standard (yet). We can deduce with some level of certainty that in fact we are dealing with sprained / strained tissues. When we add segmental dysfunctions, trigger points, spasm and a whole host of other things (that probably also fail the "valid and reliable" thesis), it appears to give us sufficient indications as to what is wrong and how to help it. It appears that suggesting sprain / strain is a default diagnosis (prediction) based more on the fact nothing "worse" appears to bethe case.

In our method of decompression classification we recognize 70 percent of back pain may potentially be sprained tissues. However, with the availability of decompression (and the marketing typically used with it), we may get several patients a month with a less nebulous (and potentially more mechanically amenable) diagnostic profile – i.e., disc herniation, prolapse and nerve compression. Many have diagnostic cues that are somewhat more valid, such as nerve tension signs, compression signs, pain referral patterns and MRI findings of prolapse and focal herniation. I believe these findings allow us a more direct and accurate treatment algorithm.

We look for positive compression tests such as Millgram's, slump, first 1/3rd ROM pain / impairment and the peripheralization of symptoms. We use Valsalva, Lindner's, force / form closure and other overt compression tests, scrutinizing findings such as relief posturing, antalgia and directional preference. These signs and symptoms, when viewed with the patient history, help us predict a compression disc syndrome versus a sprain with fair to good accuracy.

Disc pain can come in many varieties, both amenable to decompression traction and irritated from it, such as a recent sprain or certain types of annular tears. Decompression can burden some conditions while relieving others. Observational clarity and a keen awareness of these variables are necessities for the best outcomes with the least adverse effects. (This is precisely why I hound on the lie of the magic decompression system. We drop our guard in regards to proper patient classification when we believe we're dealing with a table that does our thinking for us.)

We tend to find nuclear extrusions responding better than annular tears / sprains. Internal disc disruption and severe desiccation likely diminish or eliminate the benefit of decompression at those levels. The breakdown of the nucleus creates loss of hydrostatic pressure and thus the disc is no longer sustaining an internal positive pressure.

The annulus can't technically be "decompressed." In these cases, of course, nonsurgical decompression therapy becomes relatively ineffectual. This is not to suggest traction (stretch) of the spinal structures couldn't afford some temporary subjective effects (pain gate, reduction of local paraspinal hypertonicity and placebo effect), but direct decompression of that disc would be unlikely.

When decompressive positions afford relief, it is an obvious suggestion that decompression as a therapy may well perpetuate the benefits. As Cyriax pointed out some 50 years ago, traction is expedited bed rest ... without the disuse side effects. If recumbence fosters pain relief, traction may promulgate and expand the effect. It remains an intuitive and sensible approach in cases of disc compression, and the enthusiasm seen in both the doctors who use it and the general public seems to reinforce that.

Our research suggests practices marketing "decompression therapy" tend to attract a slightly different cross-section of patients than those entering a chiropractic adjustment-only practice. Good, bad or otherwise, many surveys suggest the limited percentage of the population we treat may be partially based on fear and misunderstanding of what we do. Like it or not, many patients with herniations who may be unlikely to try "regular chiropractic" may be likely to try decompression therapy offered by a chiropractor. (This same paradigm is seen in many instrument-adjusting practices as well.) And this gives us the opportunity to introduce chiropractic where we may have been unable to previously.

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The Carpal Tunnel Syndrome

By Deborah Pate, DC, DACBR

Carpal tunnel syndrome (CTS) is a relatively common, chronic and disabling condition. This syndrome is typically characterized by nocturnal hand discomfort, finger paresthesias in the median nerve distribution and thenar muscle atrophy.

This condition is most frequently caused by compression of the medial nerve in the carpal tunnel. This disorder occurs most often between the ages of 30 and 60 and is 2 to 5 times more common in women than men. The dominant hand is affected frequently; however, 32 to 50% of cases occur bilaterally.

Anatomically, the carpal tunnel is formed by all the carpals of the wrist, which is deepened by the tubercles of the scaphoid and trapezium on the radial side and by the pisiform and hook of the hamate on the ulnar side. This concavity is converted into a tunnel by the tough flexor retinaculum which stretches between the tubercle of scaphoid and the ulnar styloid. The eight flexors of the fingers, the long flexor of the thumb and the median nerve all share the space in the tunnel.

There are three main theories regarding the etiology of CTS:

1. The local entrapment of the median nerve within the carpal tunnel, can be classified into three groups:

a. The decrease in the size of the carpal tunnel due to bony or soft tissue changes such as misalignment of the carpal bones, fractures, dislocation, or hypertrophic osteophytes or fibrous scarring.

b. An increase in the volume of the normal content of the carpal tunnel. This can be due to occupational hypertrophy of the muscles and tendons in the carpal tunnel which is not uncommon in dentists, tennis and golf players, typists, factory workers, and persons confined to wheelchairs. Synovial proliferation due to arthritis, tenosynovitis, edema due to congestive heart failure, and amyloid in patients on dialysis are other less common causes for an increase in the content of the carpal tunnel.

c. Space-occupying lesions such as lipoma and ganglion cysts will also cause entrapment of the median nerve within the carpal tunnel.

2. Systemic diseases also will cause neuritis affecting the median nerve, most commonly patients with diabetes; seven percent of patients with CTS have diabetes.

3. The third cause for CTS has been labeled as idiopathic, in fact 50% of patients with CTS have an unknown etiology. CTS has also been found in association with menopause and late trimester pregnancy.

The diagnosis of CTS until recently has been mainly empirical. Present diagnostic parameters include clinical history, clinical signs, and nerve conduction studies which can be equivocal. Imaging modalities prior to magnetic resonance imaging (MRI) have been in most circumstances non-contributory, with exception of osseous lesions, such as fractures and osteophytes. Likewise, the choice of conservative or surgical treatment is largely empirical. The reason for the success or failure of conservative treatment is poorly understood, possible because the exact cause for the symptoms is generally not established prior to treatment.

The role of MRI in the evaluation of carpal tunnel syndrome presently is not definitive because the parameters for conservative and surgical treatment have not been established. Unfortunately for our patients, there is no generally accepted guide for when a patient should undergo surgery. Many times the patient undergoes surgery whenever the orthopedist feels the patient hasn't responded to conservative care. If there is no demonstrable cause of pressure on the median nerve then conservative management should be the preferred treatment. Reasons for the failure of surgical treatment or recurrences of symptoms could be due to either inappropriate diagnosis, Wallerian degeneration due to delayed treatment, inadequate incision of the flexor retinaculum, postoperative scar or neuroma, or a growing space-occupying lesions within the carpal tunnel. The diagnosis and treatment of CTS could be made substantially more objective with the use of MRI.

The location, swelling and constriction of the median nerve can be easily assessed with MRI. Edema and fluid in tendon sheaths can also be seen with MRI. Ischemic necrosis of bone, incisional neuroma, and fat within the carpal tunnel can also be demonstrated. MRI can be utilized to assess the etiology of the patient's symptoms permitting a more rational choice of treatment options directed toward the etiology. Post-treatment MRI examination could also serve as a useful means in predicting the success or failure of a given treatment.

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Young Athletes and Chiropractic Care

By Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher

Like so many others, my children are active in sports. After several seasons, both have graduated from the recreation level (American Youth Soccer Organization - AYSO) to "club soccer." They are two of an estimated 18 million soccer players in the U.S.

They began in the AYSO, which has more than 50,000 teams. Once they were good enough, they were invited to join a club team. There are an estimated 8,200 soccer clubs in the U.S. Our club has 28 teams and plays year-round in leagues and tournaments. This is in addition to the recreational teams in the club.

As we have spent more time in the club, we have begun to recognize certain realities. One of those is that sooner or later, a child (yours or someone else's) will get injured. Fortunately, these injuries rarely require hospitalization. But they do require care off the field after the game. Sometimes those injuries keep a player off the field for weeks. This hurts the team and frustrates the coach.

We have noticed that, like most sports, a number of players have learned about the value of chiropractic care through those injuries. Sadly, there are those parents who look to over-the-counter medications as their first effort to ease pain. A new study underscores just how poor a choice this is, particularly for children. The study found an association between the use of acetaminophen and asthma, eczema and allergy symptoms in adolescents.¹

A few months after my daughter, Deborah, moved to a club team, I was solicited to be the team manager. My son had been in the club for a while, so I guess the club thought I had the experience they were looking for. Having more than enough on my plate, I turned the opportunity down - several times. However, organized sports seem to be run by people who are very adept in the art of getting even the most resistant soul to volunteer. I eventually gave in.

It only took a few meetings with the other managers to recognize that the club lacks any association with a health care provider. This was clearly a great opportunity for chiropractic. A phone call to a friend who specializes in sports chiropractic has resulted in a proposal for team chiropractors for our club teams. This will provide care on the weekends during league season and at local tournaments that will make a big difference in the health and fitness of our players. If professional athletes enjoy the benefits of chiropractic care during their games, why can't our young athletes?

It will probably take four to six DCs to serve the club. This will cover the busiest fields (where two or three games might be taking place at the same time), as well as tournaments in which teams might play four or five games each in one weekend.

If you do the math, 18 million soccer players translates into 300 soccer players for every doctor of chiropractic in the U.S. On a club level alone, if it takes four DCs to serve one soccer club, we will need more than 32,000 doctors just to serve the clubs in this country.

Now consider that formula in terms of the number of football, baseball, basketball and hockey teams in America (and the number of players on each team). This doesn't even take into account the high school and college teams, let alone other sports.

While chiropractic is not just for athletes, most people don't know that. What they do know is that many sports superstars rely on chiropractic care to maintain their careers. This information is regularly in the news.

You may not be a specialist in sports chiropractic. But even if you aren't, you've probably seen your share of sports injuries. Perhaps your clinical experience doesn't make you the best choice for a professional sports team or even a high school team. But this is only the tip of the iceberg.

If you just consider the world of soccer, there are millions of young athletes under the age of 10 who need your care. Take it from me, players are there to play. They will play injured if need be. Yes, it will cost you a few Saturdays. But if you team up with other DCs in your area, you can regulate your service time to one weekend a month or even just one Saturday a month.

Our club has approximately 350-400 players. Assuming the low end, that's 350 families in our area that will get to learn more about chiropractic firsthand from a DC who is donating their time to ensure the health and safety of children. Sounds like a great opportunity to me. What about you?

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Care Options for Plantar Fasciitis

By Mark Charrette, DC

Plantar fasciitis generally presents as "a sharp heel pain that radiates along the bottom of the inside of the foot. The pain is often worse when getting out of bed in the morning."¹ Plantar fasciitis can occur in runners or other athletes who repetitively land on the foot. Another susceptible group is middle-aged people who spend much time on their feet. More rarely, the fascia becomes inflamed after a single traumatic event, such as landing wrong after a jump or running a long hill. The vast majority (95 percent) will respond to conservative care and not require surgery.² Proper treatment is necessary, however, to allow for continued participation in sports and daily activities and avoid chronic damage.

The plantar fascia is the major structure that supports and maintains the arched alignment of the foot.³ This aponeurosis functions as a "bowstring" to hold up the longitudinal arch. Plantar fasciitis develops when repetitive weight-bearing stress irritates and inflames the tough connective tissues along the bottom of the foot. High levels of strain stimulate the aponeurosis to try to heal and strengthen. If the biomechanical strain continues, it overwhelms the body's ability to repair, and the ligaments begin to fail. It is this tear/repair process that causes the chronic, variable symptoms that can eventually become unbearable for some patients.

Since the plantar fascia inserts into the base of the calcaneus, the chronic pull and inflammation can stimulate the deposition of calcium, resulting in a classic heel spur seen on a lateral radiograph. Unfortunately, there is no correlation between the presence of a heel spur and plantar fasciitis. Many heel spurs are clinically silent, and most cases of plantar fasciitis do not demonstrate a calcaneal spur.⁴

Biomechanical evaluation may reveal either excessive pronation or supination. The flatter, hyperpronating foot overstretches the bowstring function of the plantar fascia, while the high-arched, rigid foot places excessive tension on the plantar aponeurosis. In either case, it is the combination of improper foot biomechanics and excessive strain that causes the connective tissue to become inflamed. A careful assessment of the weight-bearing alignment of the lower extremities is helpful, since many patients will have functional imbalances up the kinetic chain into the pelvis and spine.

Direct palpation of the plantar fascia will demonstrate discrete painful areas, most commonly at the insertion on the anteromedial calcaneus.⁵ Fibrotic thickenings are frequently felt - these are remnants of the repetitive "tear and repair" process. With the foot relaxed, grasp the toes and gently pull them up into passive dorsiflexion. Since this maneuver stretches the irritated plantar aponeurosis, it is frequently quite painful and is an obviously positive objective sign.

Standard temporary support procedures for strained plantar fascia can be provided with figure-eight taping and initial restriction of repetitive and straining activities. Immobilization, however, is not recommended. Ice massage and/or cold packs often help to reduce pain and inflammation. Other steps that can be taken include ultrasound (initially pulsed, then constant and direct) once inflammation has subsided, along with the use of vitamin C with bioflavonoids (which is a natural anti-inflammatory that can speed healing). In addition, transverse friction massage helps to stimulate blood flow and collagen deposition.⁶

If the feet are pronated, recommend custom-made, flexible orthotics to support the arches and reduce the stress on the plantar fascia. For the rarer cases of supinated feet, recommend custom-made orthotics that support the arches and offer added viscoelastic material to cushion the feet and decrease the amount of shock at heel strike. When ordering orthotics, ask for a divot in the surface of the material under the heel. This helps to spread pressure away from the fascial insertion.

Recommend the runner's stretch for the calf and the bottom of the foot. Demonstrate toe-curl exercises (while sitting, gather a towel on the floor up under the arch) for intrinsic muscle strengthening. For extrinsic muscle strengthening, have the patient perform toe raises (standing on the edge of a stair, slowly rising up on the balls of the feet) and perform the ankle-stabilizing series with exercise tubing.⁷

Plantar fasciitis usually responds well to focused, conservative treatment. One of the most important treatment methods is to reduce any tendency to pronate excessively. In addition to custom-made orthotics, runners should wear well-designed shoes that provide good heel stability. The use of custom-made orthotics can prevent many overuse problems from developing in the lower extremities. Investigation of foot biomechanics is a good idea for all patients, but especially for those who are recreationally active.

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When to Consider Orthotics: Research-Based Recommendations

By Mark Charrette, DC

Sometimes a patient's need for custom-made foot orthotics becomes apparent only after an inadequate response to chiropractic care. Some patients, however, reveal an obvious need, and orthotics should be provided early in their care. This will allow a good response to adjustments and prevent frustration all around. What follows are some commonly seen patient characteristics that indicate the need for foot orthotics.

History

Back problems worse with standing, walking, running. When a patient reports a link between locomotor activities and their spinal symptoms, this clearly calls for orthotics to minimize the stress being transmitted from the lower extremities to the spine.¹

Recurrent ankle sprains. A history of previous sprain injuries to one or both ankles indicates biomechanical instability and probable permanent ligament damage. Custom-made stabilizing orthotics provide the support needed to help prevent re-injury.^2-3

Family history of foot problems or surgery. A patient who has family members with foot problems and/or surgery has a much higher probability of the same. Fitting for orthotics may prevent these problems from developing and could help the patient avoid surgery.

Strenuous athletic activities. Those who engage in upright, weight-bearing sports need both shock absorption and foot/ankle stability. Orthotic support can increase performance and prevent injuries in many individual and team sports.⁴

History of lower extremity stress fractures, recurring shin splints, hamstring strains. Whenever an athlete, whether recreational or competitive, reports symptoms of overuse injury (microtrauma) in the lower extremities, orthotics should be provided. These conditions are closely correlated with biomechanical asymmetries, and require better support and shock absorption.^5-6

Chronic knee pain, patellofemoral arthralgia, ACL injury. The knee joint is a sensitive indicator of abnormal biomechanical stress, and these conditions have all been shown to indicate the need for orthotics. Controlling pronation decreases the rotational forces, improving patellar tracking and protecting the anterior cruciate ligament.⁷

Exam Findings

Postural imbalances (e.g., pelvic tilt, scoliosis, forward head). When a standing structural evaluation discloses any pelvic tilt, a lower extremity asymmetry requiring orthotics for proper correction is likely. Both functional and idiopathic types of spinal curvatures can benefit from the foot stabilization and neurological stimulus provided by orthotics.⁸ Many postural complexes (forward head is one of the most common) are secondary to poor standing balance and proprioception from the feet.

Gait asymmetry (e.g., calcaneal eversion, excessive pronation, foot flare). Looking for indicators of biomechanical asymmetry while a patient walks will often demonstrate the need for orthotics.⁹ If the foot and ankle complex is not functioning correctly during the stance phase of gait, this stress is transmitted to the pelvis and spine with every step.

Foot calluses, bunions, hallux valgus. Heavy callousing, bunion development and abnormal alignment all reveal evidence of abnormal or poorly tolerated forces during walking and indicate the need for improved biomechanics and orthotics.¹⁰

Lack of an arch (especially unilateral). This is seen during the weight-bearing portion of the exam, when a foot collapses under the weight of the body. A foot without an arch will not function properly and thus requires support.¹¹

Knee instability, high Q-angle, poor patellar tracking. When the knee does not align properly or track correctly, degenerative wear-and-tear and other chronic symptoms will follow. Orthotic alignment is required to reduce the abnormal forces on this complex joint, which must be able to sustain frequent high forces during walking and running.^12-13

X-Ray Findings

Scoliosis (functional or idiopathic), widespread disc degeneration. The spine will demonstrate poor support from one of the lower extremities by developing a lateral curvature. Gait disturbances may be one of the causative factors for idiopathic scoliosis. Significant intervertebral disc degeneration is proof of poor spinal shock absorption, and orthotics with viscoelastic properties often reduce symptoms dramatically.⁹

Unlevel sacral base, sacroiliac joint degeneration. The pelvis shows evidence of inadequate support by the appearance of a tilted sacral base when standing. This is often due to a functional short leg requiring orthotic support.¹⁴ Sacroiliac degeneration is unusual; when found, it indicates significant abnormal stresses.

Low femur head, coxafemoral DJD. These conditions are due to either an anatomical or a functional short leg. Degenerative changes in the hip joint have been correlated with the stress of a longer leg. Both will benefit from the improved balance and support provided by orthotics.¹⁴

Heel spur, DJD in knees, metatarsals. X-rays of the feet and knees may reveal evidence of long-standing regional stress, such as degenerative changes in weight-bearing joints and connective tissue calcification. Calcium deposited in the calcaneal attachment of the plantar fascia specifically indicates the need for support of the arches of the foot to help reduce shock and symptoms in degenerated joints, and provide arch stabilization.¹¹

Treatment Response

Recurrent subluxations. Making the same adjustment to a patient's spine again and again suggests poor structural support for the region. Orthotics have been used for decades by chiropractors who don't want to continue adjusting the same area and who want to see the adjustment "hold" better.

Unresolving muscle strain, myalgia. Myofascial symptoms not responding to treatment often are a clue to an underlying biomechanical imbalance. Many chronic muscle spasms and strains can be corrected by providing orthotics to support and stabilize.¹⁵

Flare-ups, exacerbations. A patient who is feeling better, returns to daily activities, and then suffers a return of symptoms probably needs orthotics. Without proper biomechanical support, these patients find that every attempt to establish normal routines causes a recurrence of their symptoms.

Foot symptoms are only one of the many reasons for supplying orthotics. In fact, the feet are seldom painful in most of the conditions that are clear indicators of an need for orthotic support. All chiropractors must be alert for signs of lower extremity involvement in spinal conditions. The good news is that these conditions can all be helped. Investigation and correction of foot biomechanics can help most patients, especially the recreationally active and the elderly.

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Chiropractic: The "Natural Way" to Get Rid of Your Headache

By Joseph D. Kurnik, DC

headaches A functional relationship has been observed between the upper and lower cervical region, as evaluated by motion palpation in the supine position. Upper cervical fixations (hypomobile spinal joints) are often found as reactions to lower cervical dysfunction and pathology, such as degenerative joint disease (DJD) or disc protrusion.

It has been observed that such upper cervical dysfunction may be eliminated or reduced through traction of the lower cervical dysfunctional segments and/or the occiput in the supine position.

The most common upper cervical findings in reaction to lower cervical pathology involve motion blockades (hypomobile functioning) at C1/C2, C2/C3 and sometimes at the occiput/C1 levels. At the C1/C2 and C2/C3 levels, the most common observations are left-side coupled restrictions in combined flexion, rotation and lateral flexion, or some combination of these tested motions. The most common right-side findings are anterior-to-posterior restrictions and extension at the C2/C3 level.

The reaction of the upper cervical levels can result in headaches secondary to irritation to the greater occipital nerve. The headaches can be right- or left-sided, or they may involve both sides of the head and face. If these upper cervical levels are adjusted, there can be relief or elimination of the headaches (or even vertigo), but since the upper fixations are reactive, the patterns return.

If you observe patients with middle to lower cervical disc pathology involving posterior disc bulging, protrusion or herniation, notice the tendency to flex the neck forward. This appears to be an attempt to reduce the stenosis created by disc pathology. DJD involving thinning of the disc with the development of stenosis in the middle to lower cervical spine may result in the same tendency to flex the cervical spine forward.

The reaction to this (DJD and disc pathology) can be the extension posteriorly of the upper cervical spine in order to keep the eyes level and looking forward. To do this requires increased contraction of the posterior cervical musculature, constricting the upper cervical spinal articulations. Traction at the level of pathology and at the occiput helps to reverse this process and release the lower and upper cervical restrictions in movement.

If the lower cervical spine is tractioned in the supine position by hand or towel, with the contact at the level of pathology, then it can be followed by re-examination of the upper cervical mechanics. Most often, there will be a lessening of the upper cervical mechanical blocks or dysfunction. Sometimes, however, in serious cases, the headache will worsen if the head is allowed to extend while engaging in lower cervical traction, so caution should be used to prevent head extension.

The response to lower cervical traction can be mild, moderate or significant in creating release to the upper cervical motion blockages. When headaches are involved, supine traction with bilateral hand contact to the occiput and head also helps to release the upper cervical blockages, but also to directly decompress the greater occipital nerve by causing distraction at the occiput/C1 and C1/C2 levels. Occipital traction also can be used in the absence of headaches to release or reduce upper cervical mechanical blockage.

An important point to bear in mind is that in the presence of lower cervical disc pathology, upper cervical adjusting may appear to be appropriate, but in many of these reactions, the upper cervical mechanical blockages may be cleared or reduced with appropriate gentle traction. In an undetermined percentage of cases, mild adjusting may be required, but rough adjusting could definitely create upper cervical reactivity, instability and irritate the lower cervical pathology.

To view the article online click:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?t=19&id=54438

Instruments of Change: Overcoming Fitness Obstacles

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Dr. Cohen's Tennis Tip Of The Week

Improve Your Return of Serve

Tennis Players,

The return of serve is as important as the serve itself. Since it's the shot that starts the point out when receiving, it is critical that we are successful at it. Having a high percentage on the return of serve will pay big dividends.

Some key points for this shot include the split step, quick turn of the front shoulder, compact backswing and early contact with the ball. A very common mistake on the return is that the backswing is bigger than necessary and the ball is caught late. The harder the serve, the shorter the backswing. Players must stay alert and move their feet to be able to hit the ball in the strike zone.

Learn more about the return of serve at TennisResources.com. Simply type the word "return" into the Quick Search field or search in more detail under the Advanced Search by clicking on the "Specific shots" and choosing from Forehand or Backhand categories. The search will bring up a wide number of videos related to the topic. Each of these clips features some of the world's top teaching professionals offering their tips. Learn more!

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